Management and Treatment of Sternoclavicular Dislocation
The management of sternoclavicular dislocation (SCD) should be based on the direction of dislocation, with anterior dislocations typically managed with closed reduction while posterior dislocations require more urgent intervention due to potential life-threatening complications.
Classification and Initial Assessment
- SCDs are classified as anterior (more common) or posterior (more dangerous) based on the direction of clavicular displacement relative to the sternum 1
- Posterior dislocations carry significant risk of injury to vital structures including subclavian vessels, trachea, esophagus, and brachial plexus 1
- Patients typically present with shoulder and clavicular pain with decreased active range of motion 1
- Plain radiographs often miss SCDs; computed tomography (CT) is recommended for both diagnosis and evaluation of potential complications 1
Management of Anterior Sternoclavicular Dislocation
Acute Management
- First-line treatment for acute anterior SCD is closed reduction under anesthesia 2
- Closed reduction should be performed in the emergency department with appropriate analgesia and sedation 1
- The procedure involves placing the patient supine with a rolled towel between the scapulae, then applying posterior pressure on the medial clavicle while the arm is abducted and extended 1
Management of Failed Closed Reduction
- If closed reduction fails or if recurrent instability develops, surgical intervention may be necessary 2, 3
- Surgical options include:
- Open reduction and internal fixation
- Ligament reconstruction using soft tissue grafts 3
Surgical Technique for Anterior SCD
- Reconstruction using autograft hamstring tendon woven in a figure-of-eight (Roman numeral X) pattern through bone tunnels in the clavicle and sternum has shown good outcomes 3
- This technique has demonstrated full range of motion restoration and return to preoperative activities in most patients 3
Management of Posterior Sternoclavicular Dislocation
Emergency Management
- Posterior SCDs require urgent assessment and management due to potential life-threatening complications 1
- If airway, hemodynamic, or vascular compromise is present, emergent reduction is indicated with immediate cardiothoracic surgery consultation 1
- All posterior SCDs require orthopedic consultation, with consideration for cardiothoracic or vascular surgery notification 1
Reduction Technique
- Closed reduction for posterior SCD should be performed under general anesthesia with thoracic surgery backup available 4
- The technique involves placing the patient supine with a sandbag between the scapulae, then applying traction to the abducted arm with lateral and anterior pressure on the affected shoulder 4
- If closed reduction fails, open reduction is indicated 1
Post-Reduction Management
- After successful reduction, immobilization is recommended to prevent recurrence 1
- Appropriate catheter stabilization is important to prevent dislocation of central venous catheters, which can be achieved using manufactured catheter stabilization devices rather than stitches 5
- For anterior SCDs, patients may return to normal activities within 4-6 weeks if stability is maintained 4
- For posterior SCDs, a longer period of immobilization and more cautious return to activities may be necessary 1
Special Considerations
- In athletes, particularly those in contact sports, return to play should be carefully managed 4
- Professional athletes with properly treated posterior SCDs have been able to return to competition within 5 weeks of injury 4
- Recurrent instability may develop in some patients, requiring surgical reconstruction 3
- The surgical reconstruction technique using soft-tissue grafts has shown good outcomes with improved functional scores and return to preoperative activities 3