Trust the Physical Exam

​BY ALI OZCAN, MD; AYUSH GUPTA, MD; ISABEL NEACATO, MD; DAVID DONALDSON, DO; & SHANNA JONES, MDA 17-year-old boy presented to the pediatric emergency department complaining of a right shoulder injury and right clavicular pain for two hours. The pain started after he checked another player into the boards while playing hockey. He had no head injury, loss of consciousness, or other trauma. He took 600 mg of ibuprofen with no relief, so he came to the ED.He had no past medical or surgical problems, and reported his pain as 4/10 over the clavicle region. His review of system was otherwise negative. The patient's vitals were within normal limits. He had tenderness over the medial side of the right clavicle and no visible deformity or crepitus. He had intact distal neurovascularity over the right upper extremity and normal breath sounds bilaterally. All other systems were normal.An x-ray of the right clavicle was negative for acute fracture. (Image 1.) The right clavicle appeared inferiorly displaced relative to the left. The patient was reevaluated, and was still complaining of pain despite receiving morphine. We ordered a CT without intravenous contrast of the sternoclavicular joint (SCJ), which revealed the diagnosis. (Images 2 and 3.)Image 1. The chest x-ray showing an inferiorly displaced right clavicle relative to the left may be positional.Images 2 and 3. CT of the sternoclavicular joint without contrast: Acute comminuted fracture involving the medial most right cl...
Source: The Case Files - Category: Emergency Medicine Tags: Blog Posts Source Type: research