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Sternoclavicular Joint Dislocation

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Other Names

  • SC Joint Dislocation
  • Sternoclavicular Joint Subluxation
  • SC Joint Subluxation
  • SCJ Dislocation
  • SCJ Subluxation
  • Sternoclavicular Dislocation

Background

  • This page refers to all traumatic injuries to the Sternoclavicular Joint
  • Posterior dislocation associated with life threatening conditions
  • Due to uncommon nature of disease, clinically uncertainty may exist about evaluation and management

Epidemiology

  • Relatively rare phenomenon
  • Represent only 3% of shoulder dislocations[1]
  • Anterior 9x more common than posterior dislocations (need citation)

Pathophysiology

  • Anterior
    • Typically results from lateral compressive force to the shoulder girdle
    • Results in rupture of the anterior capsule, part of the costoclavicular ligament
  • Posterior
    • Typically caused by a direct force over the anteromedial aspect of the clavicle or an indirect force to the posterolateral shoulder,
    • Subsequently forcing the medial clavicle posteriorly

Etiology

  • Traumatic
    • Trauma most common etiology, usually MVC or collision sports (need citation)
  • Atraumatic
    • Occurs with overhead elevation of the arm
    • Subluxed cases may reduce with lowering the arm
    • Less common, seen with collagen deficiency syndromes such as Hypermobility Syndrome[2]
    • Even less commonly is congenital deformity, abnormal muscle pattern, infection or osteoarthritis

Pathoanatomy

  • Sternoclavicular Joint
    • Articular of Sternum, medial Clavicle
    • Inherently unstable due to minimal osseus articulation, thus dependent on ligamentous structures for stability
  • Stabilizers
    • Joint capsule and capsular ligaments (most important)
    • Costoclavicular Ligament
    • Interclavicular Ligament
    • Sternoclavicular ligaments
    • Subclavius

Associated Injuries

  • Posterior dislocation
    • Primary concern: compression of mediastinum which can be life threatening
    • Neurovascular injuries including brachial plexus
    • Tracheal inury
    • Esophageal injury
  • Other orthopedic injuries

Risk Factors


Differential Diagnosis


Clinical Features

  • History
    • Will generally report high energy collisions (i.e. sports, MVC, etc)
    • Anterior: complain of painful lump lateral to sternum
    • Posterior: medial clavicular pain
    • Posterior may also report dypsnea, dysphagia or other vascular or neurological symptoms
  • Physical: Physical Exam Shoulder
    • You may observe patient with shoulder adducted across chest to prevent excessive motion
    • Prominence increases with abduction, elevation of arm
    • Swelling, bruising may be noted
    • Reduced ROM at shoulder
    • Critical to perform thorough pulmonary, laryngeal, esophageal and neurovascular examination

Evaluation

Right superior SC dislocation (serendipity view)

Radiographs

  • Standard Radiographs Shoulder
  • Routine chest radiographs have poor sensitivity and are notoriously challenging to identify SCJ dislocations
  • Mandatory to exclude other associated injuries (pneumothorax, hemothorax, pneumomediastinum, etc)
  • Serendipity View
    • Beam with 40° cephalic tilt[3]
    • Presents the anterior dislocation as a superiorly displaced medial clavicle
    • Presents the posterior dislocation as an inferiorly displaced medial clavicle
  • Heining View
    • Beam is directly perpendicular to the SCJ[4]
    • Allows the SCJ to be visualised without underlying vertebral bodies distorting the view

CT

  • Diagnostic modality of choice in suspected sternoclavicular dislocation
  • Visualizes mediastinal structures
  • Helps differentiate from physeal injuries
  • Angiography may be indicated if vascular injury suspected

MRI

  • Poorer resolution than CT
  • Useful to evaluate ligamentous injuries

Ultrasound

  • Case reports using point-of-care ultrasound to identify sternoclavicular dislocations[5]

Classification

  • Direction: anterior, posterior, superior, inferior
  • Instability: acute, recurrent, persistent

