Sternoclavicular Joint Injury

What is Sternoclavicular Joint Injury?

Injuries to the sternoclavicular (SC) joint, which joins the collarbone (clavicle) to the breastbone (sternum), are quite rare. This joint has multiple supporting ligaments and a disc sandwiched between the two joint surfaces that function as a shock absorber. It’s the only joint that connects our arm to our body’s main framework, sustained further by the subclavius muscle. Near this joint are important structures such as arteries, veins, nerves, and parts of our breathing and digestion system. In young adults, a part of the collarbone only hardens fully around the age of 25.

The SC joint moves together with the shoulder, and its movement is crucial in various actions such as lifting your arm. However, it can be injured in high-energy instances like a car accident or playing high-impact sports. Sometimes, a sprain can happen without making the joint loose or unstable. It’s more common for the injury to cause the joint to dislocate towards the front rather than the back, and a backward dislocation has more significant health risks due to proximity to critical body structures. In younger people, particularly adolescent girls, the joint can slip out of place (subluxation) without a traumatic event – this usually happens when the arm is lifted overhead. This condition is typically painless and does not interfere with daily activities. Occasionally, it might happen alongside conditions affecting the neck muscles or nerves.

What Causes Sternoclavicular Joint Injury?

The sternoclavicular joint, where your collarbone (clavicle) meets your sternum (the bone in the middle of your chest), can sometimes partially slip out of place on its own. This condition is typically found in women who have naturally loose or flexible joints. In these cases, the collarbone moves slightly away from the sternum, but not completely – a condition often referred to as a sprain.

A more severe situation is sternoclavicular dislocation, which happens when all the ligaments connecting the collarbone to the sternum are torn. This usually occurs because of a significant injury, like a car accident or a collision during sports, such as rugby or American football. The force that causes the dislocation usually comes from the side and pushes the shoulder forward or backward.

Risk Factors and Frequency for Sternoclavicular Joint Injury

Sternoclavicular joint injuries make up a small portion of all shoulder injuries, specifically 3% to 5%. Injuries to the acromioclavicular and glenohumeral joints are much more common. The primary causes of these injuries are car accidents, sports-related injuries particularly in contact and collision sports, and falls. As a result, these injuries typically occur in active young men.

Within these injuries, sprains and non-dislocated fractures to the medial clavicular physis are more common than dislocations. In identifying diseases of the sternoclavicular joint, it’s crucial to be able to tell them apart from a medial clavicle physeal fracture. This is a particular concern for young adults, as the medial physis is the last growth plate to solidify, usually doing so between the ages of 20 and 25.

Signs and Symptoms of Sternoclavicular Joint Injury

People with sternoclavicular joint injuries usually suffer from pain in the front of the chest and shoulder. This pain can happen suddenly after a severe injury, or it could develop without an apparent reason. Often, they will identify the source of the shoulder pain as the sternoclavicular joint. Some people may experience repeating subluxation, where the clavicle or collarbone slips out during certain movements and then goes back to its original position when the arm returns to a neutral stance.

A physical examination can give several clues about the extent and nature of the injury. There might be visible swelling at the front of the chest or collarbone due to anterior or posterior dislocation. The affected shoulder might look shorter than the other one. Lifting or moving the arm sideways could make this difference more noticeable. Further characteristics can include pain, sensitivity, swelling and bruising over the joint area, and limited arm and shoulder movements. Sometimes, turning the head towards the affected side might ease the pain, which usually worsens with movement or lying on the back.

The stability of the joint can be evaluated by holding the middle of the collarbone and gently moving it side-to-side. Comparing this to the non-affected side can help determine the level of injury. Grade I injuries don’t typically show instability. Grades II and III may be trickier to distinguish, but usually Grade III injuries cause more joint pain than Grade II. Manually testing the joint may reveal instability in Grade II injuries; Grade III injuries may have too much swelling or a fixed dislocation which can prevent a correct assessment.

People with anterior dislocations probably won’t have injuries to other parts of the chest. But, posterior dislocations are more critical and require a detailed assessment. Patients may show signs of significant inner chest injuries, like shortness of breath, noisy breathing, difficulty swallowing, or numbness. Further indications can include respirational issues, problems dealing with secretions, color changes, swelling, or feeble pulses in the affected limb.

