High Yield Topics

Sternoclavicular Joint Injury

By admin



Ovid: 5-Minute Sports Medicine Consult, The


Sternoclavicular Joint Injury
Alysia L. Green
Douglas Comeau
Basics
  • The sternoclavicular joint (SCJ) is a saddle-type joint that participates in all movements of the upper extremity.
  • The SCJ provides free movement of the clavicle in nearly all planes.
  • The joint is weakest inferiorly and reinforced superiorly, anteriorly, and posteriorly by the interclavicular, anterior, and posterior sternoclavicular and costoclavicular ligaments.
Description
  • Sternoclavicular joint injuries are graded into 3 types:
    • Grade I: Incomplete tear or stretching of the sternoclavicular and costoclavicular ligaments
    • Grade II: Complete tear of the sternoclavicular ligament and a partial tear of the costoclavicular ligament secondary to an anterior or posterior subluxation of the clavicle from the manubrium
    • Grade III: Complete rupture of the sternoclavicular and costoclavicular ligaments
  • The ligaments and capsule of the SCJ contribute to its stability, making it one of the least dislocated joints in the body.
  • Dislocations are primarily due to trauma from vehicular or athletic injuries; congenital dislocations are extremely rare.
Epidemiology
Incidence
  • Overall incidence is higher in males than in females.
  • Incidence is increased in young adult males.
Etiology
  • Anterior dislocation is much more common than posterior dislocation (9:1 ratio):
    • Caused by an anterolateral force compressing the shoulder that rotates the shoulder backward and transmits stress to the joint
  • Posterior dislocation is caused either from a direct anterior-to-posterior blow to the medial clavicle or from a posterolateral force compressing the shoulder followed by forward rolling.
  • Posterior dislocation is a surgical emergency and has an estimated 25% complication rate:
    • Compression of trachea, esophagus, and great vessels in the mediastinum demand immediate reduction.
Diagnosis
  • Elicit mechanism of injury, time from injury, and initial symptoms.
  • Respiratory, neurologic, and vascular assessments mandatory
  • Appropriate analgesia for patient comfort
History
  • Mechanism of injury: Direct trauma (motor vehicle accident, athletic injury), falls, dislocations can also be secondary to congenital, degenerative, and inflammatory processes
  • Symptoms: Chest and/or shoulder pain exacerbated by arm movement or by lying down, dyspnea, dysphagia, or paresthesias
Physical Exam
  • Patient presents with the affected arm foreshortened and supported across the chest by opposite hand
  • Inability to abduct or externally rotate the affected arm because of severe pain over sternoclavicular junction
  • In anterior dislocation, medial end of the clavicle is visibly prominent, palpable, and may be fixed or mobile
  • In posterior dislocation, loss of normal inner prominence of the clavicular head may be masked by significant local swelling:
    • Head tilted toward injured side because of spasm of the sternocleidomastoid muscle
    • Venous congestion in the neck or upper extremities, diminished pulses on affected extremity, shortness of breath, hoarseness, dysphagia, or signs of shock may suggest life-threatening impingement of the posteriorly displaced clavicle upon vascular structures in the mediastinum.
  • Check vital signs and perform a complete neurovascular examination of the affected extremity.
Pediatric Considerations
  • True dislocations of the SCJ are extremely rare in children because of the strong ligamentous attachments about the medial physis.
  • The medial physeal growth plates of the clavicles may not be radiographically apparent until age 18 and generally fuse between ages 22 and 25. It is the last physis to close.
  • Presumed SCJ dislocations are often actually fractures through the medial physis.
  • In patients <25 yrs of age, SCJ dislocations are classified as Salter-Harris type I or type II fractures.
Diagnostic Tests & Interpretation
  • Routine radiographs can be difficult to interpret and may appear normal.
  • In patients with posterior dislocations, a plain chest radiograph is needed to rule out possible pneumothorax.
  • Rockwood view (serendipity view): A specialized view that allows for better visualization of the position of the medial clavicle:
    • X-ray beam aimed at manubrium in a 40° caudal tilt
  • CT scan is the best study to evaluate the SCJ:
    • Useful in the emergency department when plain films are inconclusive
    • Accurately differentiates fractures from dislocations
    • Demonstrates the position of the medial end of the clavicle in relation to the structures in the mediastinum
    • Shows detailed anatomy of the structures of the thoracic outlet and mediastinum
Differential Diagnosis
  • Sternoclavicular sprain/subluxation
  • Medial clavicle fracture
  • Rib fracture
  • Septic joint
  • Osteoarthritis
Treatment
Pediatric Considerations
  • During childhood, the medial physeal growth plate of the clavicle provides 80% of longitudinal bone growth.
  • Fractures in the medial clavicle have tremendous capability for healing and remodeling.
  • Nonunion and significant malunion rarely occur.
  • Anteriorly displaced fractures of the medial clavicle that mimic SCJ dislocation can be placed in a figure-8 splint without reduction.
  • Posteriorly displaced fractures uniformly require reduction and should be considered a surgical and orthopedic emergency.

