How should a sternoclavicular dislocation be diagnosed and managed?

Sternoclavicular Dislocation: Diagnosis and Management

Immediate Diagnostic Approach

CT scan is the imaging modality of choice for diagnosing sternoclavicular dislocation and must be obtained to determine the direction of dislocation and assess for life-threatening mediastinal complications 1, 2. Plain radiographs are inadequate and frequently miss this injury 1.

Clinical Presentation to Recognize

• Shoulder and clavicular pain with decreased active range of motion 1
• For anterior dislocation: Visible/palpable prominence of the medial clavicle
• For posterior dislocation: Medial clavicle NOT palpable in its normal position 3
• Assess immediately for signs of vascular compromise, respiratory distress, or dysphagia (posterior dislocations only)

Imaging Algorithm

1. Point-of-care ultrasound can aid rapid bedside diagnosis 3
2. CT scan (without contrast initially) is mandatory for:
   • Confirming diagnosis
   • Determining anterior vs. posterior direction
   • Evaluating proximity to mediastinal structures (subclavian vessels, trachea, esophagus, brachial plexus)
   • Identifying associated fractures 1, 2

Management Based on Dislocation Type

Anterior Sternoclavicular Dislocation

Closed reduction with analgesia and sedation in the emergency department is the primary treatment 1, 4.

Key Management Points:

• Acceptable for low-demand patients despite high recurrence rates 4
• Physical therapy following reduction
• Surgical intervention indicated for:
  • Persistently symptomatic recurrent dislocations 4
  • High-demand patients (athletes) - consider robust techniques like suture repair with internal brace or hamstring tendon autografts 4
  • Patients with poor bone quality - may require plating techniques 4
  • Associated fractures 1

All anterior dislocations with fracture require emergent orthopedic consultation 1.

Posterior Sternoclavicular Dislocation

This is a surgical emergency requiring immediate action 1, 5, 2.

Immediate Management Protocol:

1. If airway, hemodynamic, or vascular compromise present: Emergent closed reduction under analgosedation with cardiothoracic surgery on standby 1, 2
2. Attempt closed reduction under general anesthesia for acute injuries without immediate life threat 2, 3
3. If closed reduction fails or diagnosis is delayed: Open reduction and internal fixation required 2, 3

Critical Consultation Requirements:

• ALL posterior dislocations require emergent orthopedic consultation 1
• Cardiothoracic or vascular surgery notification for complicated cases 1
• Note: Recent data suggests vascular injury occurs in only 1.2% of pediatric cases and exclusively with polytrauma, though current guidelines still recommend cardiothoracic standby 6

Surgical Techniques When Indicated

• Arthrodesis with suture cerclage shows good results 7
• Tendon grafts and specialized hook plates increasingly used for better biomechanical stability 7
• Locking plates for open reduction and internal fixation 7
• Figure-of-eight suture fixation 3

Critical Pitfalls to Avoid

1. Do not rely on plain radiographs alone - they frequently miss sternoclavicular dislocations 1
2. Do not delay CT imaging when sternoclavicular injury is suspected
3. Do not miss posterior dislocations - absence of palpable medial clavicle is the key physical finding 3
4. Do not attempt reduction of posterior dislocation without emergency backup due to risk of pneumothorax and vascular injury 1, 5
5. Do not discharge patients with posterior dislocation without surgical consultation - these require admission and specialist management 1

Prognosis

With early diagnosis and appropriate treatment, long-term outcomes are consistently positive 2, 7. Pediatric patients achieve full range of motion quickly with appropriate treatment and physiotherapy 3.