Basics
Description
- 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 shoulder
- Reciprocal anterior displacement of the medial clavicle
- May be associated with pneumothorax, hemothorax, pulmonary contusion, and rib fractures
- Subluxation and dislocation may occur spontaneously.
- Posterior SCJ dislocation results from:
- Anterior-to-posterior blow to the medial clavicle
- Anteriorly directed force to the lateral aspect of the ipsilateral shoulder
- A 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 vessels
- Recurrent 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 fractures
- True 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 shock
- Difficulty breathing or speaking
- Upper 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 extremities
- Hoarseness may signify injury to the recurrent laryngeal nerve.
- Motor or sensory deficits suggest brachial plexus injury
- Assess 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 side
- More useful to assess coexisting bony, pulmonary, and mediastinal injury
- Chest 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 trauma
- Use high-frequency linear probe
- In 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 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.
- 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 subluxation
- Better suited after the initial period of diagnosis and treatment
- Can 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 airway
- Signs of shock
- Diminished pulses
- Hoarseness
- Dysphagia
- Neurovascular compromise:
- Upper extremity weakness
- Paresthesia
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 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.
- 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 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
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)