Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Sternoclavicular Joint Injury Treatment & Management

  • Author: John P Rudzinski, MD, FACEP; Chief Editor: Trevor John Mills, MD, MPH  more...
 
Updated: Nov 24, 2015
 

Prehospital Care

Depending upon the mechanism of injury (eg, motor vehicle crash) and the close proximity of the sternum and clavicle to the vital structures of the neck and chest, patients with sternoclavicular joint injuries (SJIs) may incur severe and life-threatening injuries.

Foremost, address the ABCs during prehospital care, with rapid transport to an appropriate trauma care facility if indicated.

For patients with seemingly isolated SJI, immobilization of the affected upper extremity with a sling stabilizes the joint and minimizes pain.

Next

Emergency Department Care

Patients with posterior SCJ dislocations frequently (reportedly 27-43% of the time) sustain associated potentially serious injuries that may take treatment precedence over the dislocation.

Sprains of the SCJ require only symptomatic treatment (eg, immobilization with a sling, ice for 24-48 h, analgesics, and anti-inflammatory medications).

The most common treatment for acute anterior dislocations in a review was nonoperative, with good to excellent results reported in 69% of patients.[16] Interposition of the joint capsule or the ligaments can make the joint irreducible, and maintenance of reduction can be problematic.[17] Once the diagnosis is made, prompt treatment is indicated, since functional outcomes are significantly improved for acute over chronic dislocations. If indicated, carry out closed reduction of an anterior dislocation as follows[18] :

  • Place the patient in a supine position on the stretcher.
  • Place a 3- to 4-inch thick bolster (rolled sheet or sandbag) between the scapula and spine (to help separate the clavicle from the manubrium).
  • Have an assistant abduct (to 90°) and extend (10-15°) the shoulder on the affected side and apply traction.
  • If reduction does not occur, apply pressure to the medial clavicle in a posterior and inferior direction.
  • Treatment options for recurrent/unreduced anterior SCJ dislocations may include open reduction and internal fixation, or acceptance of some degree of permanent instability, depending on the patient's characteristics and functionality.
  • Closed reduction with conscious sedation or general anesthesia is the preferred initial treatment, but may not be possible or necessary on an emergent basis. Because of potential associated vascular injury, the operating room may be the more appropriate setting for reduction.

Acute posterior dislocations are a more serious injury because of their potential association with other injuries, with symptoms of mediastinal compression present in 30% in some series. The most common treatment for posterior dislocations in one review was attempted closed reduction, with subsequent open reduction after a failed closed attempt. Good-to-excellent results were reported in 96% of patients.[16] Additional imaging may be necessitated to evaluate the presence of other injuries, and appropriate consultation with additional specialties may be indicated.

Once the diagnosis is made, prompt treatment is indicated because functional outcomes are significantly improved for acute over chronic dislocations. The treatment of associated injuries and/or complications may take priority over the SCJ dislocation. Emergent closed reduction of a posterior dislocation is as follows:[19]

  • Place the patient in a supine position on the stretcher.
  • Place a 3- to 4-inch thick bolster (rolled sheet or sandbag) between the scapula and spine (to help separate the clavicle from the manubrium).
  • Abduct (90°) and extend (10-15°) the shoulder on the affected side and apply traction to the arm as an assistant applies countertraction to the trunk.
  • If traction fails to reduce the dislocation, pull the medial clavicle forward while an assistant maintains traction and an abduction force on the affected limb.
  • In situations in which the clavicle cannot adequately be grasped by the fingers, use a towel clip to grip the clavicle (after sterile preparation of the skin) and pull forward.
  • Treatment options for unreduced posterior SCJ dislocations may include open reduction and internal fixation, or acceptance of some degree of permanent instability, depending on the patient's characteristics and functionality. Open operative intervention must be considered for unstable fractures, irreducible fractures, and repair of posteriorly displaced physeal fractures of the medial clavicle.
  • An alternative technique for reduction of a posterior SCJ dislocation (proposed by Buckerfield and Castle) suggests caudal traction accompanying adduction of the affected arm, along with downward pressure on both shoulders.
  • Closed reduction attempts for posterior SCJ dislocations may fail or may be associated with complications such as injury to the adjacent mediastinal structures.
  • Closed reduction may be unsuccessful or not attempted, depending on the age and activity level of the patient. In such patients, an immobilizing sling, analgesics, and anti-inflammatory agents may be used for symptomatic relief.

