Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

Featured on Channel NewsAsia

Sternoclavicular Joint Disloclation

Basics
Description
  • The medial end of the clavicle dislocates from its articulation with the sternum.
  • Dislocations may be anterior or posterior.
    • Posterior dislocations:
      • May cause neurovascular or respiratory compromise.
    • Posterior reductions:
      • Must be reduced.
    • Anterior dislocations often are unstable, even if reduced, but few functional deficits occur with this instability.
Epidemiology
  • Rare injury:
    • 1% of all joint dislocations
    • 3% of all shoulder girdle injuries
    • 40% from vehicular trauma
    • 21% from sports-related injury
    • 63% of dislocations are anterior.
Pathophysiology
  • The sternoclavicular joint is a diarthroidal connection between the clavicle and sternum.
  • Strong ligaments bind the 2 bones together.
    • The capsular sternoclavicular ligaments are the primary restraints to AP movement.
    • Assisting the capsular ligaments are the costoclavicular and intra-articular disc ligaments.
  • Several vital structures lie immediately posterior to the sternoclavicular joint.
    • Innominate artery and vein
    • Trachea
    • Esophagus
    • Vagus and phrenic nerves
    • Anterior jugular vein
    • Posterior dislocation can cause compression of these structures.
  • The medial clavicular physis is the last physis to fuse, usually at the age of 23-25 years.
    • A presumed sternoclavicular dislocation in a patient <25 years old may be a physeal fracture rather than a dislocation.
    • The prognosis for physeal fractures is better than that for dislocations.
Etiology
  • Often a result of motor vehicle collisions or sports
  • 2 common mechanisms:
    • Direct blow to medial clavicle:
      • Usually causes posterior dislocation
    • Lateral compression of shoulder:
      • Football pile up
      • Side-impact motor vehicle collision
Associated Conditions
High-energy injuries should have a full ATLS workup to exclude additional thoracic, spinal, and extremity injury.
Diagnosis
Signs and Symptoms
  • Patients may report history of direct blow or lateral compression injury.
  • Patients usually report pain with any movement of arm.
    • Worse with compressing shoulders together
    • Patient usually supports arm with the contralateral hand.
History
  • Ask about numbness or weakness in arms.
  • Ask about shortness of breath or difficulty with talking.
  • Ask about difficulty with swallowing.
Physical Exam
  • With anterior dislocations, the medial end of the clavicle will be more prominent than the contralateral side.
  • With posterior dislocations, the medial clavicle may no longer be palpable and a sulcus may be present.
  • The affected shoulder appears shortened and thrust forward.
  • Perform a thorough neurologic examination of both arms.
  • Compare pulses between arms.
  • Look for venous congestion in the neck and arms.
Tests
Imaging
  • Radiography:
    • The sternoclavicular joint is difficult to image on plain radiographs.
    • A chest radiograph may give some hint of deformity, and specialized views are difficult to obtain and interpret.
  • CT:
    • Provides most information about a sternoclavicular dislocation
    • Shows the bony anatomy of the dislocation
    • Shows what, if any, structures are being compressed in a posterior dislocation
    • Is the study of choice if a sternoclavicular joint dislocation is suspected
    • If a posterior dislocation is suspected, consider using CT angiography.
Differential Diagnosis
  • The sternoclavicular joints also can be sprained, for which the treatment is symptomatic sling use.
  • Other thoracic trauma, such as a pneumothorax, can cause shortness of breath, in which case the ATLS protocol should be followed.
Treatment
Initial Stabilization
  • In general, sternoclavicular dislocations should be reduced.
  • Anterior dislocations often are unstable after reduction, but most orthopaedic surgeons prefer an attempt at reduction.
  • Posterior dislocations always should be reduced and usually are stable thereafter.
General Measures
  • Reduction of a sternoclavicular joint dislocation often can be performed closed, but general anesthesia or deep sedation often is necessary secondary to pain and muscle spasm.
  • Reduction of an anterior dislocation:
    • Position the patient supine with a 3-4-inch bolster between the scapulae.
      • A common error is to use too small a bolster.
      • Abduct the affected shoulder to 90°.
      • Extend the affected shoulder 15°.
      • Have the assistant apply traction to affected arm.
      • Apply direct posterior pressure to the medial clavicle.
