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Sternoclavicular Joint Injury, Emergency Medicine

Basics

Description

- Posterior dislocation may be accompanied by signs of vascular compromise or damage to mediastinal structures: - Signs of shock - Difficulty breathing or speaking - Upper extremity pain or neurologic symptoms

- CT scan is best to evaluate the SCJ: - Useful when plain films are inconclusive - Accurately differentiates fractures from dislocations - Demonstrates the position of the medial clavicle - Shows detailed anatomy of the thoracic outlet and mediastinum - Contrast CT can show related vascular injuries and is the imaging modality of choice.

- Endotracheal intubation for signs of airway compromise or as needed in the trauma patient - Emergent SCJ reduction for: - Unstable or compromised airway - Signs of shock - Diminished pulses - Hoarseness - Dysphagia - Neurovascular compromise: - Upper extremity weakness - Paresthesia

- Sprains and subluxations may be treated symptomatically with ice, NSAIDs, sling immobilization, and orthopedic follow-up. - Anterior dislocations may be reduced in the ED: - Procedural sedation for adequate pain control and muscle relaxation - Rolled towel placed between the shoulder blades in the supine position: - Longitudinal traction applied to the extended arm with shoulder abducted 90 ‚ ° - Assistant applies gentle pressure over the displaced end of the clavicle. - After reduction, immobilize with a well-padded figure-of-8 dressing.

- Posterior dislocations require urgent reduction best achieved in the OR under general anesthesia: - Orthopedic and thoracic surgery consults - Closed reduction is preferred (and often successful) but may not be possible in injuries >48 hr. - If surgeon not immediately available, emergent reduction in the ED may be necessary: - Relieve serious airway, neurologic, or vascular compromise - Adequate sedation and analgesia are essential - Patient placed supine with a roll between shoulder blades - Affected arm is abducted and extended - Increased traction as arm is brought into extension - If unsuccessful, a sterile towel clamp is used to grasp medial clavicular head and apply gentle anterior traction

  • Sternoclavicular joint (SCJ) is the only joint that connects the upper limb to the trunk.
  • Among the least frequently injured joints in the body
  • Most commonly due to athletic or vehicular injuries
  • Congenital or spontaneous dislocation and subluxation are rarely seen
  • SCJ stability depends on ligamentous attachments, primarily anterior and posterior sternoclavicular ligaments, interclavicular ligament, and costoclavicular ligament

Etiology

  • Injury to the SCJ can be from sprains, subluxations, or dislocations of the ligamentous structure
  • In sprains, ligamentous capsule remains intact
  • Subluxation occurs when sternoclavicular ligament ruptures while costoclavicular ligament remains intact
  • Complete ligamentous disruption leads to dislocation
  • The SCJ can dislocate anteriorly or posteriorly. A large force is required. A greater force is required to displace the clavicle posteriorly.
  • Direction of dislocation depends on the shoulder position:Anterior dislocation more likely when the acromion is posterior to the manubrium.Posterior dislocation more likely when the acromion is anterior to the manubrium.
  • Anterior dislocation is more common (more than 90% of dislocations):Caused by a posteriorly directed force to the anterolateral aspect of the shoulderReciprocal anterior displacement of the medial clavicleMay be associated with pneumothorax, hemothorax, pulmonary contusion, and rib fracturesSubluxation and dislocation may occur spontaneously.
  • Posterior SCJ dislocation results from:Anterior-to-posterior blow to the medial clavicleAnteriorly directed force to the lateral aspect of the ipsilateral shoulderA blow to the contralateral shoulder when the injured side is braced against an immobile object
  • Posterior dislocation is a surgical emergency:Indications for immediate reduction:Compression or tear of trachea, esophagus, or great vesselsRecurrent laryngeal nerve injury
  • The medial epiphyseal growth plates of the clavicles are last to ossify, and fuse between ages 22 and 25:Until fusion, growth plate is the weakest part of the joint
  • Fractures through the medial epiphysis mimic SCJ dislocations:Most commonly Salter " “Harris type I or II fracturesTrue dislocations of the SCJ are extremely rare in children because of strong ligamentous attachments.

Diagnosis

Signs and Symptoms

  • Pain and swelling localized to the medial clavicle and SCJ with appropriate mechanism
  • Affected arm supported across the chest by the contralateral arm
  • Inability to abduct or externally rotate arm
  • If subluxed or sprained, the SCJ is tender on direct palpation and with shoulder movement:No deformity or significant AP mobility
  • If the SCJ is dislocated, shoulder appears shortened:Head tilts toward injured side due to sternocleidomastoid muscle spasm
  • In anterior dislocation, medial end of the clavicle is visibly prominent and palpable.
  • In posterior dislocation, there may be a sulcus of the SCJ area through which the lateral border of the manubrium may be palpated:Dislocation may be masked by significant swelling over the SCJ region, and may mimic anterior dislocation.
  • Posterior dislocation may be accompanied by signs of vascular compromise or damage to mediastinal structures:Signs of shockDifficulty breathing or speakingUpper extremity pain or neurologic symptoms

History

  • High-energy direct blow, most often from athletic injuries or motor vehicle collisions
  • Sprains and subluxations may be associated with other injuries of the shoulder girdle.

