Sternoclavicular Joint Injection

Other Names

• Sternoclavicular Joint Injection
• SC Joint Injection
• Sternoclavicular Joint Aspiration
• Sternoclavicular Joint Arthrocentesis
• SC Joint Arthrocentesis
• SC Joint Aspiration

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Background

The sternoclavicular joint

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Shoulder Ultrasound: Sternoclavicular Joint Osteoarthritis

• This page refers to injections of the Sternoclavicular Joint
  • This includes both aspiration and injection as the approach is the same

Key Points

• Use high frequency, linear array transducer
• Use caution to avoid passing the needle through the joint into the thorax
• This can be accomplished by measuring needle depth prior to procedure

Anatomy

• Sternoclavicular Joint
  • Joint formed between the clavicle, first rib and manubrium of the sternum
  • This is a synovial joint enveloped by a joint capsule

Palpation vs Ultrasound Guidance

• One study estimated the palpation guided approach to be successful 78% of the time
• Currently, there are no papers reviewing ultrasound guided approach or comparing it to the palpation guided

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Aspiration

Indications

• Rule out Septic Arthritis
• Diagnose Gout or other spondyloarthropathy
• Symptomatic relief
• Unexplained joint effusion or monoarthritis

Contraindications

• Absolute
  • No absolute contraindications
• Relative
  • Abnormal or altered anatomy
  • Overlying infection or bacteremia
  • Coagulation
  • Prosthetic joint
  • Uncooperative patient
  • Diagnosis can be made with less invasive method

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Injection

Indications

• Sternoclavicular Joint Arthritis

Contraindications

• Absolute
  • Anaphylaxis to injectates
  • Overlying cellulitis, skin lesion or systemic infection
• Relative
  • Can be treated with less invasive means
  • Hyperglycemia or poorly controlled diabetes
  • Lack of symptom improvement with previous injection

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Procedure

Ligaments and tendons of the sternoclavicular region. a Anterior sternoclavicular ligament (white arrows) (upward and outward oblique transverse plane). b Interclavicular ligament (white arrow indicating anterosuperior aspect) attached on sternum (transverse plane with caudal tilt). c Longitudinal view of sternal tendon of the sternocleidomastoid muscle (white arrows) covering the medial aspect of the sternoclavicular joint (slightly upward and outward oblique sagittal plane). White broken lines show the articular disc, thin white lines show the anterior sternoclavicular ligament. C, Clavicle; S, Sternum

Sonographically guided SCJ injection technique. A and B demonstrate an out-of-plane technique while C and D demonstrate an in-plane technique (click to enlarge)

Techniques for accessing the SCJ joint. a, b 52-year-old female with right-sided medial chest pain likely due to OA, for steroid injection. Graphic illustration (a) and long-axis US image (b) demonstrate the in-plane approach with the transducer parallel to the joint and the needle (arrows in B) inserted in a lateral to medial direction. c, d 71-year-old male with longstanding SCJ OA and repeat injection for recurrent chest pain. Graphic illustration (c) and short-axis US image (d) demonstrate the out-of-plane approach with the transducer perpendicular to the joint and the needle (arrow in D) inserted in a lateral to medial direction

Equipment

• Sterile gloves
• Sterile gauze
• Antiseptic (e.g. chlorhexidine, iodine or alcohol)
• Syringe (3-5 mL is typically sufficient)
• Needles (large bore for drawing up local, small gauge for injection)
  • Small joints recommend 21 - 23 gauge, 0.5 - 1 inch needle
• Anesthetic (e.g. 1-2% lidocaine or 0.5% bupivacaine)
• Ultrasound machine (optional, but highly recommended)
  • High frequency linear probe
  • Sterile ultrasound probe cover

Ultrasound Findings

• General
  • The SC joint is best visualized in long axis, perpendicular to the joint line
  • The intra-articular disk may be visualized as a hypoechoic structure
• Common ultrasound findings:
  • Cortical irregularities
  • Widening or instability of the joint (static or dynamic)
  • Joint effusion with capsular distension

Preparation

• Patient should be supine
• Identify sternum and clavicle in long axis
  • Center the joint space
  • Identify optimal needle position

Ultrasound Guided Technique: Short Axis, In-Plane

• Patient Position
  • Patient is supine or seated, arm in neutral position
• Transducer Position
  • Sagittal oblique plane over the anterior SC joint
• Needle orientation
  • In plane
  • Approach is anterior to posterior
• Pearls and Pitfalls
  • Careful not to advance needle too deeply into the thorax

Ultrasound Guided Technique: Long Axis, In-Plane

• Patient Position
  • Patient is supine or seated, arm in neutral position
• Transducer Position
  • Coronal oblique plane over the medial aspect of the SC joint
• Needle Orientation
  • In plane
  • Approach is medial to lateral
• Pearls and Pitfalls
  • Careful not to advance needle too deeply into the thorax
  • A gel step-off may be needed to maintain continuous needle visualization

Ultrasound Guided Technique: Long Axis, Out-of-Plane

• Patient Position
  • Patient is supine or seated, arm in neutral position
• Transducer Position
  • Coronal oblique plane over the long axis of the SC joint
• Needle Orientation
  • Out-of-plane
  • Approach is inferior to superior
• Pearls and Pitfalls
  • Careful not to advance needle too deeply into the thorax
  • Follow the needle down in a step-wise approach

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Aftercare

• Apply bandage
• No major restrictions in most cases
• Can augment with ice, NSAIDS

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Complications

• Pneumothorax
• Pain
• Infection
• Recurrence of effusion
• Damage to surrounding soft tissue structures

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See Also

• Procedures Main
• Ultrasound Main
• Shoulder Pain Main

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