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Sternoclavicular Joint Dislocation
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Contents
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
- 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
- Atraumatic
- Hypermobility Syndrome
- Ehlers-Danlos Syndrome
- Other collagen deficiency conditions
- Osteoarthritis
Differential Diagnosis
- Fractures
- Proximal Humerus Fracture
- Humeral Shaft Fracture
- Clavicle Fracture
- Scapula Fracture
- First Rib Fracture (traumatic or atraumatic)
- Dislocations & Separations
- Arthropathies
- Muscle & Tendon Injuries
- Rotator Cuff
- Bursopathies
- Ligament Injuries
- Neuropathies
- Other
- Pediatrics
- Coracoid Avulsion Fracture
- Humeral Head Epiphysiolysis (Little League Shoulder)
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
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
- Anterior
- Most can be managed non-surgically
- Shoulder Sling initially
- Physical Therapy
- Analgesia including NSAIDS, Acetaminophen
- Small subgroup develop persistent symptomatic instability
- Posterior
- At discretion of orthopedic surgeon
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
- 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
- Internal
- External
- Sports Medicine Review Shoulder Pain: https://www.sportsmedreview.com/by-joint/shoulder/
References
- ↑ Cave E. Shoulder girdle injuries. In: Fractures and other injuries., editor. Chicago: Year book publishers; 1958. pp. 58–259.
- ↑ 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
- ↑ 3.0 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.
- ↑ Robinson CM, Jenkins PJ, Markham PE, Beggs I J Bone Joint Surg Br. 2008 Jun; 90(6):685-96.
- ↑ 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.
- ↑ 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.
- ↑ cute traumatic retrosternal dislocation of the clavicle. Buckerfield CT, Castle ME J Bone Joint Surg Am. 1984 Mar; 66(3):379-85.
- ↑ Savastano AA, Stutz SJ. Traumatic sternoclavicular dislocation. Int Surg. 1978;63:10–13.
- ↑ Nettles JL, Linscheid RL. Sternoclavicular dislocations. J Trauma. 1968;8:158–164.
- ↑ 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:
1 October 2022 19:05:58
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