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Basics ⬇

Author(s): DouglasComeau, DO, CAQSM, FAAFP and Angelene M.Elliott, DO

Description

  • SCJ injuries are graded into three types:
    • Grade I: incomplete tear or stretching of the sternoclavicular and costoclavicular ligaments; joint stability and minimal pain
    • Grade II: complete tear of the sternoclavicular ligament and a partial tear of the costoclavicular ligament secondary to an anterior or posterior subluxation of the clavicle from the manubrium; pain and swelling of joint with mild deformity
    • Grade III: complete rupture of the sternoclavicular and costoclavicular ligaments; massive pain, swelling, and deformity
  • The ligaments and capsule of the SCJ contribute to its stability, making it one of the least dislocated joints in the body.
  • Dislocations are primarily due to trauma from vehicular or athletic injuries (>80%); congenital dislocations are extremely rare.

Epidemiology

Incidence

  • 1% of all dislocations; 3% of shoulder-girdle lesions (1)
  • Overall incidence is higher in males than in females.
  • Incidence is increased in young adult males.

Etiology and Pathophysiology

  • Anterior dislocation is much more common than posterior dislocation (9:1 ratio):
    • Caused by an anterolateral force compressing the shoulder that rotates the shoulder backward and transmits stress to the joint
  • Posterior dislocation is caused either from a direct anterior-to-posterior blow to the medial clavicle or from a posterolateral force compressing the shoulder followed by forward rolling.
  • Posterior dislocation is a surgical emergency and has an estimated 25% complication rate:
    • Compression of trachea, esophagus, and great vessels in the mediastinum demand immediate reduction.

Diagnosis ⬆ ⬇

  • Elicit mechanism of injury, time from injury, and initial symptoms.
  • Respiratory, neurologic, and vascular assessments mandatory
  • Appropriate analgesia for patient comfort

History

  • Mechanism of injury: Direct trauma (motor vehicle accident, athletic injury), falls, and dislocations can also be secondary to congenital, degenerative, and inflammatory processes.
  • Symptoms: chest and/or shoulder pain exacerbated by arm movement or by lying down, dyspnea, dysphagia, or paresthesias

Physical Exam

  • Patient presents with the affected arm foreshortened and supported across the chest by opposite hand.
  • Inability to abduct or externally rotate the affected arm because of severe pain over sternoclavicular junction
  • In anterior dislocation, medial end of the clavicle is visibly prominent, palpable, and may be fixed or mobile.
  • In posterior dislocation, loss of normal inner prominence of the clavicular head may be masked by significant local swelling:
    • Head tilted toward injured side because of spasm of the sternocleidomastoid muscle
    • Venous congestion in the neck or upper extremities, diminished pulses on affected extremity, shortness of breath, hoarseness, dysphagia, or signs of shock may suggest life-threatening impingement of the posteriorly displaced clavicle on vascular structures in the mediastinum.
  • Check vital signs and perform a complete neurovascular examination of the affected extremity.
ALERT
  • True dislocations of the SCJ are extremely rare in children because of the strong ligamentous attachments about the medial physis.
  • The medial physeal growth plates of the clavicles may not be radiographically apparent until age 18 yr and generally fuse between ages 22 and 25 yr. It is the last physis to close.
  • Presumed SCJ dislocations are often actually fractures through the medial physis.
  • In patients <25 yr of age, SCJ dislocations are classified as Salter-Harris type I or type II fractures.

Differential Diagnosis

Diagnostic Tests & Interpretation

  • Routine radiographs can be difficult to interpret and may appear normal.
  • In patients with posterior dislocations, a plain chest radiograph is needed to rule out possible pneumothorax.
  • Rockwood view (serendipity view): a specialized view that allows for better visualization of the position of the medial clavicle:
    • X-ray beam aimed at manubrium in a 40 degrees caudal tilt
  • Point of care ultrasound can be useful, especially for prompt diagnosis in posterior dislocations (2).
  • Magnetic resonance imaging (MRI) can be used to distinguish a dislocation from a physeal injury in children and young adults.
  • Computed tomography (CT) scan is the best study to evaluate the SCJ:
    • Useful in the emergency department (ED) when plain films are inconclusive
    • Accurately differentiates fractures from dislocations
    • Demonstrates the position of the medial end of the clavicle in relation to the structures in the mediastinum
    • Shows detailed anatomy of the structures of the thoracic outlet and mediastinum

