Sternoclavicular Joint Dislocation

Dr. Harun Ar Rashid, MD - Arthritis, Bones, Joints Pain, Trauma, and Internal Medicine Specialist Dr. Harun Ar Rashid, MD - Arthritis, Bones, Joints Pain, Trauma, and Internal Medicine Specialist
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Sternoclavicular joint dislocation are uncommon injuries that involve the sternoclavicular joint and its associated ligaments. They can be traumatic or atraumatic. In traumatic injuries, the trauma often occurs in a motor vehicle accident or during contact or collision sports. A sprain of the joint can occur when no instability or laxity occurs.

Other Names

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

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

Causes

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

The SC joint itself receives direct supply by the medial supraclavicular nerve (C3-C4) and the nerve to the subclavius (C5-C6). It is also worth mentioning nerves are involved in the various movements at the joint.

  • Elevation: accomplished by the levator scapulae, upper trapezius, rhomboid major and minor muscles

    • Innervation: dorsal scapular nerve, C5 ventral ramus, C3-C4 ventral rami
  • Depression: pectoralis minor, lower trapezius, serratus anterior and inferior muscles

    • innervation: medial pectoral nerve, spinal accessory nerve, long thoracic nerve
  • Protraction: pectoralis minor, serratus anterior muscles

    • Innervation: medial pectoral nerve, long thoracic nerve
  • Retraction: middle trapezius, latissimus dorsi, rhomboid major and minor muscles

    • innervation: spinal accessory nerve, thoracodorsal nerve, dorsal scapular nerve
  • Rotation via elevation of the glenoid cavity: upper and lower trapezius, serratus anterior and inferior muscles

    • Innervation: suprascapular nerve, axillary nerve, long thoracic nerve
  • Rotation via depression of the glenoid cavity: levator scapulae, latissimus dorsi, pectoralis minor, rhomboid major and minor muscles

    • Innervation: dorsal scapular nerve, thoracodorsal nerve, medial pectoral nerve, dorsal scapular nerve

Pathoanatomy

  • Sternoclavicular Joint
    • Articular of Sternum, medial Clavicle
    • Inherently unstable due to minimal osseous articulation, thus dependent on ligamentous structures for stability
  • Stabilizers
    • The 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 injury
    • Esophageal injury
  • Other orthopedic injuries
    • Acromioclavicular Joint Separation (rare)
  • 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 & Seperations
    • Acromioclavicular Joint Separation
    • Glenohumeral Dislocation (Acute)
    • Sternoclavicular Joint Dislocation
    • Glenohumeral Instability (Chronic)
  • Arthropathies
    • Glenohumeral Arthritis
    • Acromioclavicular Joint Arthritis
  • Muscle & Tendon Injuries
    • Pectoralis Major Injuries
    • Pectoralis Minor Injuries
    • Proximal Biceps Tendon Injuries
    • Scapular Dyskinesis
  • Rotator Cuff
    • Rotator Cuff Tear
    • Rotator Cuff Tendonitis
    • Calcific Tendinitis of the Rotator Cuff
    • Subcoracoid Impingement Syndrome
  • Bursopathies
    • Subacromial Bursitis
    • Scapulothoracic Bursitis
  • Ligament Injuries
    • Glenoid Labral Tears
  • Neuropathies
    • Suprascapular Nerve Injury
    • Parsonage-Turner Syndrome
    • Quadrilateral Space Syndrome
    • Winged Scapula
  • Other
    • Adhesive Capsulitis
    • Paget-Schroetter Syndrome
  • Pediatrics
    • Coracoid Avulsion Fracture
    • Humeral Head Epiphysiolysis (Little League Shoulder)

Diagnosis

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

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 is an inferiorly displaced medial clavicle
  • Heining View
    • The beam is directly perpendicular to the SCJ[4]
    • Allows the SCJ to be visualized 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, nonstructural
    • Structurally intact
    • Muscles, namely Pectoralis Major causing SCJ subluxation or dislocation

Treatment

Acute Management

  • Anterior Dislocation
    • Acute anterior dislocation attempted closed reduction with procedural sedation or in the OR
    • Procedure
      • The 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 Immobilizer for 3-4 weeks
  • Posterior Dislocation
    • Acute posterior dislocation attempted closed reduction with procedural sedation or in the OR
    • Rockwood Technqiue[3]
      • A 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 develops persistent symptomatic instability
  • Posterior
    • At the discretion of the orthopedic surgeon

Operative

  • Anterior Indications
    • Acute (<2-3 weeks)
    • Failure of a 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 neurovascular, esophageal or tracheal injuries
    • Medial clavicle excision if persistent pain or chronic instability

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