Chapter 80. Sternoclavicular Joint Dislocation Reduction

Sternoclavicular dislocations are uncommon injuries and account for less than 3% of shoulder girdle dislocations.1 The medial clavicle may be displaced anteriorly or posteriorly. Anterior dislocations are more common by a ratio of 3:1 to 20:1.2,3 Case reports of the less common posterior dislocations are more common in the literature due to the higher incidence of associated complications. Posterior sternoclavicular joint dislocations are often seen in younger individuals.2,4

Sternoclavicular dislocations are the result of direct trauma to the sternoclavicular joint or to the glenohumeral joint with the force directed toward the sternoclavicular joint. This injury is usually associated with a tremendous force. The most commonly reported mechanisms of injury are motor vehicle collisions and contact sports.2,5 Anterior dislocations are often due to indirect forces transmitted through the anteromedial shoulder. As the shoulder is externally compressed and rolled backward, the lateral clavicle is pulled back and down beyond its limit of motion. The first rib acts as a fulcrum to spring the sternal end of the clavicle anteriorly from its articulation.2,6

Posterior dislocations may be due to direct or indirect forces.3,4,7–13 With indirect trauma, the shoulder is externally compressed and rolled forward from a posterolaterally applied force to the shoulder. The costoclavicular ligament acts as a fulcrum that produces displacement of the sternal end of the clavicle posteriorly from its articulation.4,9,11,13 Less commonly, a posterior dislocation may be due to a direct blow to the anteromedial clavicle.

There are reports of spontaneous and nontraumatic sternoclavicular subluxations and dislocations.14 These are usually seen in females less than 20 years of age with sternoclavicular joint laxity. The clavicle dislocates anteriorly during abduction or flexion of the arm to the overhead position. The clavicle reduces spontaneously when the arm is returned to the side. This condition is usually associated with laxity in numerous other joints.

The sternoclavicular joint is a diarthrodial joint with both surfaces covered by fibrocartilage (Figure 80-1). The intraarticular disk ligament divides the joint into two separate compartments, each of which is lined with synovium.15 This joint is freely movable and functions almost like a ball-and-socket joint in that it has motion, including rotation, in almost all planes.3,6,16 This includes 30° to 35° of upward elevation, 35° of combined forward/backward movement, and 40° to 45° of rotation about its long axis.3,6,16 Less than half of the medial clavicle articulates with the upper angle of the sternum. This gives the sternoclavicular joint the distinction of having the least amount of bony stability of any of the major joints.3 Given this amount of joint incongruity, it is surprising that sternoclavicular joint dislocations are uncommon. However, its stability comes from strong surrounding ligaments (Figure 80-1). These ligaments include the intraarticular disk ligament, the extraarticular costoclavicular ligament (rhomboid ligament), the anterior and posterior sternoclavicular ligaments, and the interclavicular ligament.15

The region that lies directly posterior to the sternoclavicular joint contains numerous vital structures (Figure 80-2). Within the confines of the thoracic inlet are the trachea, esophagus, lungs, and great vessels. This proximity, and the small size of the thoracic inlet, accounts for the injuries that may occur to these structures with posterior sternoclavicular joint dislocations.

The medial clavicular epiphysis is the last epiphysis of the long bones to appear. It usually ossifies by the age of 18 to 20 and occasionally not until the age of 25.3,17 It is also the last to fuse.3,17 This epiphysis is difficult to see on plain radiographs. Many injuries in patients under 25 years of age that are initially felt to be sternoclavicular joint dislocations are actually Salter I or II epiphyseal injuries.3,10,18–23

The diagnosis of a traumatic sternoclavicular joint dislocation may be difficult and delayed. This is particularly true in the patient with multiple injuries.7,24,25 Symptoms include severe pain that increases with movement of the ipsilateral arm. Physical signs include edema and ecchymosis over the region of the sternoclavicular joint. The patient usually holds the injured arm adducted across the trunk. Their head may be tilted toward the affected side to relieve the pain caused by traction of the sternocleidomastoid muscle on the medial clavicle. With anterior dislocations, the medial end of the clavicle may be palpated anterior to the sternum. It may also be fixed or mobile. A visible depression may be noted or a hollow palpated at the location of the sternoclavicular joint with posterior sternoclavicular joint dislocations. However, accompanying edema may obscure these physical findings. The shoulder may be held forward. When the patient is supine, the affected shoulder does not lie flat against the bed.

Additional signs and symptoms associated with a posterior sternoclavicular joint dislocation may also be due to injury or compression of mediastinal structures.3,4,7,9,11–13,18,25–32 It is extremely important to perform a careful and complete physical examination, as associated injuries are common. Compression of the trachea or esophagus may result in cyanosis, dyspnea, or dysphagia. Circulation to the ipsilateral arm may be reduced if the subclavian artery is compressed. Venous congestion of the upper extremity or neck can result from compression of the subclavian or jugular veins. The patient may present in shock due to compression or injury to the retrosternal great vessels. Paresthesias of the upper extremity are due to a brachial plexus injury. Voice changes are due to compression of the recurrent laryngeal nerve. Tracheal or lung injuries can result in pneumothoraces.

