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Sternoclavicular Joint Disloclation

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Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.
Title: 5-Minute Orthopaedic Consult, 2nd Edition
> Table of Contents > Sternoclavicular Joint Disloclation

Sternoclavicular Joint Disloclation
Theodore T. Manson MD
John H. Wilckens MD
Basics
Description
  • The medial end of the clavicle dislocates from its articulation with the sternum.
  • Dislocations may be anterior or posterior.
    • Posterior dislocations:
      • May cause neurovascular or respiratory compromise.
    • Posterior reductions:
      • Must be reduced.
    • Anterior dislocations often are unstable, even if reduced, but few functional deficits occur with this instability.
Epidemiology
  • Rare injury (1):
    • 1% of all joint dislocations
    • 3% of all shoulder girdle injuries
    • 40% from vehicular trauma
    • 21% from sports-related injury
    • 63% of dislocations are anterior.
Pathophysiology
  • The sternoclavicular joint is a diarthroidal connection between the clavicle and sternum.
  • Strong ligaments bind the 2 bones together.
    • The capsular sternoclavicular ligaments are the primary restraints to AP movement.
    • Assisting the capsular ligaments are the costoclavicular and intra-articular disc ligaments.
  • Several vital structures lie immediately posterior to the sternoclavicular joint (Fig. 1).
    • Innominate artery and vein
    • Trachea
    • Esophagus
    • Vagus and phrenic nerves
    • Anterior jugular vein
    • Posterior dislocation can cause compression of these structures.
      Fig.
      1. Cross-sectional view of the anatomy of the vital structures
      posterior to the sternoclavicular joint. (Reprinted by permission from:
      Rockwood CA, Jr. Disorders of the sternoclavicular joint. In: Rockwood
      CA, Jr, Matsen FA, III, eds. The Shoulder: Philadelphia: WB Saunders, 1990;477–525.
  • The medial clavicular physis is the last physis to fuse, usually at the age of 23–25 years.
    • A presumed sternoclavicular dislocation in a patient <25 years old may be a physeal fracture rather than a dislocation.
    • The prognosis for physeal fractures is better than that for dislocations.
Etiology
  • Often a result of motor vehicle collisions or sports
  • 2 common mechanisms:
    • Direct blow to medial clavicle:
      • Usually causes posterior dislocation
    • Lateral compression of shoulder:
      • Football pile up
      • Side-impact motor vehicle collision
Associated Conditions
High-energy injuries should have a full ATLS workup (2) to exclude additional thoracic, spinal, and extremity injury.
Diagnosis
Signs and Symptoms
  • Patients may report history of direct blow or lateral compression injury.
  • Patients usually report pain with any movement of arm.
    • Worse with compressing shoulders together
    • Patient usually supports arm with the contralateral hand.
History
  • Ask about numbness or weakness in arms.
  • Ask about shortness of breath or difficulty with talking.
  • Ask about difficulty with swallowing.
Physical Exam
  • With anterior dislocations, the medial end of the clavicle will be more prominent than the contralateral side.
  • With posterior dislocations, the medial clavicle may no longer be palpable and a sulcus may be present.
  • The affected shoulder appears shortened and thrust forward.
  • Perform a thorough neurologic examination of both arms.
  • Compare pulses between arms.
  • Look for venous congestion in the neck and arms.
Tests
Imaging
  • Radiography:
    • The sternoclavicular joint is difficult to image on plain radiographs.
    • A chest radiograph may give some hint of deformity, and specialized views are difficult to obtain and interpret.
  • CT:
    • Provides most information about a sternoclavicular dislocation
    • Shows the bony anatomy of the dislocation
    • Shows what, if any, structures are being compressed in a posterior dislocation
    • Is the study of choice if a sternoclavicular joint dislocation is suspected
    • If a posterior dislocation is suspected, consider using CT angiography.
Differential Diagnosis
  • The sternoclavicular joints also can be sprained, for which the treatment is symptomatic sling use.
  • Other thoracic trauma, such as a
    pneumothorax, can cause shortness of breath, in which case the ATLS
    protocol should be followed.

