Emergency Department Care
Patients with posterior SCJ dislocations frequently sustain associated potentially serious injuries that may take treatment precedence over the dislocation. [12] Sprains of the SCJ require only symptomatic treatment (eg, immobilization with a sling, ice for 24-48 hr, analgesics, and anti-inflammatory medications).
Reductions performed in the ED require stabilization of the affected shoulder with a soft figure-of-eight dressing, a commercial clavicular harness, or secure sling. Maintain immobilization for at least 4 weeks. [13, 14]
Anterior
In one study, nonoperative repair for treatment of acute anterior dislocations resulted in good to excellent results in 69% of patients. [29] Interposition of the joint capsule or the ligaments can make the joint irreducible, and maintenance of reduction can be problematic. [30] Once the diagnosis is made, prompt treatment is indicated, since functional outcomes are significantly improved for acute over chronic dislocations. If indicated, carry out closed reduction of an anterior dislocation as follows [31] :
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Place the patient in a supine position on the stretcher.
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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).
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Have an assistant abduct (to 90°) and extend (10-15°) the shoulder on the affected side and apply traction.
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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 is the preferred initial treatment, but it may not be possible or necessary on an emergent basis. Because of potential associated vascular injury, the operating room may be the more appropriate setting for reduction.
Posterior
Acute posterior dislocations are a more serious injury because of their potential association with other injuries, with symptoms of mediastinal compression present in up to 30%. In one study, closed reduction, with subsequent open reduction after a failed closed attempt, resulted in good to excellent results in 96% of patients. [29] Additional imaging may be necessitated to evaluate the presence of other injuries, and appropriate consultation with additional specialties may be indicated.
Once the diagnosis is made, prompt treatment is indicated because functional outcomes are significantly improved for acute over chronic dislocations. 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: [32]
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Place the patient in a supine position on the stretcher.
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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).
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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.
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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.
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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, and repair of posteriorly displaced physeal fractures of the medial clavicle.
An alternative technique 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.
In a study of skeletally immature patients (12 boys; mean age, 14.8±2.74 yr) with sternoclavicular injuries with posterior displacement, medial clavicular physeal fractures and sternoclavicular dislocations were effectively managed with closed or open reduction. Of the 12 patients, 8 were initially treated with closed reduction, 2 successfully and 6 requiring subsequent open reduction. Four of the 12 patients underwent an immediate open reduction. [33]
In another study, of the 140 adolescent patients (12-18 yr; mean, 15.24 yr) with posterior sternoclavicular joint injuries, 49 patients (35%) underwent closed treatment only, 42 (30%) open treatment alone, and 47 (33.57%) closed treatment followed by open treatment. Additionally, 55.8% of closed reductions performed within 48 hours were successful, as compared to 30.8% of those performed more than 48 hours after injury. [34]
Inpatient admission may be necessary for patients with posterior SCJ dislocations or for patients in need of treatment of associated injuries.
Patients thought to have sustained additional significant injuries may require transfer to an advanced facility, such as a trauma center.
Issues of patient stability and transfer benefit are best addressed based on the clinical setting and available resources.
Patients with posterior SCJ dislocation and/or potential complications may benefit from transfer to a facility with thoracic, vascular, orthopedic or other specialty consultation services.
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This 80-year-old woman presented 1 week after a fall because of persistent pain and discoloration in the anterior part of her chest. Certain movements of her right arm were especially painful though not incapacitating. Note the extensive ecchymosis of the anterior part of her thorax and the swelling of the right upper parasternal/lower anterior neck area. The right sternoclavicular joint area was tender and edematous to palpation.
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Superior mediastinal contents may be threatened in posterior dislocations of the sternoclavicular joint.
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CT scan of a left sternoclavicular dislocation demonstrates anterior and superior displacement of the clavicle from its normal articulation with the manubrium. The right sternoclavicular joint is normal.
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CT scan of a left sternoclavicular dislocation demonstrates anterior and superior displacement of the clavicle from its normal articulation with the manubrium. The right sternoclavicular joint is normal.
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CT scan of a left sternoclavicular dislocation demonstrates anterior and superior displacement of the clavicle from its normal articulation with the manubrium. The right sternoclavicular joint is normal.
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The right sternoclavicular joint appears edematous on lateral inspection. Palpation confirms the apparent anterior dislocation.
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Comparison of the normal left sternoclavicular joint emphasizes the abnormalities.
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The patient refused further workup and treatment beyond a temporary sling, stating that the injury had not significantly affected her lifestyle. She was discharged home in the company of her daughter with over-the-counter analgesics.
