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Management of Traumatic Sternoclavicular Joint Injuries

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Management of Traumatic Sternoclavicular Joint Injuries Review Article Management of Traumatic Sternoclavicular Joint Injuries Abstract Gordon I. Groh, MD Traumatic sternoclavicular joint injuries account for <3% of all Michael A. Wirth, MD traumatic joint injuries. Proper recognition and treatment are vital because these injuries may be life threatening. Injuries are classified according to patient age, severity, and, in the setting of dislocation, the direction of the medial clavicle. Anterior injuries are far more common than posterior injuries. Posterior dislocation may be associated with complications such as dyspnea, dysphagia, cyanosis, and swelling of the ipsilateral extremity as well as paresthesia associated with compression of the trachea, esophagus, or great vessels. These life-threatening complications may present at the time of injury but can develop later, as well. Radiography has been largely supplanted by CT for evaluation of this injury, although an oblique view developed by Wirth and Rockwood is useful in evaluating isolated sternoclavicular injury. From the Blue Ridge Bone and Joint MRI is useful in differentiating physeal injury from sternoclavicular Clinic, Asheville, NC (Dr. Groh), and dislocation in patients aged <23 years. the Department of Orthopaedics, University of Texas Health Science Center, San Antonio, TX (Dr. Wirth). Dr. Groh or an immediate family ternoclavicular joint injury has the medial end of the clavicle is the member has received royalties from Sbeen reported to account for only last of the long bones to appear and Encore Medical; is a member of a 3% of all shoulder girdle injuries.1 is the last epiphysis to close. It does speakers’ bureau or has made paid Some orthopaedic surgeons will not ossify until age 18 to 20 years. presentations on behalf of ArthroCare, DePuy, and DJO; never see or treat a sternoclavicular The epiphysis does not fuse with the serves as a paid consultant to or is dislocation during their entire ca- shaft of the clavicle until age 23 to an employee of ArthroCare, DePuy, reers. Although rare, sternoclavicular 25 years.2 The sternoclavicular joint Ascension Orthopedics, UPex, and DJO; has received research or dislocations are associated with sev- is freely mobile, and it functions in institutional support from Ascension eral life-threatening complications almost all planes, including the Orthopaedics and DePuy; and has because of the close proximity of the transverse (ie, in rotation). This stock or stock options held in UPex. small, diarthrodial joint is the only Dr. Wirth or an immediate family hilar structures. These structures in- member serves as a board member, clude the trachea, esophagus, and true articulation between the upper owner, officer, or committee member lungs, any of which may be damaged extremity and the axial skeleton. The of the American Shoulder and Elbow in traumatic injury. Systematic evalu- ligamentous supporting structure, Surgeons; has received royalties which comprises the intra-articular from DePuy; is a member of a ation and treatment is essential to speakers’ bureau or has made paid successful management of traumatic disk, costoclavicular, capsular, and presentations on behalf of and sternoclavicular joint injuries. interclavicular ligaments, yields a serves as a paid consultant to or is strength that can withstand the an employee of DePuy and Tornier; and has stock or stock options held forces directed at the joint and ac- in Tornier. Anatomy counts for a low dislocation rate (Figure 1, A). The costoclavicular J Am Acad Orthop Surg 2011;19:1-7 The clavicle is the first long bone to (rhomboid) ligament is the strongest Copyright 2011 by the American ossify and does so by intrauterine supporting ligament and is made up Academy of Orthopaedic Surgeons. week 5. However, the epiphysis at of two separate bands, which give it January 2011, Vol 19, No 1 1 Management of Traumatic Sternoclavicular Joint Injuries Figure 1 cation in mind while performing the clinical evaluation. Anterior sternoclavicular injuries may exhibit prominence of the me- dial clavicle. This prominence is more easily appreciated while the pa- tient is in the supine position. Poste- rior dislocation is less common than anterior dislocation. Patients with posterior dislocation demonstrate a higher level of pain, and the corner of the sternum may be discerned as A, The articular disk ligament (held by forceps) attached to the right medial the medial clavicle is displaced poste- clavicle appears normal after removal of the capsular ligaments. B, Left 7 medial clavicle demonstrating the anterior sternoclavicular capsular ligament riorly. However, swelling may pre- (arrow) and the rhomboid appearance of the costoclavicular ligament clude