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Scapular, Clavicular, Acromioclavicular and Sternoclavicular Joint Injuries 169

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Scapular, Clavicular, Acromioclavicular and Sternoclavicular Joint Injuries 169 Scapular, Clavicular, Acromioclavicular and Sternoclavicular Joint Injuries 169 Scapular, Clavicular, Acromioclavicular and 11 Sternoclavicular Joint Injuries Peter Brys and Eric Geusens CONTENTS 11.1 Introduction 11.1 Introduction 169 11.1.1 Scapula 169 11.1.1 11.1.2 Clavicle 169 Scapula 11.1.3 Acromioclavicular Joint 169 11.1.4 Sternoclavicular Joint 170 The scapula is a fl at bone with three prominences, 11.2 Imaging 171 11.2.1 Plain Radiography 171 the spine and acromion, the glenoid, and the coracoid 11.2.1.1 Scapula 171 process. Medial to the base of the coracoid process is 11.2.1.2 Clavicle 171 the scapular notch arched by the superior transverse 11.2.1.3 AC-Joint 171 scapular ligament. The spinoglenoid notch arched by 11.2.1.4 SC Joint 171 11.2.2 Ultrasound 172 the inferior transverse scapular ligament is situated 11.2.2.1 AC Joint 172 between the lateral margin of the base of the scapular 11.2.2.2 SC Joint 172 spine and the dorsal side of the glenoid. Both notches 11.2.3 CT 172 are important fi xation points along the course of the 11.2.3.1 Scapula and Clavicle 172 suprascapular nerve. 11.2.3.2 SC Joint 172 11.2.4 MRI 172 11.2.4.1 AC Joint 172 11.2.4.2 SC Joint 172 11.1.2 11.2.5 Scintigraphy 173 Clavicle 11.3 Specifi c Overuse Trauma 173 11.3.1 Scapula 173 The growth plates of the medial and lateral clavicular 11.3.1.1 Fractures 173 11.3.1.2 Lateral Acromial Apophysitis 173 epiphyses do not fuse until the age of 25 years. The 11.3.1.3 Stress-related Growth Plate Injury of the deltoid, trapezius, and pectoralis major muscles have Coracoid Process 174 important attachments to the clavicle. The deltoid 11.3.1.4 Stress Fractures 174 muscle inserts onto the anterior surface of the lateral 11.3.1.5 Suprascapular Nerve Entrapment (SSNE) 174 third of the clavicle, and the trapezius muscle onto the 11.3.1.6 Long Thoracic Neuropathy 175 posterior aspect. The pectoralis major muscle inserts 11.3.2 Clavicle 175 onto the anterior surface of the medial two thirds. 11.3.2.1 Fractures 175 11.3.2.2 Lateral Clavicular Osteolysis (LCO) 175 11.3.2.3 Stress Fractures 176 11.3.3 AC Joint 177 11.1.3 11.3.3.1 Sprain/Dislocation 177 Acromioclavicular Joint 11.3.3.2 Osteoarthritis (OA) 178 11.3.4 SC Joint 179 The synovium-lined AC joint has interposed between 11.3.4.1 Sprain/Dislocation 179 its fi brocartilaginous joint surfaces a fi brocartilagi- Things to Remember 180 nous disc of variable size which is frequently com- References 180 pletely absent (Wickiewicz 1983). The joint has a thin capsule, reinforced by the AC ligaments of which P. Brys, MD E. Geusens, MD the superior one is continuous with the deltoid and Dept. of Radiology, University Hospitals Leuven, Herestraat 49, trapezius aponeuroses. The lateral clavicle is anchored 3000 Leuven, Belgium to the coracoid process by the coracoclavicular liga- 170 P. Brys and E. Geusens Box 11.1. Plain radiography Box 11.4. MRI ● Initial modality in osseous or articular disease ● No clear role in sprain or isolated disease of ● Tailored approach and good quality essential AC joint ● ● Only AC stress views when therapeutical con- Limited role in SC sprain sequences ● Soft tissue trauma ● No special SC views when CT available ● Posterior shoulder pain: muscle denervation? ● Low sensitivity for early stress fracture or LCO paralabral cyst? Box 11.2. CT Box 11.5. Scintigraphy ● Second stage evaluation of fractures or SC dis- location ● When plain radiography is negative ● If plain radiography negative and bone scan ● Suspected active osseous disease positive ● Occult fracture ● Stress fracture Box 11.3. Ultrasound ● Growth plate injury or apophysitis ● Limited role in AC joint ● Arthritis or osteoarthritis ● Lateral clavicular osteolysis ● AC sprain: type 1 or muscular status ● AC joint: joint distension? Arthrosynovial cyst? ● Limited role in SC joint: distension? ● Posterior shoulder pain/weakness: paralabral cyst? ● Soft tissue trauma Trapezoid Conoid ligament AC ligament ligament ment, composed of the lateral trapezoid and medial conoid parts (Fig. 11.1). The static joint stabilizers are the AC ligaments, controlling the horizontal stability, clavicle and the CC ligament controlling the vertical stability. acromion The dynamic stabilizers are the deltoid and trapezius muscles. The trapezius muscle attaches at the dorsal coracoid aspect of the acromion, part of the anterior deltoid muscle inserts on the clavicle medial to the AC joint. Their force vectors prevent excessive superior migra- tion of the distal clavicle after disruption of the AC and CC ligaments alone (Wulker 1998). Fig. 11.1. Normal anatomy: the acromioclavicular and cora- coclavicular ligament, the latter with