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I have completed bits of my EM training from India. Currently I am boarded with credentials from Christian Medical College, Vellore and also from the prestigious Royal College of Emergency Medicine, UK.  I am currently working in London as an A&E doctor, trying to appreciate the differences in the practise and culture of Emergency Medicine across different healthcare systems. I have always been an avid FOAMed supporter because FOAMed played an indispensable role during the days of my initial training. Through this blog, I aspire to disseminate knowledge and stay up to date with the EM literature. 

Monday, November 6, 2017

Sternoclavicular joint Injuries

Sternoclavicular joint is an  extremely stable joint, due to the strong surrounding ligaments, and thus fracture/dislocations are rare and most injuries simple sprains. Significant forces are required to disrupt the strong ligamentous stabilizers of this joint. The most common causes are MVCs and injuries sustained in contact sports.
 The joint may be anteriorly or posteriorly dislocated.





Grading on Injury
Injuries to the SCJ can be graded into three types. A grade I injury is a mild sprain secondary to stretching of the sterno-clavicular and costoclavicular ligaments. A grade II injury is associated with subluxation of the joint (anterior or posterior) secondary to rupture of the sternoclavicular ligament. The costoclavicular ligament remains intact. Complete rupture of the sternoclavicular and costoclavicular ligaments results in a grade III injury (dislocation).

Minor trauma may result in a sprain are treated with with ice, sling, and analgesics and follow up with Orthopaedics. 

Anterior and Posterior Dislocation
Results from a direct blow to the shoulder, causing the shoulder to roll forward. Patients present with severe pain which is exacerbated by arm movement and lying supine. The pain will be exacerbated by lateral shoulder compression, arm movements, deep breathing or coughing.The shoulder may appear shortened and rolled forward. 


http://msk-anatomy.blogspot.co.uk/2012/06/sternoclavicular-joint.html

On examination, anterior dislocations have a prominent medial clavicle end that is visible and palpable anterior to the sternum while in posterior dislocations, the medial clavicle end is less visible and often not palpable, and the patient may have signs and symptoms of impingement of the superior mediastinal contents, such as stridor, dysphagia, and shortness of breath. 



Imaging
CXR is needed to exclude a injuries such as a  pneumothorax, pneumomediastinum, and hemopneumothorax. Routine radiographs have a low sensitivity for the detection of dislocation and thus special views and comparison with the other clavicle may be required. CT remains the imaging procedure of choice and is recommended especially in any posterior dislocation with concern for injury to the mediastinal structures. 



Management

Anterior Dislocation
Patients with uncomplicated anterior dislocations may be discharged without an attempted reduction. Look for concomitant Glenohumeral and Acromioclavicular joint injuries. Clavicular splinting, ice, analgesics, sling, and orthopedic referral are required.

Closed reduction may be performed within 10 days of the injury by placing the patient supine with a towel rollin between the shoulder blades. The arm is then abducted to 90 degrees and longitudinal traction is applied with slight extension by moving the arm toward the ground, and pressure is placed over the medial end of the clavicle. The application of direct pressure over the medial end of the clavicle may also reduce the joint. Post reduction, the patient should be placed in a figure of * brace for 4-6 weeks. Despite successful reduction, the joint is usually remains unstable and redislocates in half of the cases.




The use of acute reduction of anterior dislocations is controversial as most end up redislocating and reduction techniques risk injury to mediastinal structures.


Posterior Dislocation
Posterior dislocations may be associated with life-threatening injuries to adjacent structures, including pneumothorax or injury to surrounding great vessels, trachea, or oesophagus.  Orthopedic consultation is necessary for closed or open reduction. Open reduction should be performed in the operating room.


Take Home
  • Posterior dislocations necessitate prompt orthopaedic referral and looking for evidence of compression of retrosternal structures.
  • Anterior dislocations often remains unstable post treatment and thus acute reduction is debatable. 


Further Reading:
  • Rosen's Emergency Medicine - 7th Edition
  • TIntinalli's Emergency Medicine - 8th Edition
  • LIFTL
  • ALiEM
  • Morell, D. J., & Thyagarajan, D. S. (2016). Sternoclavicular joint dislocation and its management: A review of the literature. World Journal of Orthopedics7(4), 244–250. http://doi.org/10.5312/wjo.v7.i4.244

Posted by:

              
     Lakshay Chanana
     
     Speciality Doctor
     Northwick Park Hospital
     Department of Emergency Medicine
     England

     @EMDidactic




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