Physical Exam

  • Tenderness and swelling in sprains and subluxations
  • In anterior dislocation, prominence of medial clavicle
  • For any concern of posterior dislocation, assess for signs of airway or neurovascular compromise:Dysphagia or respiratory distress may signify compression or disruption of trachea or esophagus.Assess pulses in upper extremitiesHoarseness may signify injury to the recurrent laryngeal nerve.Motor or sensory deficits suggest brachial plexus injuryAssess venous return in upper extremities:Venous compression may lead to engorged upper extremity veins or venous thrombosis

Essential Workup

  • Comprehensive trauma evaluation and resuscitation for other life-threatening injuries
  • Special attention to respiratory, neurologic, and vascular status
  • A posterior dislocation implies substantial mechanism of injury; other life-threatening injuries must be ruled out.
  • Appropriate analgesia for patient comfort

Diagnosis Tests & Interpretation

Imaging

  • Difficult to assess SCJ injury with routine radiographs:May demonstrate asymmetry of the SCJ compared with contralateral sideMore useful to assess coexisting bony, pulmonary, and mediastinal injuryChest x-rays may be read as normal and further imaging is warranted if index of suspicion is high
  • US can reliably demonstrate SCJ dislocations:May be useful in the initial ED evaluation of unstable patients with chest traumaUse high-frequency linear probeIn anterior dislocation, medial clavicle seen anterior relative to manubrium compared to contralateral side
  • CT scan is best to evaluate the SCJ:Useful when plain films are inconclusiveAccurately differentiates fractures from dislocationsDemonstrates the position of the medial clavicleShows detailed anatomy of the thoracic outlet and mediastinumContrast CT can show related vascular injuries and is the imaging modality of choice.
  • MRI can be useful in demonstrating ligamentous and soft tissue SCJ injuries:The articular disc is the most vulnerable soft tissue structure in SCJ injury.Can demonstrate specific ligamentous injuries in the setting of joint subluxationBetter suited after the initial period of diagnosis and treatmentCan help distinguish true dislocation from physeal injury in pediatric patients

Differential Diagnosis

  • Sternoclavicular sprain, subluxation, or dislocation
  • Medial clavicle fracture
  • Septic arthritis
  • Osteomyelitis of medial clavicle

Treatment

Pre-Hospital

  • Attention to airway and vital signs, and neurovascular status of affected extremity
  • Affected arm should be splinted in the position of comfort before transport to the ED.

Initial Stabilization/Therapy

  • Endotracheal intubation for signs of airway compromise or as needed in the trauma patient
  • Emergent SCJ reduction for:Unstable or compromised airwaySigns of shockDiminished pulsesHoarsenessDysphagiaNeurovascular compromise:Upper extremity weaknessParesthesia

Ed Treatment/Procedures

  • Sprains and subluxations may be treated symptomatically with ice, NSAIDs, sling immobilization, and orthopedic follow-up.
  • Anterior dislocations may be reduced in the ED:Procedural sedation for adequate pain control and muscle relaxationRolled towel placed between the shoulder blades in the supine position:Longitudinal traction applied to the extended arm with shoulder abducted 90 ‚ °Assistant applies gentle pressure over the displaced end of the clavicle.After reduction, immobilize with a well-padded figure-of-8 dressing.Many anterior dislocations remain unstable after reduction.Surgery rarely indicated, as deformity is mainly cosmetic
  • Posterior dislocations require urgent reduction best achieved in the OR under general anesthesia:Orthopedic and thoracic surgery consultsClosed reduction is preferred (and often successful) but may not be possible in injuries >48 hr.If surgeon not immediately available, emergent reduction in the ED may be necessary:Relieve serious airway, neurologic, or vascular compromiseAdequate sedation and analgesia are essentialPatient placed supine with a roll between shoulder bladesAffected arm is abducted and extendedIncreased traction as arm is brought into extensionIf unsuccessful, a sterile towel clamp is used to grasp medial clavicular head and apply gentle anterior traction

Medication

Procedural sedation: ‚

  • Etomidate: 0.1 mg/kg IV
  • Fentanyl: 1 " “2 ˇ ¼g/kg IV
  • Ketamine: Peds: 1 mg/kg IV " “ up to 2 additional doses of 0.5 mg/kg IV PRN
  • Midazolam: 0.01 mg/kg (peds: 0.05 " “0.1 mg/kg) IV q2 " “3min
  • Propofol: Initial bolus 1 mg/kg IV, then 0.5 mg/kg q3min as needed (adults and peds)

