What is the recommended reduction technique for posterior sternoclavicular dislocation?

Posterior Sternoclavicular Dislocation Reduction Technique

The recommended reduction technique for posterior sternoclavicular dislocation is closed reduction under general anesthesia with the patient in supine position, using abduction of the arm with posterior traction on the shoulder while applying direct anterior pressure on the medial clavicle. 1

Diagnosis and Pre-Reduction Assessment

• Posterior sternoclavicular dislocations are rare but potentially life-threatening injuries due to the proximity of vital mediastinal structures 1, 2
• Initial radiographs may be negative or inconclusive; CT imaging is essential for accurate diagnosis and preoperative planning 1, 3
• CT angiography should be performed to assess the proximity to underlying vascular structures, particularly the innominate vein, and to identify any bleeding 4

Closed Reduction Technique

• Patient should be placed under general anesthesia to achieve adequate muscle relaxation 1
• Position the patient supine with a rolled towel or sandbag between the scapulae 1
• The reduction maneuver consists of:
  • Abduction of the affected arm to 90 degrees 1
  • Application of posterior traction on the shoulder 1
  • Simultaneous direct anterior pressure on the medial clavicle 1
• Success rates for closed reduction are high when performed within 48 hours of injury, and can be attempted up to 10 days post-injury 4

Important Safety Considerations

• All reduction attempts should be performed in the presence of a cardiothoracic surgeon who can gain vascular control in case of hemorrhage 4
• A multidisciplinary approach involving orthopedic and cardiothoracic surgeons is recommended due to the risk of serious vascular complications 4
• Pre-emptive discussion and rehearsal for managing potential intra-operative bleeding should be undertaken with the entire surgical team 4

Post-Reduction Management

• Post-reduction CT scan should be performed to confirm adequate reduction 1
• Immobilization in a figure-of-eight bandage or shoulder immobilizer for 4-6 weeks is typically recommended 1

When to Consider Open Reduction

• Failed closed reduction 5
• Irreducible dislocations 5
• Redislocation after closed reduction 5
• Delayed presentation with callus formation (>10 days) 4

Open Reduction Techniques

• When open reduction is necessary, stabilization can be achieved using:
  • Large-bore cannulated screws (minimizes risk of hardware migration compared to pins and wires) 5
  • Tunnelled suture fixation for physeal fractures 4
  • Palmaris graft with internal figure-of-eight bracing (preferred method for reconstruction) 4

Complications to Monitor

• Massive hemorrhage can occur during reduction maneuvers and drilling 4
• Potential for injury to mediastinal structures including trachea, esophagus, and major vessels 2
• Post-reduction symptoms may include globus sensation and voice changes in some patients 4
• Fracture of the medial clavicle around drill holes has been reported as a complication of open reduction 4