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Gas in the SternoclavicularJoints of

Patients with Blunt Chest Trauma:
Significance and Frequency of CT Findings

Randall M. Patten1 OBJECTIVE. In trauma patients, gas (vacuum phenomenon) in the sternoclavicular joints
Jill Dobbins could represent sequelae of significant distraction forces and thus serve as a potential marker
Steven R. Gunberg for severe intrathoracic injury. We evaluated the significance and frequency of the finding of
gas in the sternoclavicularjoints on chest CT of patients with blunt trauma.
SUBJECTSAND METHODS. We prospectively studied all chest CT examinations per-
formed at our institution over a 14-week period for the finding of gas in the sternoclavicular
joints. Chest CT examinations (ii = 267) were performed in 234 patients. We excluded data
from follow-up CT examinations (is = 33), limiting our evaluation to the initial CT examina-
tion for each patient. Of the study population, 103 patients (83 men and 20 women) who
ranged in age from 14 to 79 years (mean, 40 years) had sustained blunt chest trauma. For all
trauma patients, we recorded the mechanism of injury and the associated thoracic injuries.
RESULTS. CT revealed gas in the sternoclavicular joints in 47 patients (2 1%). Gas was
unilateral in 27 patients and bilateral in 20 patients. Sternoclavicularjoint gas was seen in 39
(38%) ofthe 103 trauma patients but was found in only eight(6%) ofthe 131 nontrauma pa-
tients (p < .0001 ). In the 39 trauma patients with sternoclavicular joint gas, associated tho-
racic injuries were seen in 17 patients (44%); either a sternal fracture or a retrosternal
hematoma was seen in three patients. Radiographically evident thoracic injury was revealed
in 20 (31%) of the 64 trauma patients who had no gas in the sternoclavicularjoint: however,
I 0 of these 20 patients had either a sternal fracture or a mediastinal hematoma.
CONCLUSION. Although gas in the sternoclavicular joints is more frequently seen in
patients with blunt chest trauma than in patients undergoing chest CT for other indications,
this finding does not indicate a greater risk of significant mediastinal or thoracic injury.

C T is an increasingly important im- the sternoclavicular joints on chest CT in pa-

aging technique for examining pa- tients with blunt thoracic trauma.
tients with blunt chest trauma and
Subjects and Methods
screening them for injury to the thoracic aorta.
We prospectively studied all chest CT examina-
In reviewing chest CT scans of trauma pa-
tions performed at our level I trauma center over a
tients, we observed several patients with gas in
14-week period forthe finding ofga.s in the sternoclav-
one or both of the sternoclavicular joints. Al-
icularjoint.s. We evaluated 267 chest CT examinations
though such a finding can be normal (vacuum in 234 patients. We excluded data obtained from 33
phenomenon), we hypothesized that the pres- follow-up CT scans. limiting our data collection to the
ence of gas in the stemoclavicular joints could initial CT examination for each patient obtained dur-
represent the sequelae of a significant distrac- ing this 14-week period. Of 234 patients in the
tion force, such as one that might be encoun- study population, 103 patients (83 males and 20 fe-
tered from either direct trauma to the sternum, males) who ranged in age from 14 to 79 years (mean
transient dislocation or subluxation of the ster- age, 40 years) had sustained blunt chest trauma. Indi-
Received October 6, 1998; accepted after revision
November 25, 1998. cations for chest CT in trauma patients at our institu-
noclavicular joint, or indirect trauma to the
tion include either a significant mechanism of injury
‘All authors: Department of Radiology, Denver Health shoulder girdle. In the setting of blunt chest
Medical Center, 777 Bannock St. Denver, CO 80204. (e.g.. a high-speed motor vehicle collision or a fall
trauma, therefore, the presence of gas in the
Address correspondence to R. M. Patten. from >10 ft [>3 ml) or a clinical suspicion of thoracic
sternoclavicular joints might be a marker for aortic injury (e.g.. a widened mediastinum on chest ra-
AJR 1999;172:1633-1635
significant thoracic or mediastinal injury. The diography). The remaining 131 patients (69 males and
0361-803X/99/1 726-1633 purpose of this study was to evaluate the sig- 62 females) who ranged in age from I yearto 92 years
© American Roentgen Ray Society nificance and frequency ofthe finding ofgas in (mean age, 51 years) underwent chest CT for a variety

AJR:172, June 1999 1633

 Patten et al.