Testing for Sternoclavicular Joint Injury

If your doctor suspects that you’ve injured your sternoclavicular (the area where your sternum – or breastbone – and collarbone meet), they’ll likely start by ordering X-rays. An anterior-posterior view (this views the body from front to back) is usually useful, while a lateral view (from the side) is less helpful because other body structures might block a clear view of the joint. There’s also a special X-ray view called the serendipity view, where the X-ray beam is angled 40-degrees upwards, that can provide a better look at the sternoclavicular joint. Another option is a Hobbs view. In X-rays, if the affected collarbone (also called the clavicle) appears above the one on the other side, it indicates an anterior dislocation (dislocation towards the front of the body), while the reverse indicates a posterior dislocation (dislocation towards the back of the body).

If the injury is confirmed or still suspected after the X-rays, your doctor might order a CT scan. This type of imaging allows a more detailed look at the joint from various angles and can even provide a three-dimensional reconstruction. It’s especially useful in case of posterior dislocations, as it provides a clearer picture of the structures inside the chest (mediastinum) and any additional injuries. In children, a CT scan is important to establish whether the injury is a dislocation or a growth plate (the developing tissue at the ends of long bones in children) fracture, as this is more accurately visualized with a CT scan. If they suspect a vascular (related to the blood vessels) injury, they may choose to do angiography, which is an imaging test that uses X-rays to view your body’s blood vessels.

While ultrasound can also identify posterior dislocations, the image quality is not as high as with a CT scan. MRI scans can be useful in assessing damage to ligaments (the fibrous tissue connecting bones to other bones), but they are ordered based on the judgment of the healthcare providers involved in the patient’s care.

Treatment Options for Sternoclavicular Joint Injury

If a patient suffers from a non-traumatic [atraumatic] subluxation [partial dislocation] or a chronic anterior dislocation [misalignment of the joint which is long-lasting and located towards the front], they can typically be treated without surgery. Usually, treatment involves rest and wearing a sling for comfort, gradually increasing physical activity, painkillers, and then a return to normal activities including sports. Minor injuries called grade I sprains usually heal in one to two weeks. Grade II sprains, which involve some tearing of ligaments, can also recover without surgery but need more resting and precautions. For these patients, a figure-of-eight brace may be necessary for support.

When someone experiences a sudden acute anterior dislocation [misalignment of the joint towards the front], the preferred treatment approach can vary. These instances are less common and harder to study, making them subject to debate in medical circles. As most anterior dislocations don’t significantly impact long-term quality of life, non-surgical treatments are usually recommended. Still, the decision finally rests with the orthopedic surgeon overseeing the case. Some surgeons may advise trying a closed reduction, a procedure done under general anesthesia to reset the joint, but this can leave the joint unstable. Often, the risks of surgery for this condition are considered greater than the benefits, and so it’s not commonly performed.

If someone suffers an acute posterior [rear facing] dislocation that’s less than three weeks old and doesn’t present signs of a mediastinal injury [problems in the area between the lungs], the standard treatment is a closed reduction under general anesthesia. The procedure is similar to how an anterior dislocation is treated. If the closed reduction is unsuccessful or the joint remains unstable, the patient has the option to live with the misaligned joint or have surgery. In such a case, the orthopedic surgeon could perform an osteotomy of the medial clavicle, meaning a surgical operation to cut and reshape the inner part of the clavicle [collarbone] to achieve a stable joint.

However, when an acute posterior dislocation presents with any signs of vascular [related to blood vessels] injuries, like decreased peripheral pulses, or involves injuries to the area between the lungs like difficulty in swallowing or shortness of breath, immediate open reduction, and internal fixation surgery is required. During this surgery, surgeons who specialize in the chest area or vascular system should be available. This is because there have been cases where complications occurred from not resetting posterior dislocations even when there were initially no signs of injury in the area between the lungs. In these cases, an unsuccessful closed reduction is taken as an indication for open reduction and internal fixation.

Finally, chronic or recurrent dislocations that occur either at the front or the back, as well as persistent pain at the joint between the sternum [chest bone] and the collar bone, can be treated with medical clavicle osteotomy.