In a study of skeletally immature patients (12 boys; mean age, 14.8±2.74 yr) with sternoclavicular injuries with posterior displacement, medial clavicular physeal fractures and sternoclavicular dislocations were effectively managed with closed or open reduction. Of the 12 patients, 8 were initially treated with closed reduction, 2 successfully and 6 requiring subsequent open reduction. Four of the 12 patients underwent an immediate open reduction.[20]  

In another study, of the 140 adolescent patients (12-18 yr; mean, 15.24 yr) with posterior sternoclavicular joint injuries, 49 patients (35%) underwent closed treatment only, 42 (30%) open treatment alone, and 47 (33.57%) closed treatment followed by open treatment. Additionally, 55.8% of closed reductions performed within 48 hours were successful, as compared with 30.8% of those performed more than 48 hours after injury.[21]

Previous
Next

Consultations

Consider consultation of an orthopedic surgeon for reduction and possible operative stabilization of SCJ dislocations.

Suspicion of additional injuries secondary to a posterior SCJ dislocation may necessitate consultation by additional specialties, such as a vascular or thoracic surgeon.

Previous
 
 
Contributor Information and Disclosures
Author

John P Rudzinski, MD, FACEP Clinical Professor of Surgery, Department of Surgery, Clinical Professor of Medicine, Department of Internal Medicine, University of Illinois College of Medicine; Visiting Professor, American University of the Caribbean; Vice-Chairman, Emergency Department, Director of Medical Education, Rockford Health System; Staff Physician, Emergency Department, Rockford Memorial Hospital

John P Rudzinski, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Alina Perez University of Illinois College of Medicine at Rockford

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

David B Levy, DO, FAAEM Senior Consultant in Emergency Medicine, Waikato District Health Board, New Zealand; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine

David B Levy, DO, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, Fellowship of the Australasian College for Emergency Medicine, American Medical Informatics Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Daniel J Dire, MD, FACEP, FAAP, FAAEM Clinical Professor, Department of Emergency Medicine, University of Texas Medical School at Houston; Clinical Professor, Department of Pediatrics, University of Texas Health Sciences Center San Antonio

Daniel J Dire, MD, FACEP, FAAP, FAAEM is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Pediatrics, American Academy of Emergency Medicine, American College of Emergency Physicians, Association of Military Surgeons of the US

Disclosure: Nothing to disclose.

References
  1. Lee JT, Campbell KJ, Michalski MP, Wilson KJ, Spiegl UJ, Wijdicks CA, et al. Surgical anatomy of the sternoclavicular joint: a qualitative and quantitative anatomical study. J Bone Joint Surg Am. 2014 Oct 1. 96 (19):e166. [Medline].

  2. Torretti J, Lynch SA. Sternoclavicular joint injuries. Curr Opin Orthop. 2004. 15(4):242-7.

  3. Albarrag MK. Bilateral asymmetrical traumatic sternoclavicular joint dislocations. Sultan Qaboos Univ Med J. Nov 2012. 12(4):512-516. [Medline]. [Full Text].

  4. Fenig M, Lowman R, Thompson BP, Shayne PH. Fatal posterior sternoclavicular joint dislocation due to occult trauma. Am J Emerg Med. 2010 Mar. 28(3):385.e5-8. [Medline].

  5. Chotai PN. Posterior sternoclavicular dislocation presenting with upper-extremity deep vein thrombosis. Orthopedics. Oct/2012. 35(10): e1542-7:[Medline].

  6. Friedman RS, Perez HD, Goldstein IM. Septic arthritis of the sternoclavicular joint due to gram-positive microorganisms. Am J Med Sci. 1981 Sep-Oct. 282(2):91-3. [Medline].

  7. Womack J. Septic arthritis of the sternoclavicular joint. J Am Board Fam Med. 2012 Nov-Dec. 25 (6):908-12. [Medline].

  8. Marcus MS, Tan V. Cerebrovascular accident in a 19-year-old patient: a case report of posterior sternoclavicular dislocation. J Shoulder Elbow Surg. 2011 Oct. 20(7):e1-4. [Medline].

  9. Kirby JC, Edwards E, Kamali Moaeveni A. Management and functional outcomes following sternoclavicular joint dislocation. Injury. Oct 2015. 46(10):1906-1913. [Medline]. [Full Text].