      • Place the affected arm in a figure-8 bandage or sling and swath after reduction.
  • Reduction of a posterior dislocation:
    • Position the patient supine with a 3-4-inch bolster between the scapulae.
    • A thoracic surgeon should be involved when reducing a posterior dislocation because a clavicle pulled from a punctured subclavian vessel or lung can lead to a catastrophic intrathoracic hemorrhage or pneumothorax.
    • 2 common techniques of closed reduction:
      • Abduction traction technique; apply traction to the abducted, extended arm; apply downward pressure to the shoulder over the glenohumeral joint; grasp the medial clavicle with fingers and attempt to pull the clavicle anteriorly; if closed manipulation fails, prepare the skin and use a sharp towel clamp to grasp the medial clavicle and pull it anteriorly; the clavicle usually reduces with an audible and palpable pop.
      • Adduction traction technique:
        • Adduct the arm; apply lateral traction to the adducted arm; push down on the shoulder over the glenohumeral joint; if needed, grasp the medial clavicle with fingers or a sterile towel clamp; after reduction, place the arm in a sling and swathe or figure-8 dressing.
Activity
  • The affected arm should be immobilized for 4-6 weeks after reduction.
  • Patients may benefit from sleeping upright (i.e., in a recliner) for pain relief and comfort.
Nursing
  • Patients should have parenteral access and adequate pain relief.
  • Patients may be more comfortable sitting upright with a sling until definitive treatment is rendered.
Special Therapy
Physical Therapy
  • Hand and wrist exercises and elbow ROM exercises can begin immediately.
  • Shoulder exercises usually should wait 4-6 weeks.
Medication
  • Medications for pain control are appropriate.
    • Parenteral and oral narcotics in the acute setting
  • NSAIDs in the acute and chronic settings
Surgery
  • Posterior dislocations for which closed reduction has failed should undergo open reduction in the operating room.
    • A thoracic surgeon should be present.
    • After open reduction, the stability of the joint is assessed (often, it is stable).
    • Unstable joints may be stabilized with one of many suture techniques and a graft reconstruction.
    • Kirschner wire or Steinmann pin fixation are contraindicated secondary to the disastrous sequelae of implant migration into the mediastinum.
  • Posterior dislocations untreated for >7-10 days after injury often require open reduction because of retrosternal adhesions.
  • In most cases, anterior dislocations with instability or residual deformity may be treated nonoperatively.
    • Residual anterior subluxation or dislocation usually causes few functional problems.
    • Symptomatic patients may be treated using open reduction and stabilization, much like patients with a posterior dislocation.
Follow-up
  • A patient with a sternoclavicular joint dislocation should be referred to an orthopaedic surgeon for follow-up.
  • Shoulder ROM exercises usually can be started at 4-6 weeks.
  • In stable reductions, a sling and swathe or figure-8 dressing usually is worn for 4-6 weeks.
  • Unstable anterior dislocations can be treated symptomatically with a sling until symptoms resolve.
Prognosis
  • Posterior dislocations usually are stable after reduction.
  • Anterior dislocations often are unstable, but the instability causes few functional deficits.
    • An unstable anterior dislocation usually remains prominent with a cosmetic deformity.
Complications
  • The most disastrous complications occur with posterior sternoclavicular dislocations .
    • Compression or laceration of great vessels
    • Compression of trachea, resulting in respiratory compromise
    • Compression of esophagus, causing swallowing difficulties
    • Brachial plexopathy
    • TOS
  • Anterior dislocations can have sequelae as well, but they are much more benign.
    • Cosmetic deformity (less than a surgical scar)
    • Degenerative changes
    • Recurrent instability and pain with activity
Patient Monitoring
Patients should be followed until pain resolves and motion and function are restored.
Miscellaneous
Codes
ICD9-CM
839.61,839.71 Dislocation, sternoclavicular joint

FAQ
Q: If a patient has a posterior sternoclavicular joint dislocation and difficulty with swallowing, shortness of breath, difficulty with talking, or neck venous distention, how urgent is the condition?
A: In this scenario, the patient should be emergently transferred to a facility with a CT scanner and a thoracic or trauma surgeon. The medial clavicle has injured or compressed 1 of several important mediastinal structures: The trachea, esophagus, and/or the subclavian vessels.

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