Review Question - QID 219488

Posterior sternoclavicular (SC) joint dislocations can cause neurovascular compromise due to compression or direct injury to the great vessels and the current recommendation remains that cardiothoracic surgery be notified prior to formal reduction.

The SC joint is a diarthrodial saddle joint formed by the medial clavicle and sternum and stabilized by the costoclavicular ligaments as well as the anterior/posterior sternoclavicular ligaments. The posterior SC ligament is most important for stability and is injured in the setting of a posterior SC joint dislocation. CT scan is most reliable in formally diagnosing this injury pattern. Symptoms may include dyspnea, dysphagia, tachypnea, paresthesias in the affected arm and venous congestion due to compression of the hilar vessels, trachea, and esophagus. Reduction should be attempted in the operating room and should be done more urgently if the patient is decompensating. The recommendation is that cardiothoracic surgery be consulted prior to performing a closed reduction of a posterior dislocation in case vascular injury were to be encountered. This recommendation has become somewhat controversial but, in general, most still recommend that a cardiothoracic surgeon be nearby in case of emergency.

Martetschlager et al. published a current concepts review in AJSM looking at instability and degenerative arthritis of the SC joint. They note most can be treated nonoperatively but posterior dislocations almost always need to be addressed surgically in order to minimize risk to the surrounding neurovascular structures. The authors note that a cardiothoracic surgeon should be contacted prior to reduction of posterior dislocations because in rare cases, a vascular injury requiring an emergent thoracotomy may become necessary.

Groh and Wirth published a JAAOS review article looking at the management of traumatic SC joint injuries. They point out that anterior dislocations are much more common but posterior dislocations are important to recognize with symptoms including dyspnea, dysphagia, cyanosis, and ipsilateral extremity swelling/paresthesias. They discuss their algorithm for management including consultation with cardiothoracic surgery prior to formal reduction attempts of posterior dislocations.

Incorrect Answers:
Answers 1, 2, 4, and 5: While vascular injury can occur with any of these surgeries, the risk is low with appropriate technique and none of these surgeries would require a cardiothoracic surgery team on standby.