When a person has an injury involving the sternoclavicular area, which is where your collar bone connects with your breastbone, there could be several possible causes for the pain. These possibilities could include:

Fractures of the sternum, clavicle, or ribs
Sternoclavicular sprains
Partial or full displacement of the joint (subluxation or dislocation), either towards the front (anterior) or back (posterior)

However, not all sternoclavicular pain is due to trauma or injury. Some non-injury related causes could include:

Joint diseases such as osteoarthritis, rheumatoid arthritis, or crystal deposit diseases
Infections in the joint (septic arthritis) or bone (osteomyelitis)
A group of conditions known as SAPHO syndrome which include inflammation of the joints (synovitis), acne, skin lesions (pustulosis), excessive bone growth (hyperostosis), and bone inflammation (osteitis)
Condensing osteitis, a rare bone disease
Friedrich disease, a rare bone disorder
Multidirectional instability, when the joint is loose and can move or dislocate too easily in more than one direction

What to expect with Sternoclavicular Joint Injury

Injuries to the sternoclavicular joint, which is where your sternum (breastbone) meets your collarbone, often have a good outlook. For sprains or minor injuries, where the ligaments (connective tissues) are still intact, patients usually fully recover in 1 to 2 weeks. For more severe injuries that involve partial dislocation, the recovery period may take longer. There could be some visible aftermath but it usually doesn’t affect function.

Anterior dislocations – when the collarbone pops out in the front – often heal well, but how to treat these can be a subject of debate and should involve a consultation with an orthopedic surgeon. Posterior dislocations, in which the collarbone pops out towards the back, carry a high risk of complications and are considered a surgical emergency. This requires immediate consultation with an orthopedic surgeon and repositioning of the dislocated bone. If there’s any sign of injury to the nerves and blood vessels, or the structures in the space in the chest between the lungs (mediastinum), immediate surgery is required to reposition and secure the fracture. However, most patients heal well after receiving treatment for their sternoclavicular joint injuries.

Possible Complications When Diagnosed with Sternoclavicular Joint Injury

The main complications following an injury to the sternoclavicular joint – the joint that connects the sternum (breastbone) and clavicle (collarbone) – usually include pain and visible deformation of the joint. The injury can often result in sternoclavicular arthritis, and the severity of this risk increases with the extent of the joint injury. Surgery to manage such injuries can lead to other problems such as movement of implanted surgical hardware, infection, reoccurrence of dislocation, and unsatisfactory cosmetic outcomes.

Injuries involving the displacement of the sternoclavicular joint towards the back or within the chest (retrosternal or posterior dislocations) can create serious complications. Approximately 30% of such dislocations can cause damage to the windpipe, food pipe, nerves at the junction of the neck and shoulder, and major blood vessels. This injury can even be fatal in some cases. Specific injuries may include compression (squeezing) of the windpipe or food pipe, accumulation of air (pneumothorax) or blood (hemothorax) in the chest cavity, creation of an abnormal connection between the windpipe and the food pipe (tracheoesophageal fistula), dislocation of the joint where the collarbone and shoulder blade connect or fracture of the collarbone, and compression of various arteries and veins. Generally, surgery to put the sternoclavicular joint back into position improves these symptoms.

Common Complications:

Pain
Cosmetic deformation of joint
An increased risk of sternoclavicular arthritis
Complications following surgery
Serious complications from retrosternal or posterior dislocations
Potential fatal outcomes

Recovery from Sternoclavicular Joint Injury

After a certain procedure known as closed reduction which is conducted for dislocations at your shoulder’s front part, your arm would be immobilized using a special device known as a sling. Depending on how stable the joint is, you may be weaned off the immobilization device sooner (if the joint is stable) or later (if the joint is not stable) and you would be guided on performing some elbow and shoulder movement exercises gradually.

In the case of closed reduction for dislocations at the shoulder’s back part, the arm will be immobilized with a strap, known as the figure-of-8 strap, for a minimum of 6 weeks. After about 12 weeks or so, you’ll be able to begin exercises focused on strengthening your joint and improving its range of motion.

Preventing Sternoclavicular Joint Injury

There aren’t any specific guidelines on how to prevent or avoid injuries to the sternoclavicular joint, which connects your sternum (or breastbone) to your clavicle (or collarbone).

It’s important to know that this type of injury is a rare source of shoulder pain. These injuries can sometimes occur on their own, but they’re most commonly caused by severe incidents like car accidents or sports-related collisions. The most common signs of a sternoclavicular joint injury include pain, swelling, and a noticeable change in the shape of the joint.

If you experience these symptoms after a traumatic event, it’s crucial to seek medical attention immediately. These injuries are usually managed without surgery. However, if the joint is dislocated backward, an orthopedic surgeon—a doctor specialized in the treatment of bones and muscles—will likely need to perform a surgery. This is because a backward dislocation can lead to other injuries due to the close proximity of vital structures in the chest.

Frequently asked questions

Sternoclavicular joint injury refers to injuries that occur to the joint that connects the collarbone to the breastbone. These injuries are rare and can be caused by high-energy instances or traumatic events. The joint can also be affected in younger individuals without a traumatic event, causing it to slip out of place.

