Posterior Sternoclavicular Joint Dislocation: Reduction, Risks, and Recovery

How do you reduce a posterior sternoclavicular joint?

Reducing a posterior sternoclavicular (SC) joint dislocation is a complex medical procedure that must be performed by trained healthcare professionals due to the significant risks involved. It typically involves specific maneuvers to reposition the clavicle, often under sedation or anesthesia, and may require surgical intervention in some cases.

Understanding the Sternoclavicular Joint

The sternoclavicular (SC) joint is a crucial articulation connecting the upper limb to the axial skeleton. It is formed by the medial end of the clavicle (collarbone) and the manubrium of the sternum (breastbone), along with a small portion of the first costal cartilage.

• Anatomy and Function: Despite its small size, the SC joint is remarkably strong, supported by robust ligaments including the anterior and posterior sternoclavicular ligaments, the interclavicular ligament, and the costoclavicular ligament. It is the only true articulation between the upper limb and the trunk, allowing for significant movement of the shoulder girdle – elevation, depression, protraction, retraction, and rotation – which is essential for the full range of motion of the arm.
• Types of SC Joint Dislocation: SC joint dislocations are relatively rare injuries, often resulting from high-energy trauma. They are categorized based on the direction of displacement of the clavicle relative to the sternum:
  • Anterior Dislocation: More common (about 90% of cases), where the clavicle displaces forward, anterior to the sternum. While often painful and cosmetically noticeable, it is generally less dangerous.
  • Posterior Dislocation: Less common but significantly more serious, where the clavicle displaces backward, posterior to the sternum. This type of dislocation poses a substantial risk to vital structures located behind the sternum.

Why Posterior SC Dislocation is a Medical Emergency

A posterior sternoclavicular joint dislocation is considered a medical emergency due to its proximity to critical mediastinal structures. The displaced clavicle can compress or injure:

• Trachea: Leading to airway obstruction and difficulty breathing.
• Esophagus: Causing dysphagia (difficulty swallowing).
• Major Blood Vessels: Such as the subclavian artery and vein, brachiocephalic veins, and superior vena cava, potentially leading to life-threatening hemorrhage or thrombosis.
• Nerves: Including the brachial plexus or phrenic nerve, which can result in neurological deficits.
• Apex of the Lung: Risk of pneumothorax.

Immediate and accurate diagnosis, followed by prompt reduction, is crucial to prevent or mitigate these severe complications.

The Principles of Posterior SC Joint Reduction (Performed by Medical Professionals)

It is critical to reiterate that the reduction of a posterior SC joint dislocation is a highly specialized procedure that must only be performed by experienced medical professionals (e.g., orthopedic surgeons, emergency physicians) in a hospital setting. It is never to be attempted by an untrained individual.

• Immediate Medical Attention is Paramount: Upon suspicion of a posterior SC joint dislocation, immediate transport to an emergency department is required.
• Diagnosis and Imaging: Diagnosis typically involves a thorough clinical examination, assessing pain, deformity, and any signs of neurovascular or respiratory compromise. Imaging studies are essential:
  • X-rays: Standard chest X-rays may not clearly show the dislocation due to overlapping structures, but specialized views (e.g., serindipity view) or comparison views can be helpful.
  • Computed Tomography (CT) Scan: This is the gold standard for diagnosing SC joint dislocations, providing detailed cross-sectional images that clearly show the direction of clavicle displacement and its relationship to surrounding vital structures. A CT angiogram may be performed if vascular injury is suspected.
• Reduction Techniques: The goal of reduction is to safely restore the clavicle to its anatomical position.
  • Non-Surgical (Closed Reduction): This is the preferred initial approach if no immediate life-threatening complications are present. It is typically performed under general anesthesia or strong sedation to ensure muscle relaxation and patient comfort. Various maneuvers may be employed:
    • Traction-Adduction Maneuver: The patient is supine, often with a bolster between the scapulae. Traction is applied to the abducted and extended arm on the affected side, while direct pressure may be applied to the medial clavicle to guide it anteriorly and laterally over the manubrium.
    • "Towel Clip" or "Sterile Clamp" Technique: In some cases, a sterile towel clip or bone reduction clamp may be used to grasp the medial clavicle directly and pull it anteriorly while traction is applied to the arm. This is a more invasive closed reduction technique.
  • Surgical Intervention (Open Reduction): Surgery may be necessary if:
    • Closed reduction is unsuccessful.
    • There is irreducible displacement due to soft tissue interposition.
    • There are signs of significant neurovascular compromise requiring direct visualization and repair.
    • The joint is unstable after closed reduction.
    • Chronic dislocations that become symptomatic.
    • Surgical approaches involve an incision to directly visualize the joint and surrounding structures, allowing for precise reduction and, if necessary, internal fixation (e.g., with sutures or plates, though hardware across the joint is generally avoided due to risk of migration into vital structures).
• Post-Reduction Management: After successful reduction, the joint is typically immobilized using a sling or figure-of-eight bandage for several weeks to allow ligamentous healing. Close monitoring for recurrence or complications is essential.

What to Do If You Suspect a Posterior SC Joint Dislocation

If you, or someone you know, experiences trauma to the chest or shoulder and presents with symptoms such as severe pain in the upper chest/shoulder, difficulty breathing or swallowing, hoarseness, or signs of vascular compromise (e.g., arm discoloration, numbness), and there is a suspicion of posterior SC joint dislocation:

• Call Emergency Services Immediately: This is a life-threatening injury requiring urgent medical assessment and intervention.
• Do Not Attempt Self-Reduction: Attempting to manipulate the clavicle without proper medical training and imaging can worsen the injury, cause further damage to vital structures, or lead to catastrophic complications. Keep the individual still and comfortable until medical help arrives.

Rehabilitation and Recovery

Following successful reduction and initial immobilization, a structured rehabilitation program is crucial for optimal recovery. This typically involves:

• Pain and Swelling Management: Modalities such as ice, rest, and anti-inflammatory medications.
• Gradual Range of Motion (ROM) Exercises: Starting with passive and then active-assisted ROM to prevent stiffness, carefully progressing to active ROM as pain allows.
• Strengthening Exercises: Focusing on the muscles of the shoulder girdle and upper back (e.g., pectoralis major, deltoid, rotator cuff, trapezius, rhomboids) to improve stability and function.
• Proprioceptive Training: Exercises to re-educate joint position sense and control.
• Return to Activity: A progressive return to daily activities, work, and sport, guided by the healthcare team and physical therapist, ensuring full recovery of strength, stability, and function. Full recovery can take several months.

Conclusion and Key Takeaways

A posterior sternoclavicular joint dislocation is a rare but serious injury demanding immediate professional medical attention. While an understanding of the anatomy and mechanics of this joint is valuable for fitness enthusiasts and professionals, the reduction of such an injury is strictly within the domain of trained medical practitioners. Prioritizing rapid diagnosis and expert intervention is paramount to minimize the risk of severe complications and ensure the best possible outcome for the affected individual.