What is the recommended approach for reducing a sternoclavicular (SC) joint dislocation?

Sternoclavicular Joint Dislocation Reduction

For sternoclavicular joint dislocations, anterior dislocations should be managed with closed reduction under sedation in the emergency department, while posterior dislocations require immediate reduction with cardiothoracic surgery consultation due to potential life-threatening complications. 1

Types and Initial Assessment

• Sternoclavicular joint (SCJ) dislocations are classified as anterior (more common) or posterior, with posterior dislocations carrying higher risk of serious complications including injury to the subclavian vessels, trachea, esophagus, and brachial plexus 1, 2
• Patients typically present with shoulder and clavicular pain with decreased active range of motion 1
• Plain radiographs are often inadequate for diagnosis; CT imaging is the recommended diagnostic modality for both confirming the dislocation and evaluating potential complications 1, 2

Reduction Technique for Anterior Dislocations

• Anterior SCJ dislocations should be managed with closed reduction in the emergency department setting 1
• The procedure requires adequate analgesia and sedation to achieve muscle relaxation 1, 3
• Reduction technique:
  • Position the patient supine with a rolled towel or sandbag between the scapulae 2
  • Apply direct pressure over the medial clavicle while abducting and extending the ipsilateral arm 1, 2
  • A distinct "clunk" may be felt when reduction is achieved 2
• Success rates for closed reduction of anterior dislocations are approximately 50%, with higher success when performed within 48 hours of injury 3
• Post-reduction immobilization with a figure-of-eight bandage or sling for 4-6 weeks is recommended 2

Management of Posterior Dislocations

• Posterior dislocations require more urgent attention due to potential life-threatening complications 1, 2
• If the patient shows signs of airway, hemodynamic, or vascular compromise, emergent reduction is indicated 1
• Reduction technique for posterior dislocations:
  • Position the patient supine with a sandbag between the scapulae 2
  • Apply traction to the abducted arm (30°) with extension 2, 3
  • If closed reduction fails or is not possible, immediate open reduction is necessary 1, 3
• Cardiothoracic surgery consultation is essential for posterior dislocations due to proximity to vital mediastinal structures 1
• Post-reduction CT scan is mandatory to confirm adequate reduction and assess for any remaining complications 3

Surgical Management

• Indications for surgical management include:
  • Failed closed reduction 3
  • Unstable reduction with recurrent dislocation 2
  • Epiphyseal disruptions (which have a higher failure rate with closed reduction) 3
  • Chronic dislocations 2
• Surgical stabilization techniques include:
  • Costoclavicular cerclage or tenodesis 3
  • Figure-of-eight reconstruction using autograft or allograft 2
  • Avoid using Kirschner wires due to risk of migration 3
• Functional outcomes are significantly better when stabilization procedures are performed rather than reduction alone 3

Important Considerations and Pitfalls

• Delayed diagnosis is common due to the rarity of the injury and limitations of standard radiography 1, 2
• Always obtain post-reduction CT imaging to confirm adequate reduction and rule out complications 3
• Epiphyseal disruptions with posterior displacement should be treated surgically as closed reduction typically fails in these cases 3
• Monitor for potential complications including pneumothorax, vascular injury, and neurologic compromise, especially with posterior dislocations 1
• Reduction attempts should ideally be performed within 48 hours of injury for better outcomes 3