Sternoclavicular joint injuries make up a small portion of all shoulder injuries, specifically 3% to 5%.

Signs and symptoms of Sternoclavicular Joint Injury include: - Pain in the front of the chest and shoulder - Sudden onset of pain after a severe injury or pain that develops without an apparent reason - Repeating subluxation, where the clavicle or collarbone slips out during certain movements and then goes back to its original position - Visible swelling at the front of the chest or collarbone due to anterior or posterior dislocation - The affected shoulder might look shorter than the other one - Pain, sensitivity, swelling, and bruising over the joint area - Limited arm and shoulder movements - Pain that worsens with movement or lying on the back - Turning the head towards the affected side might ease the pain - Instability of the joint, which can be evaluated by gently moving the collarbone side-to-side - Grade I injuries don't typically show instability - Grade II injuries may show instability upon manual testing - Grade III injuries may have too much swelling or a fixed dislocation - Anterior dislocations usually don't cause injuries to other parts of the chest - Posterior dislocations are more critical and may be accompanied by significant inner chest injuries, such as shortness of breath, noisy breathing, difficulty swallowing, or numbness - Respirational issues, problems dealing with secretions, color changes, swelling, or feeble pulses in the affected limb may also be indications of posterior dislocations.

Sternoclavicular joint injuries can occur due to significant injuries such as car accidents or collisions during sports, particularly in contact and collision sports.

Fractures of the sternum, clavicle, or ribs; sternoclavicular sprains; partial or full displacement of the joint (subluxation or dislocation), either towards the front (anterior) or back (posterior); joint diseases such as osteoarthritis, rheumatoid arthritis, or crystal deposit diseases; infections in the joint (septic arthritis) or bone (osteomyelitis); a group of conditions known as SAPHO syndrome which include inflammation of the joints (synovitis), acne, skin lesions (pustulosis), excessive bone growth (hyperostosis), and bone inflammation (osteitis); condensing osteitis, a rare bone disease; Friedrich disease, a rare bone disorder; multidirectional instability, when the joint is loose and can move or dislocate too easily in more than one direction.

The types of tests that may be ordered to diagnose a sternoclavicular joint injury include: - X-rays: An anterior-posterior view and a serendipity view can provide a clear look at the joint and determine if there is a dislocation. - CT scan: This imaging test allows for a more detailed view of the joint and any additional injuries, especially in cases of posterior dislocations. - Angiography: If a vascular injury is suspected, this test can be done to view the blood vessels. - Ultrasound: While not as high quality as a CT scan, ultrasound can identify posterior dislocations. - MRI scan: This can be useful in assessing ligament damage, but is not always ordered based on the healthcare provider's judgment.

Sternoclavicular joint injuries can be treated in various ways depending on the specific condition. Non-traumatic subluxations or chronic anterior dislocations can typically be treated without surgery. Treatment involves rest, wearing a sling for comfort, gradually increasing physical activity, painkillers, and a return to normal activities. Grade I sprains usually heal in one to two weeks, while Grade II sprains may require more resting and precautions, possibly including a figure-of-eight brace for support. Acute anterior dislocations usually do not require surgery and non-surgical treatments are recommended. However, the final decision rests with the orthopedic surgeon overseeing the case. Acute posterior dislocations less than three weeks old and without signs of mediastinal injury are typically treated with closed reduction under general anesthesia. If closed reduction is unsuccessful or the joint remains unstable, the patient may choose to live with the misaligned joint or undergo surgery, such as an osteotomy of the medial clavicle. Immediate open reduction and internal fixation surgery is required for acute posterior dislocations with signs of vascular injuries or injuries to the area between the lungs. Chronic or recurrent dislocations and persistent pain at the sternoclavicular joint can be treated with medical clavicle osteotomy.

The side effects when treating Sternoclavicular Joint Injury include pain, cosmetic deformation of the joint, an increased risk of sternoclavicular arthritis, complications following surgery, serious complications from retrosternal or posterior dislocations, and potential fatal outcomes.

The prognosis for sternoclavicular joint injuries varies depending on the severity of the injury. Here are the possible outcomes: - For sprains or minor injuries where the ligaments are still intact, patients usually fully recover in 1 to 2 weeks. - More severe injuries that involve partial dislocation may take longer to recover from, but most patients heal well after receiving treatment for their sternoclavicular joint injuries.

An orthopedic surgeon.