of nontraumatic indications. For all trauma patients. oclavicularjoint gas was seen in 39 (38%) of the clavicular notch of the manubrium, and the car-
the mechanism of injury was recorded as one of the 103 patients sustaining blunt chest trauma but in tilage of the first rib [1]. Because of its bony
following: being in a motor vehicle collision, a = 80: only eight (6%) of the 13 1 nontrauma patients. configuration, this diarthrodial joint is relatively
being in a motorcycle crash, it = 7: falling from a
This difference was highly statistically significant unstable and relies on an intraarticular disk, a
height of more than 10 ft (3 m). n = 6: being struck
(p < .0001). No significant difference in age be- strong capsule, and ligaments to maintain its in-
(pedestrian) by an automobile, n = 5; being crushed.
tween trauma patients with stemoclavicular joint tegrity. When traction is applied to a joint, such
11 = I; and being injured by an unspecified mechanism,
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?l 4. In addition. all radiographically identifiable tho- gas and those with no sternoclavicular joint gas as the sternoclavicular joint, reduced intraartic-
racic were listed. All scans were obtained on a
injuries (mean age for both groups, 38 years) was seen. ular pressure may cause blood gases (primarily
HiSpeed helical scanner (General Electric Medical Similarly, we found no significant difference in nitrogen) to come out of solution, presenting as
Systems, Milwaukee, WI). For trauma patients. imag- age between the nontrauma patients with sterno- a thin, translucent, dark line or a dark space that
ing parameters included 5-mm-thick helical scans clavicular joint gas (mean age, 55 years) and is visible on conventional films 121. This phe-
through the upper and mid chest and 7-mm-thick heli- those without sternoclavicular joint gas (mean nomenon, the “vacuum” phenomenon, has
cal scans through the lower chest and upper abdomen age, 50 years). There were nine trauma patients been described in the spine, hip, knee, and
during administration of a 120-mI bolus of IV contrast
who were less than 21 years old. We did not find shoulder 13-61. Because of the low attenuation
agent (ioversol [Optiray 2401: Mallinckrodt Medical.
sternoclavicularjoint gas in any ofthese patients. values of gas or air, the vacuum phenomenon is
St. Louis, MO) at 2-3 mI/sec with a 30-sec scan delay
In trauma patients with sternoclavicular joint readily identifiable on CT scans and has been
and a pitch of 1.5. Imaging parameters varied accord-
ing to indication (1w the nontrauma patients. Slice
gas, associated thoracic injuries were seen in 17 reported to occur during distraction of the stern-
thickness varied frum 5 to 10 mm, and the use of IV patients (44%); either a sternal fracture or a ret- oclavicularjoint, which sometimes allows visu-
contrast agent was alsj variable. For most of the non- rosternal hematoma was seen in three of these alization of the intraarticular disk [ I J.
trauma patients (76%). helical scans were obtained 17 patients (Fig. 3). Radiographically identifi- Air in the sternoclavicularjoints thus may be
through the chest using a thickness of 7 mm. able thoracic injury was seen in 20 of the a normal incidental finding; it was detected by
All images were obtained with the standard soft- trauma patients (3 1%) without sternoclavicular Goodman et al. 171 on chest CT scans in one
tissue algorithm and were filmed at mediastinal joint gas, but 10 of these patients had either a (4%) of 25 healthy subjects (age, >50 years).
window settings (width. 3OO-4#{128}X
H: level. 30-50 H).
sternal fracture or a retrostemal or mediastinal However, the difl#{232}rentialdiagnosis for intraartic-
Details of lung parenchyma were reconstructed with
hematoma. This difference in percentage of tho- ular gas also includes infection, osteoarthropa-
the lung algorithm and filmed at standard lung win-
racic injuries between the two groups was not thy, osteonecrosis, and calcium pyrophosphate
dow settings (width. 1500-2000 H: level, -5(X) H).
Images through the sternoclavicularjoints were evalu-
statistically significant (p = .2 1 ). No correlation deposition disease [8J. In addition, because the
ated for the presence of linear or bubbly hypodense between the laterality of the sternoclavicular formation of the vacuum phenomenon requires
foci with CT attenuation values comparable with joint gas and the side of bony or thoracic injury traction on the joint, the presence of gas in the
those of air in the lungs. The presence of gas was de- was seen. Similarly, no correlation between the sternoclavicular joints in patients with a history
tected by visual inspection of the hard-copy images type of injury and the presence or absence of of significant blunt chest trauma could signify a
filmed at mediastinal window settings and was con- gas in the sternoclavicularjoints was revealed. distraction-type injury. such as one that might
firmed on lung windows. In equivocal cases, evalua- None of the patients showed evidence of dis- occur from a direct blow to the stemoclavicular
lion of the images on the CT monitor was peiThrmed
location or subluxation of the sternoclavicular joints (transient sternoclavicularjoint dislocation
using region-of-interest of CT numbers
determination
joint. The only trauma patient in our series with or subluxation) or from an indirect force trans-
to detectgas (Fig. I). We applied the Fisher’s exact test
an injury to the thoracic aorta did not show evi- mitted from a clavicle or shoulder injury.
to determine the statistical significance ofour results.
dence ofgas in the sternoclavicular joints. Traumatic dislocations of the posterior sterno-
Results clavicularjoint, although rare, may be associated
We detected the presence of gas in the sterno- Discussion with mediastinal and great vessels injury [9j, and
clavicular joints (Fig. 2) in 47 patients (21 %). The stemoclavicular joint is the only articu- therefore the finding of gas in the sternoclavicu-
Gas was unilateral in 27 patients (right-sided in lation between the trunk and upper extremity, lar joints could be a marker for significant tho-
15 and left-sided in 12) and bilateral in 20. Stern- formed by the medial end of the clavicle, the racic injury. We performed this study to evaluate