an accurate clinical assessment (arrowhead). (Reproduced with permission from Wirth MA, Rockwood CA Jr: of injury. Patients with posterior dis- Disorders of the sternoclavicular joint, in Rockwood CA Jr, Matsen FA III, placement may report shortness of Wirth MA, Lippitt SB, Fehringer EV, Sperling JW, eds: The Shoulder,ed3. Philadelphia, PA, WB Saunders, 2009, pp 527-558.) breath or difficulty breathing be- cause of compression of the trachea or pneumothorax. Similarly, com- pression of the esophagus may result a twisted appearance. These separate in dysphagia. Compression of the fibers provide critical resistance to Clinical Indications posterior vascular structures can re- both anterior and posterior rotation sult in decreased circulation to the forces of the medial clavicle3 (Figure Sprain and Subluxation ipsilateral extremity or venous con- 1, B). The capsular ligaments also In a mild sprain, the ligaments of the gestion in the extremity or neck. provide anteroposterior and rota- sternoclavicular joint remain intact. Tingling or numbness may be the tional stability.4 The patient reports pain and tender- predominant complaint with com- ness with palpation over the joint. pression of the brachial plexus. Pos- Swelling may be present, but no in- terior sternoclavicular dislocation or Mechanism of Injury stability is noted. Swelling and pain associated injuries may render the become more pronounced as the lig- patient medically unstable. Given the strong support provided to aments are stretched, which results the sternoclavicular joint by the sur- in subluxation of the joint. Pain is rounding ligaments, dislocation re- Radiographic Evaluation marked with motion of the ipsilat- quires tremendous force. Direct an- eral extremity. Laxity of the joint teromedial force to the joint typically In general, routine radiographic may be apparent compared with the results in the clavicle being pushed studies of the sternoclavicular joint contralateral joint. posteriorly behind the sternum into are difficult to interpret due to the mediastinum. Examples of this overlap of the medial clavicle, ribs, mechanism of injury include an ath- Dislocation sternum, and vertebrae. However, lete’s being jumped on while lying Severe pain and deformity accom- Wirth and Rockwood10 developed an supine or a kick delivered to the pany dislocations of the sternoclavic- oblique view of the sternoclavicular front of the medial clavicle. By com- ular joint. Surprisingly, clinical ex- joint, called the serendipity view, parison, indirect force, (eg, motor ve- amination to determine the direction that permits comparison of the in- hicle accidents) the most common of the dislocation may be inconclu- jured clavicle to the normal clavicle. mechanism of injury, may result in sive because of swelling. In addition The serendipity view is obtained by either anterior or posterior force to swelling, compression of the vital pointing the radiographic beam at a across the sternoclavicular joint.5,6 structures posterior to the joint may 40° angle tilted cephalically with the Motor vehicle accidents and athletic occur with dislocation injuries. The beam centered on the sternoclavicu- injuries account for >80% of injuries orthopaedic surgeon should keep lar joint. The technique is best suited to this joint.7-9 this potential life-threatening compli- for isolated sternoclavicular injuries. 2 Journal of the American Academy of Orthopaedic Surgeons Gordon I. Groh, MD, and Michael A. Wirth, MD CT is more effective than radiogra- Figure 2 phy for evaluation of sternoclavicu- lar injury because sprains, disloca- tions, and medial clavicle fractures are easily distinguishable (Figure 2). To facilitate an accurate diagnosis, the patient’s history and the mechan- ism of injury should be communi- cated to the radiologist, and a CT scan of the chest should be obtained to identify injuries to the structures that surround the sternoclavicular joint. The scan also should include both medial clavicles so that the in- jured joint can be compared with the contralateral joint. In children and young adults, MRI may also be used to distinguish a dis- Axial CT scan demonstrating a right posterior sternoclavicular dislocation location of the sternoclavicular joint (arrow). (Reproduced with permission from Rockwood CA Jr, Wirth MA: from a physeal injury. MRI displays Injuries to the sternoclavicular joint, in Rockwood CA Jr, Green DP, Bucholz RW, et al, eds: Rockwood and Green’s Fractures in Adults,ed4. soft tissue and allows assessment of Philadelphia, PA, Lippincott-Raven, 1996, vol 2, p 1439.) the trachea, esophagus, and great vessels as well as the integrity of the costoclavicular ligament and attach- controversy regarding management be- history and physical examination. ments of the intra-articular disk. cause good long-term results have been Dyspnea, choking,
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