The clinician cannot always rely on the clinical findings of observation and palpation to distinguish between anterior and posterior sternoclavicular joint dislocations.3 Documentation with appropriate radiologic studies is recommended prior to the decision to treat. Routine radiographs of the sternoclavicular joint are often difficult to interpret due to overlapping structures. Several different radiographic projections have been reported to improve the ability to demonstrate asymmetry of the joints.3,8,9,33 Computed tomography (CT) is the preferred imaging modality to study the sternoclavicular joint. It should always be performed if the diagnosis is uncertain.9,10 The use of ultrasound to aid in the diagnosis has also been reported.12,34

With posterior sternoclavicular joint dislocations, the Emergency Physician should also consider appropriate studies to rule out associated injuries to neighboring structures. This could include a chest radiograph, which may reveal mediastinal widening, a pneumomediastinum, or a pneumothorax. CT will reveal the relationship of the clavicle to the great vessels, esophagus, and trachea. It may also demonstrate compression of these structures, a mediastinal hematoma, or mediastinal emphysema. Angiography, venography, and Doppler studies may be considered to investigate potential vascular injury. Esophagoscopy and/or an esophagram may be employed to evaluate the esophagus. Bronchoscopy is indicated if a tracheal or bronchial injury is suspected.

It is generally held that closed reduction should be attempted on all acute traumatic anterior and posterior sternoclavicular joint dislocations.3,10,27 Anterior sternoclavicular joint dislocations have been reduced via closed techniques up to 10 days postinjury.9 Successful closed reduction of posterior sternoclavicular joint dislocations has been reported up to 5 days postinjury.12,27 Posterior sternoclavicular joint dislocations are uncommon injuries. Early consultation with an Orthopedic Surgeon is recommended. Careful evaluation of the patient's airway, breathing, and circulation should be performed prior to the reduction. It is recommended that the reduction be performed where staff and facilities are immediately available to intervene should any thoracic emergency develop.25 The dislocation should be reduced emergently if neurologic or vascular compromise exists in the affected extremity.

Many of these injuries are in fact Salter–Harris I or II epiphyseal injuries in patients less than 25 years of age.3,10,18–23 Closed reduction should still be attempted after consultation with an Orthopedic Surgeon.

Reduction may be postponed to attend to more serious injuries unless a posterior sternoclavicular joint dislocation is present and is compromising adjacent structures. Open reduction of posterior sternoclavicular joint dislocations may be preferred if surgery is planned for associated injuries.

Attempted reduction of chronic traumatic anterior dislocations or spontaneous anterior dislocations is not indicated.41 These patients usually have minimal discomfort, normal range of motion, and can return to normal activity.3,14 Patients do well without treatment other than nonsteroidal anti-inflammatory drugs, the application of heat, and rest.2,14,35 The results of operative treatment of such injuries have not been impressive.3,14

There is controversy regarding the necessity of reducing chronic posterior sternoclavicular joint dislocations. Some feel that all should be reduced due to the potential compression of adjacent structures or erosion into them.3,28,36,37 However, there have been reports of patients who have chronic dislocations without sequelae.6 Treatment decisions for such injuries should be made in consultation with an Orthopedic Surgeon. Reduction would require general anesthesia and operative intervention.35

• Sandbags or folded towels
• Povidone iodine or chlorhexidine solution
• Sterile towel clamps
• Sterile gloves
• Local anesthetic solution
• 18 gauge needles
• 25 gauge needles
• 10 mL syringe

Explain the risks, benefits, potential complications, and aftercare of the procedure to the patient and/or their representative. Obtain a signed consent to perform the reduction.

Place the patient supine with the affected side near the edge of the gurney. Place sandbags or towels between the patient's scapulae. They should be thick enough to raise the patient 5 cm off the gurney.4

A form of anesthesia and analgesia is required to reduce a sternoclavicular joint dislocation. Closed reduction of anterior sternoclavicular joint dislocations may be performed with local anesthetic solution infiltrated about the medial clavicle and sternoclavicular joint. Consider the administration of supplementary intravenous sedation or procedural sedation. Posterior sternoclavicular joint dislocations have also been reduced using local anesthesia. However, procedural sedation or general anesthesia is recommended. Infiltrate local anesthetic solution about the medial clavicle and sternoclavicular joint if procedural sedation will be performed.

Anterior Sternoclavicular Joint Dislocation Reduction

Position the patient as mentioned above. The patient's arms should be at their sides (Figure 80-3A). Apply analgesia and sedation. Instruct an assistant to apply downward pressure to the anterior surface of both shoulders (Figure 80-3B). Pushing the shoulders posteriorly pulls the clavicles laterally and distracts the dislocated medial clavicle. Push the medial clavicle posteriorly and into anatomic position (Figure 80-3C). Relocation of the clavicle usually occurs promptly. Carefully sit the patient upright while the assistant maintains the shoulders in a posterior position. Apply a figure-of-eight splint (Figure 90-3C).