Fig. 1-36-year-old man involved in

motor vehicle collision.
A, Chest CT shows right-sided sterno-
clavicular joint gas (arrow). Patient
had multiple rib fractures (notshown).
B, CT scan shows region of interest
(arrow) with attenuation of -397 H,
which is consistent with gas.

1634 AJR:172, June 1999

 CT of the Sternoclavicular Joints

tion to the emergency department and required

lengthy resuscitation before transport to the CT
suite. With such a significant time delay be-
tween the traumatic event and CT scanning, it
is possible that gas present initially at the time
of the traumatic event may have been reab-
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sorbed by the time the CT scan was obtained.

Moreover, five patients with chest and up-
per extremity trauma underwent scanning
with their arms at their sides because they
could not raise their arms above their head in
the CT scanning gantry. None of these pa-
tients showed sternoclavicular joint gas. Be-
cause the vacuum phenomenon can occur in
the sternoclavicular joints with the arms
Fig. 2-48-year-old man with solitary pulmonary nod- Fig. 3-54-year-old man involved in motor vehicle col- raised overhead [I1 presumably some of
ule seen on chest radiograph (not shown). CT scan ob- lision. Paramedics noted bent steering wheel at site of
these trauma patients who would have had
tamed when patient raised arms overhead shows gas crash. Chest CT shows gas in both sternoclavicular
in both sternoclavicular joints (arrows). joints (arrows) and retrosternal hematoma (asterisk). gas in the sternoclavicular joints with their
Gas in right sternoclavicular joint is partially obscured arms overhead did not show sternoclavicular
by streak artifact from dense IV contrast agent joint gas with their arms at their sides.
In summary, we found CT evidence of gas in
the frequency and significance of the finding of found comparable injuries in six trauma pa- the sternoclavicular joints more frequently in
sternoclavicularjoint gas on chest CT. tients without sternoclavicularjoint gas (9%). patients undergoing chest CT for blunt chest
We found CT evidence of gas in the sterno- The presence of gas in the stemoclavicular trauma than in those undergoing chest CT for
clavicularjoints in 6% ofthe patients undergoing joints was not associated with any specific tho- other indications. Although the increased fre-
chest CT for nontraumatic indications, a percent- racic injury; moreover, when present, the lateral- quency of this finding in patients with blunt
age consistent with published data of healthy ity of the gas collection was not a predictor of chest trauma supports the theory that distraction
subjects (age, >50 years) [71. Conversely, of the the side ofthoracic injury. Because we identified injury can be a possible cause of this phenome-
patients examined by CT for blunt chest trauma, only one patient in our series with a thoracic aor- non, the presence of gas in the sternoclavicular
38% had CT evidence ofgas in the sternoclavic- tic tear, we cannot address specifically the rela- joints does not appear to be a marker for signifi-
ularjoints. This statistically significant difference tionship of thoracic aortic injury to the presence cant mediastinal or thoracic injury.
supports the hypothesis that gas in the sterno- or absence of sternoclavicularjoint gas.
clavicular joints may be associated with a dis- Our study has limitations. We did not at-
traction-type force or injury. tempt to correlate the finding of sternoclavicu- References
However, the clinical significance of the lar joint gas to the use of seat belt restraints or I. Destouct JM, Gilula LA. Murphy WA. Sagel SS.
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pear to serve as a marker for severe mediasti- mary emphasis ofour study. In addition, the pa- 2. Fuiks DM, Grayson CE. Vacuum pneumoarthmgra-
phy and the spontaneous occurrence of gas in the joint
nal or thoracic injury. Although a higher tients who had sustained chest trauma were not
spaces. J Bo,,e Joint Surg An, 1950:32-A:933--938
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1983:65-B:428-432
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sternal or retrosternal fracture to support the cally also may have influenced detection rates simulating meniscal or cartilaginous injury of the
theory of transient posterior sternoclavicular for tiny collections of sternoclavicularjoint gas. knee at MR imaging. Radiology 1991:180:513-515
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AJR:172, June 1999 1635