P.423


Treatment
Initial Stabilization
  • In general, sternoclavicular dislocations should be reduced.
  • Anterior dislocations often are unstable after reduction, but most orthopaedic surgeons prefer an attempt at reduction.
  • Posterior dislocations always should be reduced and usually are stable thereafter.
General Measures
  • Reduction of a sternoclavicular joint
    dislocation often can be performed closed, but general anesthesia or
    deep sedation often is necessary secondary to pain and muscle spasm.
  • Reduction of an anterior dislocation:
    • Position the patient supine with a 3–4-inch bolster between the scapulae.
      • A common error is to use too small a bolster.
      • Abduct the affected shoulder to 90°.
      • Extend the affected shoulder 15°.
      • Have the assistant apply traction to affected arm.
      • Apply direct posterior pressure to the medial clavicle.
      • Place the affected arm in a figure-8 bandage or sling and swath after reduction.
  • Reduction of a posterior dislocation:
    • Position the patient supine with a 3–4-inch bolster between the scapulae.
    • A thoracic surgeon should be involved
      when reducing a posterior dislocation because a clavicle pulled from a
      punctured subclavian vessel or lung can lead to a catastrophic
      intrathoracic hemorrhage or pneumothorax.
    • 2 common techniques of closed reduction:
      • Abduction traction technique; apply
        traction to the abducted, extended arm; apply downward pressure to the
        shoulder over the glenohumeral joint; grasp the medial clavicle with
        fingers and attempt to pull the clavicle anteriorly; if closed
        manipulation fails, prepare the skin and use a sharp towel clamp to
        grasp the medial clavicle and pull it anteriorly; the clavicle usually
        reduces with an audible and palpable pop.
      • Adduction traction technique:
        • Adduct the arm; apply lateral traction to
          the adducted arm; push down on the shoulder over the glenohumeral
          joint; if needed, grasp the medial clavicle with fingers or a sterile
          towel clamp; after reduction, place the arm in a sling and swathe or
          figure-8 dressing.
Activity
  • The affected arm should be immobilized for 4–6 weeks after reduction.
  • Patients may benefit from sleeping upright (i.e., in a recliner) for pain relief and comfort.
Nursing
  • Patients should have parenteral access and adequate pain relief.
  • Patients may be more comfortable sitting upright with a sling until definitive treatment is rendered.
Special Therapy
Physical Therapy
  • Hand and wrist exercises and elbow ROM exercises can begin immediately.
  • Shoulder exercises usually should wait 4–6 weeks.
Medication
  • Medications for pain control are appropriate.
    • Parenteral and oral narcotics in the acute setting
  • NSAIDs in the acute and chronic settings
Surgery
  • Posterior dislocations for which closed reduction has failed should undergo open reduction in the operating room.
    • A thoracic surgeon should be present.
    • After open reduction, the stability of the joint is assessed (often, it is stable).
    • Unstable joints may be stabilized with one of many suture techniques and a graft reconstruction.
    • Kirschner wire or Steinmann pin fixation
      are contraindicated secondary to the disastrous sequelae of implant
      migration into the mediastinum.
  • Posterior dislocations untreated for >7–10 days after injury often require open reduction because of retrosternal adhesions.
  • In most cases, anterior dislocations with instability or residual deformity may be treated nonoperatively.
    • Residual anterior subluxation or dislocation usually causes few functional problems.
    • Symptomatic patients may be treated using open reduction and stabilization, much like patients with a posterior dislocation.
Follow-up
  • A patient with a sternoclavicular joint dislocation should be referred to an orthopaedic surgeon for follow-up.
  • Shoulder ROM exercises usually can be started at 4–6 weeks.
  • In stable reductions, a sling and swathe or figure-8 dressing usually is worn for 4–6 weeks.
  • Unstable anterior dislocations can be treated symptomatically with a sling until symptoms resolve.
Prognosis
  • Posterior dislocations usually are stable after reduction.
  • Anterior dislocations often are unstable, but the instability causes few functional deficits.
    • An unstable anterior dislocation usually remains prominent with a cosmetic deformity.
Complications
  • The most disastrous complications occur with posterior sternoclavicular dislocations (3).
    • Compression or laceration of great vessels
    • Compression of trachea, resulting in respiratory compromise
    • Compression of esophagus, causing swallowing difficulties
    • Brachial plexopathy
    • TOS
  • Anterior dislocations can have sequelae as well, but they are much more benign.
    • Cosmetic deformity (less than a surgical scar)
    • Degenerative changes
    • Recurrent instability and pain with activity
Patient Monitoring
Patients should be followed until pain resolves and motion and function are restored.
References
1. Wirth
MA, Rockwood CA, Jr. Injuries to the sternoclavicular joint. In:
Bucholz RW, Heckman JD, eds. Rockwood and Green’s Fractures in Adults,
5th ed. Philadelphia: Lippincott Williams & Wilkins, 2001:1245–1294.
2. American
College of Surgeons Committee on Trauma. Advanced Trauma Life Support
Program for Doctors, 6th ed. Chicago: American College of Surgeons,
1997.
3. Gove N, Ebraheim NA, Glass E. Posterior sternoclavicular dislocations: A review of management and complications. Am J Orthop 2006;35:132–136.
Additional Reading
Bicos J, Nicholson GP. Treatment and results of sternoclavicular joint injuries. Clin Sports Med 2003;22:359–370.
Rudzki JR, Matava MJ, Paletta GA, Jr. Complications of treatment of AC and sternoclavicular joint injuries. Clin Sports Med 2003;22:387–405.
Wirth MA, Rockwood CA, Jr. Acute and chronic traumatic injuries of the sternoclavicular joint. J Am Acad Orthop Surg 1996;4:268–278.
Miscellaneous
Codes
ICD9-CM
839.61,839.71 Dislocation, sternoclavicular joint
FAQ
Q:
If a patient has a posterior sternoclavicular joint dislocation and
difficulty with swallowing, shortness of breath, difficulty with
talking, or neck venous distention, how urgent is the condition?
A:
In this scenario, the patient should be emergently transferred to a
facility with a CT scanner and a thoracic or trauma surgeon. The medial
clavicle has injured or compressed 1 of several important mediastinal
structures: The trachea, esophagus, and/or the subclavian vessels.

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