Sternoclavicular Joint Injury Treatment & Management

• Depending upon the mechanism of injury (eg, motor vehicle crash) and the close proximity of the sternum and clavicle to the vital structures of the neck and chest, patients with sternoclavicular joint injuries (SJIs) may incur severe and life-threatening additional injuries.
• Foremost, address the ABCs during prehospital care, with rapid transport to an appropriate trauma care facility.
• For patients with seemingly isolated SJI, immobilization of the affected upper extremity with a sling stabilizes the joint and minimizes pain.

Patients with posterior SCJ dislocations frequently (up to 25% of the time) sustain associated serious injuries that take treatment precedence over the dislocation.

Sprains of the SCJ require only symptomatic treatment (ie, immobilization with a sling, ice for 24-48 h, analgesics, and anti-inflammatory medications).

Acute anterior dislocations usually can be treated nonoperatively, but interposition of the joint capsule or the ligaments can make the joint irreducible. Additionally, maintaining reduction of anterior dislocations often is difficult.^[8] If indicated, carry out closed reduction of an anterior dislocation as follows:

• Place the patient in a supine position on the stretcher.
• Place a 3- to 4-inch thick bolster (rolled sheet or sandbag) between the scapula and spine (to help separate the clavicle from the manubrium).
• Have an assistant abduct (to 90°) and extend (10-15°) the shoulder on the affected side and apply traction.
• If reduction does not occur, apply pressure to the medial clavicle in a posterior and inferior direction.
• Treatment options for recurrent/unreduced anterior SCJ dislocations may include open reduction and internal fixation, or acceptance of some degree of permanent instability, depending on the patient's characteristics and functionality.
• Closed reduction with conscious sedation or general anesthesia, while the preferred initial treatment, may not be possible. Because of potential associated vascular injury, the operating room may be the more appropriate setting for reduction.

Acute posterior dislocations are a more serious injury because of their association with vascular injuries to the intrathoracic and superior mediastinal structures and are typically reduced in an operating room with the patient under general anesthesia.^[9] The treatment of associated injuries and/or complications may take priority over the SCJ dislocation. Emergent closed reduction of a posterior dislocation is as follows^[10] :

• Place the patient in a supine position on the stretcher.
• Place a 3- to 4-inch thick bolster (rolled sheet or sandbag) between the scapula and spine (to help separate the clavicle from the manubrium).
• Abduct (90°) and extend (10-15°) the shoulder on the affected side and apply traction to the arm as an assistant applies countertraction to the trunk.
• If traction fails to reduce the dislocation, pull the medial clavicle forward while an assistant maintains traction and an abduction force on the affected limb.
• In situations in which the clavicle cannot adequately be grasped by the fingers, use a towel clip to grip the clavicle (after sterile preparation of the skin) and pull forward.
• Treatment options for unreduced posterior SCJ dislocations may include open reduction and internal fixation, or acceptance of some degree of permanent instability, depending on the patient's characteristics and functionality. Open operative intervention must be considered for unstable fractures, irreducible fractures, or late presentations of displaced posterior fractures. Proposed fixation techniques include use of Kirschner wires, plates and suture wires. When performed by an experienced surgeon, mediastinal structures can be safely avoided during surgical stabilization and repair of posteriorly displaced physeal fractures of the medial clavicle.
• An alternative technique to prepare for reduction of a posterior SCJ dislocation (proposed by Buckerfield and Castle) suggests caudal traction accompanying adduction of the affected arm, along with downward pressure on both shoulders.
• Closed reduction attempts for posterior SCJ dislocations may fail or may be associated with complications such as injury to the adjacent mediastinal structures.
• Closed reduction may be unsuccessful or not attempted, depending on the age and activity level of the patient. In such patients, an immobilizing sling, analgesics, and anti-inflammatory agents may be used for symptomatic relief.

• Consult an orthopedic surgeon for reduction and possible operative stabilization of posterior dislocations.
• Suspicion of tracheal disruption or mediastinal damage secondary to a posterior dislocation necessitates evaluation by a capable thoracic surgeon.