What is the management of sternoclavicular (SC) joint anterior dislocation in the emergency department?

Emergency Department Management of Anterior Sternoclavicular Joint Dislocation

Anterior sternoclavicular joint dislocations should be managed in the emergency department with analgesia, procedural sedation, and closed reduction, followed by immobilization and orthopedic consultation for complicated cases. 1

Initial Assessment and Diagnosis

Clinical Presentation

• Patients typically present with shoulder and clavicular pain with decreased active range of motion 1
• Examine the sternoclavicular joint specifically in all patients with shoulder symptoms following trauma 1
• Assess for visible or palpable anterior prominence of the medial clavicle 2

Imaging

• Plain radiographs are inadequate and often miss the diagnosis 1
• CT imaging is the diagnostic modality of choice for both confirming the dislocation and evaluating for complications 1, 2
• CT allows visualization of dislocation direction (anterior vs posterior) which is critical for treatment planning 2

Emergency Department Treatment Algorithm

Uncomplicated Anterior Dislocation

1. Provide adequate analgesia - use simple analgesics like paracetamol regularly unless contraindicated 3
2. Administer procedural sedation for closed reduction 1
3. Perform closed reduction using manipulative technique:
   • Apply traction to the affected shoulder with the patient supine 4
   • Direct pressure may be applied to reduce the anteriorly displaced clavicle 4
4. Immobilize after reduction with a reverse figure-8 bandage or similar device 4
5. Obtain post-reduction imaging to confirm successful reduction 4

Complicated Anterior Dislocation

• Obtain emergent orthopedic consultation for any anterior dislocation with associated fracture 1
• Consider surgical intervention if closed reduction fails or recurrence occurs 5

Critical Pitfalls to Avoid

Misdiagnosis Risk

• Do not rely on plain radiographs alone - they frequently fail to identify sternoclavicular dislocations 1
• Maintain high clinical suspicion in traumatic shoulder injuries even with normal initial imaging 1

Distinguishing Anterior from Posterior

• Always obtain CT imaging before reduction attempts to definitively determine dislocation direction 1, 2
• Posterior dislocations are life-threatening and require different management (cardiothoracic consultation, potential for emergent vascular/airway compromise) 1, 2
• Never assume direction based on mechanism alone 2

Disposition and Follow-up

Consultation Requirements

• Orthopedic consultation is mandatory for all sternoclavicular dislocations 1
• Consider cardiothoracic or vascular surgery notification for any complicated case 1

Expected Outcomes

• Successful closed reduction typically provides dramatic and instantaneous pain relief 4
• Recurrence after closed reduction may occur and necessitates surgical reconstruction 5
• Functional outcomes are generally good with appropriate treatment at 2-year follow-up 6