Follow-Up

Disposition

Admission Criteria

  • Posterior dislocations of the SCJ require admission for possible reduction in the OR and evaluation for potential intrathoracic complications.
  • Coexisting injury significant enough to warrant hospitalization

Discharge Criteria

  • SCJ sprains
  • Anterior dislocations of the SCJ without neurovascular compromise or other significant injury
  • Appropriate outpatient orthopedic follow-up arranged

Issues for Referral

Outpatient referral to an orthopedist should be recommended for patients with any significant SCJ injuries. ‚

Follow-Up Recommendations

  • It is difficult to achieve long-term stability after closed reduction of dislocations, so close orthopedic follow-up is advisable.
  • Simple sling sufficient for sprains
  • Figure-of-8 dressing for more severe injuries
  • Repeat MRI or CT imaging may be beneficial.
  • Even for mild sprains and subluxations, high-risk activity should be avoided for up to 3 mo.

Pearls and Pitfalls

  • Since SCJ injuries are rare, this potentially life-threatening injury may be missed during ED evaluation and resuscitation.
  • Posterior dislocations mandate early thoracic and cardiothoracic surgery consultation.
  • Posterior dislocation may be mistaken for anterior due to marked swelling over the joint.
  • In the pediatric population, a Salter " “Harris fracture may mimic a dislocation.

Additional Reading

  • Buckley ‚ BJ, Hayden ‚ SR. Posterior sternoclavicular dislocation. J Emerg Med. 2008;34:331 " “332.
  • Chotai ‚ PN, Ebraheim ‚ NA. Posterior sternoclavicular dislocation presenting with upper-extremity deep vein thrombosis. Orthopedics. 2012;35:e1542 " “e1547.
  • Groh ‚ GI, Wirth ‚ MA. Management of traumatic sternoclavicular joint injuries. J Am Acad Orthop Surg. 2011;19:1 " “7.
  • Jaggard ‚ MK, Gupte ‚ CM, Gulati ‚ V, et al. A comprehensive review of trauma and disruption to the sternoclavicular joint with the proposal of a new classification system. J Trauma. 2009;66:576 " “584.
  • Robinson ‚ CM, Jenkins ‚ PJ, Markham ‚ PE, et al. Disorders of the sternoclavicular joint. J Bone Joint Surg Br. 2008;90(6):685 " “696.

See Also (Topic, Algorithm, Electronic Media Element)

  • Acromioclavicular Joint Injury
  • Arthritis, Septic
  • Clavicle Fracture
  • Trauma, Multiple

Codes

ICD9

  • 839.61 Closed dislocation, sternum
  • 848.41 Sprain of sternoclavicular (joint) (ligament)

ICD10

  • S43.60XA Sprain of unspecified sternoclavicular joint, initial encounter
  • S43.203A Unspecified subluxation of unspecified sternoclavicular joint, initial encounter
  • S43.206A Unspecified dislocation of unspecified sternoclavicular joint, initial encounter
  • S43.216A Anterior dislocation of unspecified sternoclavicular joint, initial encounter
  • S43.201A Unspecified subluxation of right sternoclavicular joint, initial encounter
  • S43.202A Unspecified subluxation of left sternoclavicular joint, initial encounter
  • S43.204A Unspecified dislocation of right sternoclavicular joint, initial encounter
  • S43.205A Unspecified dislocation of left sternoclavicular joint, initial encounter
  • S43.211A Anterior subluxation of right sternoclavicular joint, initial encounter
  • S43.212A Anterior subluxation of left sternoclavicular joint, initial encounter
  • S43.213A Anterior subluxation of unspecified sternoclavicular joint, initial encounter
  • S43.214A Anterior dislocation of right sternoclavicular joint, initial encounter
  • S43.215A Anterior dislocation of left sternoclavicular joint, initial encounter
  • S43.221A Posterior subluxation of right sternoclavicular joint, initial encounter
  • S43.222A Posterior subluxation of left sternoclavicular joint, initial encounter
  • S43.223A Posterior subluxation of unspecified sternoclavicular joint, initial encounter
  • S43.224A Posterior dislocation of right sternoclavicular joint, initial encounter
  • S43.225A Posterior dislocation of left sternoclavicular joint, initial encounter
  • S43.226A Posterior dislocation of unspecified sternoclavicular joint, initial encounter
  • S43.61XA Sprain of right sternoclavicular joint, initial encounter
  • S43.62XA Sprain of left sternoclavicular joint, initial encounter

SNOMED

  • 209806001 sternoclavicular sprain (disorder)
  • 263048006 Subluxation of sternoclavicular joint (disorder)
  • 263009006 Dislocation of sternoclavicular joint (disorder)
  • 427740006 Anterior dislocation of sternoclavicular joint (disorder)
  • 209117003 Closed traumatic dislocation sternoclavicular joint (disorder)
  • 428730006 Posterior dislocation of sternoclavicular joint (disorder)