Stanmore triangle

  • Originally applied to glenohumeral instability, extrapolated to SCJ dislocation
  • Type I: traumatic structural
    • Clear history of trauma
  • Type II: atraumatic structural
    • No history of trauma, structural changes within the capsule
  • Type III: muscle patterning, non structural
    • Structurally intact
    • Muscles, namely Pectoralis Major causing SCJ subluxation or dislocation

Management

Acute Management

  • Anterior Dislocation
    • Acute anterior dislocation attempted closed reduction with procedural sedation or in the OR
    • Procedure
      • Patient is placed supine with a bolster placed between their shoulders
      • Traction is applied to the affected upper limb in 90° of abduction with neutral flexion
      • Direct pressure is applied over the medial clavicle.
    • Immobilize in Shoulder Immoblizer for 3-4 weeks
  • Posterior Dislocation
    • Acute posterior dislocation attempted closed reduction with procedural sedation or in the OR
    • Rockwood Technqiue[3]
      • Towel clip is used percutaneously to grasp the medial clavicle and pull it anteriorly
    • Abduction traction technique[6]
      • Shoulder is abducted to 90° and traction applied
      • Extension force is then applied to the shoulder resulting in anterior translation of the medial clavicle back into joint
    • Buckerfield technique[7]
      • Retraction of the shoulders with caudal traction on the adducted arm, while the patient is supported by an interscapular bolster

Nonoperative

Operative

  • Anterior Indications
    • Acute (<2-3 weeks)
    • Failure of non-surgical approach
    • Persistent pain
  • Posterior Indications
    • Acute (<2-3 weeks)
    • Neurovascular, esophageal or tracheal injury
  • Technique
    • Generally closed reduction for both anterior or posterior
    • Open reduction with thoracic surgery back up if any neurovsacular, esophageal or tracheal injuries
    • Medial clavicle excision if persistent pain or chronic instability

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play

  • Needs to be updated

Complications

  • Anterior
    • Re-dislocation rates 21-100%[8][9][10]
    • Long standing cosmetic deformity
    • Persistent pain, instability
  • Posterior
    • 30% of cases have esophageal, tracheal or neurovascular injury[10]
    • 3-4% mortality rate
    • Brachial plexus
    • Vascular injuries
    • Esophagel rupture
    • Tracheal compression

See Also


References


  1. Cave E. Shoulder girdle injuries. In: Fractures and other injuries., editor. Chicago: Year book publishers; 1958. pp. 58–259.
  2. Finsterbush A, Pogrund H. The hypermobility syndrome. Musculoskeletal complaints in 100 consecutive cases of generalized joint hypermobility. Clin Orthop Relat Res. 1982;(168):124–127
  3. 3.0 3.1 Rockwood CA. Dislocations of the sternoclavicular joint. In: Evans E, editor. American academy of orthopaedic surgeons instructional course lectures: Volume XXIV. st. Louis: CV Mosby; 1975. pp. 144–159.
  4. Robinson CM, Jenkins PJ, Markham PE, Beggs I J Bone Joint Surg Br. 2008 Jun; 90(6):685-96.
  5. Bengtzen, Rachel R., and Ryan C. Petering. "Point-of-care ultrasound diagnosis of posterior sternoclavicular joint dislocation." The Journal of emergency medicine 52.4 (2017): 513-515.
  6. Rockwood CA, Wirth M. Injuries to the sternoclavicular joint. In: Rockwood CA, Green D, Bucholz R, Heckman J, editors. Rockwood and Green’s fractures in adults. Philadelphia: 1996. pp. 1415–1471.
  7. cute traumatic retrosternal dislocation of the clavicle. Buckerfield CT, Castle ME J Bone Joint Surg Am. 1984 Mar; 66(3):379-85.
  8. Savastano AA, Stutz SJ. Traumatic sternoclavicular dislocation. Int Surg. 1978;63:10–13.
  9. Nettles JL, Linscheid RL. Sternoclavicular dislocations. J Trauma. 1968;8:158–164.
  10. 10.0 10.1 Eskola A. Sternoclavicular dislocation. A plea for open treatment. Acta Orthop Scand. 1986;57:227–228.
Created by:
John Kiel on 13 June 2019 07:46:59
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Last edited:
27 April 2021 23:51:01
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