its medial conoid and lateral trapezoid parts 11.1.4 Sternoclavicular Joint the cartilage of the fi rst rib (Fig. 11.2). Interposed between the fi brocartilaginous joint surfaces is a The synovium-lined SC joint is formed by the medial usually complete fi brocartilaginous disc, which acts clavicle, the clavicular notch of the manubrium, and to reduce the incongruities between the articulating Scapular, Clavicular, Acromioclavicular and Sternoclavicular Joint Injuries 171 joint surfaces, and as a shock absorber against medial case of a fractured coracoid process, the patient’s translation of the clavicle. The anterior and posterior pain usually precludes abduction. The fracture may SC ligaments are thickenings of the joint capsule. The be demonstrated with the so-called modifi ed axillary interclavicular ligament connects the clavicles with view (Wa l l ac e and Hellier 1983). the capsular ligaments and the upper sternum. The costoclavicular or rhomboid ligament runs from the 11.2.1.2 fi rst rib to the rhomboid fossa at the inferior side of Clavicle the medial clavicular metaphysis. This fossa should not be mistaken for a tumor when seen on radio- The Zanca view, an anteroposterior projection with graphs. The SC joint is freely movable and functions 15q of cephalic angulation, projects the lateral and almost like a ball-and-socket joint with motion in most of the middle third of the clavicle free of almost all planes, including rotation (Lucas 1973). overlying adjacent bones (Zanca 1971). Although The ligamentous support is so strong that it is one not required on a routine basis, visualisation of the of the least commonly dislocated joints in the body medial third of the clavicle is accomplished with (Wirth and Rockwood 1996). 40° cephalic angulation (Rockwood and Wirth 1996). Anterior SC ligament 11.2.1.3 Interclavicular AC-Joint clavicle ligament The best view of the AC-joint is the Zanca view. In case of an AC-trauma it is recommended to obtain Articular disc an upright view without the patient allowed to sup- port his elbow with the opposite hand, which might 1 st rib Costoclavicular ligament reduce any dislocation (Neer and Rockwood 1975). manubrium Stress or weighted views may be required after an AC-joint injury to allow more accurate differentia- tion between type 2 and 3 AC-sprains. An axillary Fig. 11.2. Normal anatomy: the sternoclavicular joint view can be helpful to determine the position of the clavicle with respect to the acromion. 11.2.1.4 SC Joint Standard radiographic views of the SC joint include 11.2 posteroanterior and oblique views. However, they Imaging are often inadequate due to overlap of the medial clavicle with the sternum, the first rib, and the 11.2.1 spine. Special projections have been described to Plain Radiography aid in the evaluation. Unless done by an experi- enced technologist these special views can be tech- Diagnostic plain fi lms are tailored to the clinical fi nd- nically difficult to perform and interpret, limiting ings and should be of impeccable quality. their utility and reproducibility (Brossman et al. 1996). 11.2.1.1 • The Rockwood projection, also called the ‘ser- Scapula endipity view, is an anteroposterior projection obtained with a 40° cephalic tilt, centered on the Routine views of the scapula include the AP view manubrium. The cassette is placed under the abducting the arm 90q and the lateral view or scapu- upper part of the shoulders and neck so that the lar Y. The axillary view, which requires abduction clavicle is projected in the middle of the fi lm. In of the arm, gives an excellent view on the anterior an anterior dislocation, the affected clavicle is pro- acromion, the glenoid, and the coracoid process. In jected superior to the normal clavicle, and with 172 P. Brys and E. Geusens posterior dislocation it is projected inferior to it 11.2.3 (Fig. 11.3) (Rockwood and Wirth 1996). Other CT special views, such as the Hobbs view and Heinig view (Hobbs 1968; Heinig 1968) are rarely per- 11.2.3.1 formed today and are currently replaced by mul- Scapula and Clavicle tidetector CT. • Stress maneuver: a reducible or intermittent SC With its excellent bony detail and its multiplanar and dislocation can look misleadingly normal on a 3D reconstruction capabilities, modern multi-detec- routine radiograph. A stress maneuver helps to tor CT equipment is the imaging technique of choice avoid this problem. This maneuver is performed in the evaluation of fractures and stress fractures. by bringing the ipsilateral arm across the chest and pulling against the contralateral elbow (Cope 11.2.3.2 1993). SC Joint CT is particularly valuable if an SC joint disloca- tion is suspected. Advantages are the short procedure time, wide availability, and the quality of 3D-refor- mating with MDCT in the assessment of the direc- tion and degree of a (sub)luxation and evaluation of fractures.
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