  10. Garretson RB 3rd, Williams GR Jr. Clinical evaluation of injuries to the acromioclavicular and sternoclavicular joints. Clin Sports Med. 2003 Apr. 22(2):239-54. [Medline].

  11. Ernberg LA, Potter HG. Radiographic evaluation of the acromioclavicular and sternoclavicular joints. Clin Sports Med. 2003 Apr. 22(2):255-75.

  12. McCulloch P, Henley BM, Linnau KF. Radiographic clues for high-energy trauma: three cases of sternoclavicular dislocation. AJR Am J Roentgenol. 2001 Jun. 176(6):1534. [Medline].

  13. Brinker MR, Simon RG. Pseudo-dislocation of the sternoclavicular joint. J Orthop Trauma. 1999 Mar-Apr. 13(3):222-5. [Medline].

  14. Ferri M, Finlay K, Popowich T, Jurriaans E, Friedman L. Sonographic examination of the acromioclavicular and sternoclavicular joints. J Clin Ultrasound. 2005 Sep. 33(7):345-55. [Medline].

  15. Benson LS, Donaldson JS, Carroll NC. Use of ultrasound in management of posterior sternoclavicular dislocation. J Ultrasound Med. 1991 Feb. 10(2):115-8. [Medline].

  16. Glass ER, Thompson JD, Cole PA, Gause TM 2nd, Altman GT. Treatment of sternoclavicular joint dislocations: a systematic review of 251 dislocations in 24 case series. J Trauma. 2011 May. 70(5):1294-8. [Medline].

  17. Yeh GL, Williams GR. Conservative management of sternoclavicular injuries. Orthop Clin North Am. 2000 Apr. 31(2):189-203. [Medline].

  18. Balcik BJ, Monseau AJ, Krantz W. Evaluation and treatment of sternoclavicular, clavicular, and acromioclavicular injuries. Prim Care. 2013 Dec. 40 (4):911-23, viii-ix. [Medline].

  19. MacDonald, P., Lapointe, P. Acromioclavicular and Sternoclavicular Joint Injuries. Orthopedic Clinics of North America. 10/08. 39:[Full Text].

  20. Tepolt F, Carry PM, Taylor M, Hadley-Miller N. Posterior sternoclavicular joint injuries in skeletally immature patients. Orthopedics. 2014 Feb. 37 (2):e174-81. [Medline].

  21. Tepolt F, Carry PM, Heyn PC, Miller NH. Posterior sternoclavicular joint injuries in the adolescent population: a meta-analysis. Am J Sports Med. 2014 Oct. 42 (10):2517-24. [Medline].

  22. Gobet R, Meuli M, Altermatt S, et al. Medial clavicular epiphysiolysis in children: the so-called sterno-clavicular dislocation. Emerg Radiol. 2004 Apr. 10(5):252-5. [Medline].

  23. Van Hofwegen C, Wolf B. Suture repair of posterior sternoclavicular physeal fractures: a report of two cases. Iowa Orthop J. 2008. 28:49-52. [Medline].

 
Previous
Next
 
This 80-year-old woman presented 1 week after a fall because of persistent pain and discoloration in the anterior part of her chest. Certain movements of her right arm were especially painful though not incapacitating. Note the extensive ecchymosis of the anterior part of her thorax and the swelling of the right upper parasternal/lower anterior neck area. The right sternoclavicular joint area was tender and edematous to palpation.
Superior mediastinal contents may be threatened in posterior dislocations of the sternoclavicular joint.
CT scan of a left sternoclavicular dislocation demonstrates anterior and superior displacement of the clavicle from its normal articulation with the manubrium. The right sternoclavicular joint is normal.
CT scan of a left sternoclavicular dislocation demonstrates anterior and superior displacement of the clavicle from its normal articulation with the manubrium. The right sternoclavicular joint is normal.
CT scan of a left sternoclavicular dislocation demonstrates anterior and superior displacement of the clavicle from its normal articulation with the manubrium. The right sternoclavicular joint is normal.
The right sternoclavicular joint appears edematous on lateral inspection. Palpation confirms the apparent anterior dislocation.
Comparison of the normal left sternoclavicular joint emphasizes the abnormalities.
The patient refused further workup and treatment beyond a temporary sling, stating that the injury had not significantly affected her lifestyle. She was discharged home in the company of her daughter with over-the-counter analgesics.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.