Posterior Sternoclavicular Joint Dislocation Reduction

Position the patient as mentioned previously. Apply analgesia and sedation. Abduct the affected extremity 90° and extend it 20° in line with the clavicle (Figure 80-4A). Spontaneous reduction may occur at this point. If not, instruct an assistant to apply distal inline traction to the extremity (Figure 80-4B). This may be aided by wrapping a sheet about the patient's upper torso to provide countertraction. The clavicle may reduce under traction. Keep the patient's arm abducted, extended, and under traction if the sternoclavicular joint does not reduce. Manually manipulate the clavicle into position. Grasp the medial clavicle and pull it upward into anatomic position (Figure 80-4C).

It may be difficult at times to achieve a secure grasp on the medial clavicle. In such cases, clean the skin surrounding the medial clavicle of any dirt and debris. Apply povidone iodine or chlorhexidine solution and allow it to dry. Grasp through the skin and around (not through) the shaft of the medial clavicle with a towel clamp (Figure 80-4D). The thick cortical bone often prevents purchase of the towel clamp into the clavicle. Ensure that the towel clamp follows the contours of the clavicle when applying it. Grasping too deep can result in injury to the subclavian artery and/or vein. Elevate the medial clavicle into anatomic position while the assistant is maintaining traction on the abducted and extended extremity (Figure 80-4D).

An alternative technique may be applied to reduce a posterior sternoclavicular joint dislocation.4 It uses the first rib as a lever and has been reported to be successful when the previous technique has failed. Position the patient with their arms adducted (Figure 80-5A). Apply analgesia and sedation. Instruct an assistant to apply distal in-line traction to the adducted arm (Figure 80-5B). This will lever the medial clavicle over the first rib and above the superior sternum (Figure 80-5B, inset). Apply downward pressure to the anterior shoulder, forcing it into retraction (Figure 80-5C). This will lever the medial clavicle anteriorly and laterally into anatomic position (Figure 80-5C, inset). Reduction may occur at this point. If not, elevate the medial clavicle either by manual grasp or using a towel clamp, as described previously. It is postulated that this technique requires less force than the prior technique. A variation of this technique involves applying lateral traction to the upper humerus using a sheet looped around the upper arm.38

Other methods of closed reduction for a posterior sternoclavicular joint dislocation have been described but are not often performed. Successful reduction has been described using 4.5 kg (10 pounds) of lateral skin traction on the abducted arm for 30 minutes.39 Reduction has also been achieved by simple forced retraction of the lateral clavicle.8 Reduction has been reported in a sedated patient who was placed for 8 hours on rolled towels between the scapulae.13

Assess all patients, both initially and following any reduction attempts, for neurologic and vascular integrity of the upper extremity. Obtain postreduction radiographs to confirm proper bony positioning. The procedure may be repeated if the radiographs show incomplete reduction. Positioning is not critical if the reduction was performed for neurologic or vascular compromise. The primary consideration is the relief of the compromised nerve and/or artery. The Orthopedic Surgeon can later reduce the defect that remains.

The general principles of orthopedic care should be applied. These include rest, ice, nonsteroidal anti-inflammatory drugs, and supplemental narcotic analgesics.

Anterior Sternoclavicular Joint Dislocations

The sternoclavicular joint is often unstable following reduction. These injuries require splinting to maintain the normal anatomic relationships and allow ligamentous healing. This is best accomplished with a figure-of-eight splint (Figure 90-3C). Unfortunately, patients do not often tolerate this splint. Alternatives include a sling, sling and swath, or a sling and Velpeau dressing (Figures 90-3A & B). Apply one of the above splints if the medial clavicle will not remain reduced. Orthopedic follow-up should be scheduled within 5 to 7 days of the reduction.

Posterior Sternoclavicular Joint Dislocations

The sternoclavicular joint is usually stable following reduction. The splinting and follow-up are the same as with an anterior sternoclavicular joint dislocation.

Anterior Sternoclavicular Joint Dislocations

Complications of the reduction are relatively minor. The sternoclavicular joint is usually unstable postreduction and often dislocates spontaneously. This should be explained to the patient prior to attempted reduction. A “cosmetic bump” can remain if reduction is not maintained. Occasionally, these patients will continue to have persistent pain.3

Posterior Sternoclavicular Joint Dislocations

Most complications result from the original injury and are due to compression or injury of neighboring structures. The incidence of associated injuries is reported to be 25%.25 Death secondary to these complications has been reported.31,40

Complications of the reduction include pain, incomplete reduction, subclavian vessel injury, and brachial plexus injury. A higher incidence of injury to the subclavian vessels may be seen if a towel clamp is used in the reduction. The reduction of a posterior dislocation can result in an anterior subluxation or dislocation.42 This conversion of a posterior to anterior dislocation during reduction should not be reduced as it may resolve spontaneously or require open management.

Sternoclavicular joint dislocations are uncommon injuries. They are usually due to high-impact forces from motor vehicle collisions or contact sports. Anterior sternoclavicular joint dislocations are easily reduced but often do not maintain reduction. However, patients tend to do well with persistent dislocations. Posterior sternoclavicular joint dislocations are even less common. The Emergency Physician should be aware of the high incidence of associated injuries. These dislocations tend to be stable after reduction.