Treatment ⬆ ⬇

ALERT
  • During childhood, the medial physeal growth plate of the clavicle provides 80% of longitudinal bone growth.
  • Fractures in the medial clavicle have tremendous capability for healing and remodeling.
  • Nonunion and significant malunion rarely occur.
  • Anteriorly displaced fractures of the medial clavicle that mimic SCJ dislocation can be placed in a figure-8 splint without reduction.
  • Posteriorly displaced fractures uniformly require reduction and should be considered a surgical and orthopedic emergency.
  • Prehospital:
    • The close proximity of the sternum and clavicle to vital structures of the neck and chest predispose patients with SCJ injuries to additional severe and life-threatening injuries.
    • Airway, breathing, and circulation (ABCs) must first be addressed in these patients.
    • Vital signs and an initial neurovascular examination should be completed.
    • For patients with isolated SCJ injuries, the affected extremity should be splinted and immobilized to stabilize the joint and minimize pain prior to transport to the hospital.
  • ED treatment:
    • Grade I and II usually with conservative treatment (immobilization or early functional therapy) (3)
    • Grade III usually closed reduction and immobilization versus open reduction and internal fixation (3)
    • Anterior dislocations may be reduced in the ED (4)[A].
    • Conscious sedation is necessary for pain control and muscle relaxation.
    • A rolled towel is placed between the shoulder blades in the supine position:
      • Longitudinal traction is applied to the ipsilateral arm in the extended position with the shoulder abducted at 90 degrees.
      • An assistant can maintain gentle inward pressure over the displaced medial end of the clavicle.
      • After reduction, immobilization is achieved using a well-padded figure-8 dressing.
      • Many anterior dislocations remain unstable after reduction; however, open reduction and internal fixation is rarely indicated, as the deformity is mainly cosmetic without functional loss.
    • Posterior dislocations require prompt reduction, best achieved in the operating room (OR) under general anesthesia (4)[A]:
      • If an appropriate surgeon is not immediately available to reduce a posterior dislocation in the OR, reduction may be attempted in the ED to relieve serious airway, neurologic, or vascular compromise.
      • After adequate sedation, a small incision is made directly over the medial head of the clavicle.
      • A sterile towel clamp can carefully be used to encircle the medial clavicular head and gentle anterior traction applied to reduce the dislocation.
      • A surgical consultant should subsequently evaluate the patient.

Medication

Anti-inflammatory agents and analgesics are the drugs of choice to decrease inflammation and reduce pain:

Admission, Inpatient, and Nursing Considerations

  • Initial stabilization:
    • Patients in respiratory distress require endotracheal intubation and immediate reduction.
    • Emergent reduction is also needed in patients with hoarseness, dysphagia, or neurovascular compromise (upper extremity weakness, paresthesia, diminished pulses, signs of shock).
    • Patients with posterior dislocations represent true orthopedic and surgical emergencies, and appropriate consults should be obtained promptly.
    • Appropriate analgesia (e.g., narcotics or nonsteroidal anti-inflammatory drugs [NSAIDs]) necessary for pain control
  • Admission criteria:
    • All posterior dislocations of the SCJ require admission for prompt reduction in the OR and evaluation for potential intrathoracic complications.
  • Discharge criteria:
    • Anterior dislocations of the SCJ that can be reduced and splinted, in the absence of neurovascular compromise, may be discharged with appropriate orthopedic follow-up.

Ongoing Care ⬆ ⬇

Follow-up Recommendations

Patient Monitoring

  • Patients with sprains should initially restrict activity, and depending on the amount of pain or discomfort, a sling can be used for immobilization.
  • Reductions performed in the ED require stabilization of the affected shoulder with a soft figure 8 or sling; immobilization for 4 wk.
  • Anterior dislocations should restrict activity and follow up with their physician as directed.
  • Patients with posterior dislocations who are discharged home should return for medical care if they exhibit symptoms of mediastinal injury.

Prognosis

Prognosis depends on extent and type of joint damage, but most patients have adequate upper extremity function following SCJ injuries.

Complications

  • Tracheal rupture
  • Pneumothorax
  • Laceration of superior vena cava
  • Occlusion of the subclavian artery
  • Recurrent dislocation
  • Deformity

Additional Reading ⬆ ⬇

  • Bicos J, Nicholson GP. Treatment and results of sternoclavicular joint injuries. Clin Sports Med. 2003;22(2):359–370.
  • Cope R. Dislocations of the sternoclavicular joint. Skeletal Radiol. 1993;22(4):233–238.
  • Gardner MA, Bidstrup BP. Intrathoracic great vessel injury resulting from blunt chest trauma associated with posterior dislocation of the sternoclavicular joint. Aust N Z J Surg. 1983;53(5):427–430.
  • Gobet R, Meuli M, Altermatt S, et al. Medial clavicular epiphysiolysis in children: the so-called sterno-clavicular dislocation. Emerg Radiol. 2004;10(5):252–255.
  • Lewonowski K, Bassett GS. Complete posterior sternoclavicular epiphyseal separation. A case report and review of the literature. Clin Orthop Relat Res. 1992;(281):84–88.
  • Winter J, Sterner S, Maurer D, et al. Retrosternal epiphyseal disruption of medial clavicle: case and review in children. J Emerg Med. 1989;7(1):9–13.

References ⬆ ⬇

  1. Boesmueller S, Wech M, Tiefenboeck TM, et al. Incidence, characteristics, and long-term follow-up of sternoclavicular injuries: an epidemiologic analysis of 92 cases. J Trauma Acute Care Surg. 2016;80(2):289–295.
  2. Bengtzen RR, Petering RC. Point-of-care ultrasound diagnosis of posterior sternoclavicular joint dislocation. J Emerg Med. 2017;52(4):513–515.
  3. Groh GI, Wirth MA. Management of traumatic sternoclavicular joint injuries. J Am Acad Orthop Surg. 2011;19(1):1–7.
  4. Cope R, Riddervold HO, Shore JL, et al. Dislocations of the sternoclavicular joint: anatomic basis, etiologies, and radiologic diagnosis. J Orthop Trauma. 1991;5(3):379–384.

Clinical Pearls ⬆

  • SCJ injuries are graded (I, II, III) based on severity of tearing of associated ligaments.
  • Dislocations are usually from trauma (direct blows/falls). Anterior dislocation is most common. Posterior dislocations are less common but require prompt reduction and is a surgical emergency.
  • Physical exam may show swelling and deformity of SCJ, and athlete may have restricted shoulder motion in abduction and external rotation.
  • Treatment for grade I and II is usually conservative. Grade III injuries may require surgery.