Approach to the Multitrauma Patient With Sternoclavicular Joint Dislocation

The emergency physician (EP) should approach the multitrauma patient in the usual fashion, ie, by first performing the primary survey. However, there may be some signs present in this early examination to indicate a posterior SCJ dislocation, including painful range of motion at the joint, inability to move the shoulder joint, hoarseness, dyspnea, dysphagia, neurovascular compromise of the arm, or frank hemodynamic instability.^6-8 After the first survey is completed, if the EP has a high level of suspicion for SCJ dislocation, it is essential to perform a thorough secondary survey to confirm the diagnosis.

Secondary Survey

Anterior SCJ dislocations might be easier to detect clinically during the secondary survey, as the patient might have a deformity of the clavicle and swelling.⁸ However, posterior and superior SCJ dislocations might be more subtle during examination, and may only exhibit tenderness and limited range of motion.

Imaging Studies

Computed Tomography. Since overlying structures often make it difficult to interpret simple radiographs, advanced imaging studies such as CT are often needed for diagnosis. A CT angiogram (CTA) may be considered if there is concern for vascular injury and compromise of the limb, as this modality is more accurate in evaluating vasculature such as the subclavian artery.^4,10

Special Radiographic Views. If advanced imaging is not immediately available or if the patient is not in a suitable condition to leave the ED, an alternative is to obtain a serendipity view X-ray. Described in 2009 by Wirth and Rockwood,¹¹ the serendipity view is obtained with the patient in the supine position and the X-ray beam tilted to a 40-degree cephalic angle centered through the manubrium. This view permits comparison of both clavicles without overlying structures. The usefulness of serendipity view X-ray, however, is limited, as it does not allow for differentiation of sprains.

Other plain radiographic views, such as the Hobbs, Heinig, and Kattan views, have also been described to evaluate for SCJ dislocation, but these views are often not feasible or easily obtained in an emergency setting with an acutely injured patient.^6,9,12

Magnetic Resonance Imaging. Though CT is typically the advanced initial imaging modality of choice for assessing the presence of an SCJ dislocation, additional studies using MRI are indicated for patients in whom there is a concern of physeal injury.¹Ultrasound. Point-of-care ultrasound has become an important tool in the EP’s armamentarium, and can easily be employed to diagnose a posterior SCJ dislocation, as well as confirm the reduction. The method described by Bengtzen and Petering¹³ involves placing a linear array probe in the long axis to the clavicle and scanning until the clavicle and sternum are identified by finding the hyperechoic areas. The hypoechoic area in between the clavicle and sternum is the SCJ space. An ultrasound of the unaffected side can be useful for comparison purposes.^6,13

Management

Posterior SCJ dislocations are considered a true emergency because of the potential structures associated with this type of injury. Concomitant injuries requiring immediate intervention include mediastinal compression, pneumothorax, laceration of the superior vena cava, tracheal erosion, esophageal injury, and brachial plexus compression and injury. Moreover, an unstable patient with an SCJ dislocation may have a lacerated thoracic vessel and need immediate thoracotomy.⁶

Anterior Reduction. Prior to any attempts at reduction, it is imperative to consult with orthopedic and cardiothoracic surgery services. However, if the patient’s dislocation is causing limb or life compromise, then the EP should attempt closed reduction in the ED.^1,3 One reduction technique is to place the patient in the supine position with a towel rolled up between his or her shoulders. The EP then extends and abducts the affected arm using a traction-countertraction approach.

Another technique is to have an assistant either pushing posteriorly or pulling anteriorly on the medial clavicle, while the EP performs lateral traction. An audible “snap” sound might be heard with successful reduction. If the assistant is unable to grasp the medial clavicle, then a towel clip should be used percutaneously to grasp it. If the joint remains reduced, the limb is immobilized with a figure-of-8 bandage^1,8

Further treatment options for complete SCJ dislocation include operative and nonoperative management. Posterior Reduction. While anterior dislocations are often managed conservatively with closed reduction and nonoperative treatment, posterior dislocations can often be reduced using either an open or closed approach.^1-3,8,9,14 If a posterior SCJ dislocation is reduced using a closed approach, it is more likely to be stable after reduction when compared to anterior SCJ dislocation reduction.

An attempt of closed reduction of posterior SCJ dislocation is often recommended before open approach is attempted, if it occurred within 48 hours and there are no signs of mediastinal compression.⁹ Some authors however, prefer immediate surgical approach and treatment of all complete dislocations due to better visualization of other structures such as the meniscus and potentially damaged fibrocartilage, which if untreated can result in decreased mobility and pain.^14,15