P.555


Pre-Hospital
  • The close proximity of the sternum and clavicle to vital structures of the neck and chest predispose patients with sternoclavicular joint injuries to additional severe and life-threatening injuries.
  • ABCs must 1st be addressed in these patients.
  • Vital signs and an initial neurovascular examination should be completed.
  • For patients with isolated sternoclavicular joint injuries, the affected extremity should be splinted and immobilized to stabilize the joint and minimize pain prior to transport to the hospital.
ED Treatment
  • Anterior dislocations may be reduced in the emergency department (ED) (1)[A].
  • Conscious sedation is necessary for pain control and muscle relaxation.
  • A rolled towel is placed between the shoulder blades in the supine position:
    • Longitudinal traction is applied to the ipsilateral arm in the extended position with the shoulder abducted at 90°.
    • An assistant can maintain gentle inward pressure over the displaced medial end of the clavicle.
    • After reduction, immobilization is achieved using a well-padded figure-8 dressing.
    • Many anterior dislocations remain unstable after reduction; however, open reduction and internal fixation is rarely indicated, as the deformity is mainly cosmetic without functional loss.
  • Posterior dislocations require prompt reduction, best achieved in the operating room (OR) under general anesthesia (1)[A]:
    • If an appropriate surgeon is not immediately available to reduce a posterior dislocation in the OR, reduction may be attempted in the ED to relieve serious airway, neurologic, or vascular compromise.
    • After adequate sedation, a small incision is made directly over the medial head of the clavicle.
    • A sterile towel clamp can carefully be used to encircle the medial clavicular head and gentle anterior traction applied to reduce the dislocation.
    • A surgical consultant should subsequently evaluate the patient.
Medication
Anti-inflammatory agents and analgesics are the drugs of choice to decrease inflammation and reduce pain:
  • Acetaminophen: 500–1,000 mg q6–8h PRN
  • Ibuprofen: 400–800 mg q4–8h PRN with meals
  • Acetaminophen 300 mg with codeine: 30 mg q6h PRN
  • Propoxyphene and acetaminophen: 1–2 tabs q4h PRN
  • Hydrocodone and acetaminophen: 1–2 tabs q4–6h PRN
In-Patient Considerations
Initial Stabilization
  • Patients in respiratory distress require endotracheal intubation and immediate reduction.
  • Emergent reduction is also needed in patients with hoarseness, dysphagia, or neurovascular compromise (upper extremity weakness, paresthesia, diminished pulses, signs of shock).
  • Patients with posterior dislocations represent true orthopedic and surgical emergencies, and appropriate consults should be obtained promptly.
  • Appropriate analgesia (eg, narcotics or NSAIDs) necessary for pain control
Admission Criteria
All posterior dislocations of the SCJ require admission for prompt reduction in the operating room and evaluation for potential intrathoracic complications.
Discharge Criteria
Anterior dislocations of the SCJ that can be reduced and splinted, in the absence of neurovascular compromise, may be discharged with appropriate orthopedic follow-up.
Ongoing Care
Follow-Up Recommendations
Patient Monitoring
  • Patients with sprains should initially restrict activity, and depending on the amount of pain or discomfort, a sling can be used for immobilization.
  • Reductions performed in the ED require stabilization of the affected shoulder with a soft figure 8 or sling. Immobilization for 4 wks.
  • Anterior dislocations should restrict activity and follow up with their physician as directed.
  • Patients with posterior dislocations who are discharged home should return for medical care if they exhibit symptoms of mediastinal injury.
Prognosis
Prognosis depends on extent and type of joint damage, but most patients have adequate upper extremity function following SCJ injuries.
Complications
  • Tracheal rupture
  • Pneumothorax
  • Laceration of superior vena cava
  • Occlusion of the subclavian artery
  • Recurrent dislocation
  • Deformity
References
1. Cope R, Riddervold HO, Shore JL, et al. Dislocations of the sternoclavicular joint: anatomic basis, etiologies, and radiologic diagnosis. J Orthop Trauma. 1991;5:379–384.
Additional Reading
Bicos J, Nicholson GP. Treatment and results of sternoclavicular joint injuries. Clin Sports Med. 2003;22:359–370.
Cope R. Dislocations of the sternoclavicular joint. Skeletal Radiol. 1993;22:233–238.
Gardner MA, Bidstrup BP. Intrathoracic great vessel injury resulting from blunt chest trauma associated with posterior dislocation of the sternoclavicular joint. Aust N Z J Surg. 1983;53:427–430.
Gobet R, Meuli M, Altermatt S, et al. Medial clavicular epiphysiolysis in children: the so-called sterno-clavicular dislocation. Emerg Radiol. 2004;10:252–255.
Lewonowski K, Bassett GS. Complete posterior sternoclavicular epiphyseal separation. A case report and review of the literature. Clin Orthop Relat Res. 1992;84–88.
Winter J, Sterner S, Maurer D, et al. Retrosternal epiphyseal disruption of medial clavicle: case and review in children. J Emerg Med. 1988;7:9–13.
Codes
ICD9
  • 839.61 Closed dislocation, sternum
  • 848.41 Sternoclavicular (joint) (ligament) sprain


Continue Reading
You might also like More from author

This website uses cookies to improve your experience. We'll assume you're ok with this, but you can opt-out if you wish. Accept Read More