| ICD-9-CM: |
| 839.61 - | Dislocations, Other, Multiple, and Ill-defined, Other Vertebra, Open, Other Location, Closed, Sternoclavicular Joint |
| 839.71 - | Dislocations, Other, Multiple, and Ill-defined, Other Location, Open, Sternum |
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The sternoclavicular joint is a saddle-like joint that links the arm to the torso and allows free movement of the collarbone (clavicle) in almost all planes. Sternoclavicular joint dislocation is the displacement of the clavicle from its normal position relative to the breast bone (sternum). Anterior sternoclavicular (SC) joint dislocation occurs when the medial end of the clavicle is pushed forward toward the outside of the chest from its normal position (anterior dislocation). Posterior (retrosternal dislocation) occurs when the clavicle is pushed backward into the chest. Direct trauma to the medial clavicle may result in a posterior SC dislocation with damage to the trachea, esophagus, thoracic duct, lung, or large blood vessels. Sternoclavicular dislocations usually require significant force; a traumatic dislocation commonly results from an indirect blow to the front of the shoulder (anterior shoulder) when the arm is held away from the body (abducted). Dislocation may also occur from congenital, degenerative, or inflammatory processes. Generalized ligamentous laxity may cause repeated SC dislocation or partial dislocation (subluxation) in the absence of trauma.
The severity of sternoclavicular joint dislocation is classified according to the extent of damage to the sternoclavicular and costoclavicular ligaments. First-degree injuries are most common and result in a stretching or incomplete tearing of the sternoclavicular and/or costoclavicular ligaments. Second-degree injury involves a complete tear of the sternoclavicular ligament and a partial tear of the costoclavicular ligament. Third-degree injury involves rupture of both ligaments and complete dislocation of the clavicle from the upper part of the breast bone (manubrium).
Risk: Young males are at greatest risk for sternoclavicular joint dislocation occurring as a result injuries sustained during a severe fall, motor vehicle accident, or contact sport such as football or hockey. Non-traumatic SC dislocations, usually due to ligamentous laxity, are most common in individuals under 20 years of age and are more common in females (Bicos). Incidence and Prevalence: Dislocation of the sternoclavicular joint is uncommon. Only about 3% of all shoulder injuries involve sternoclavicular dislocation (Rudzinski). Anterior dislocations outnumber posterior dislocations, which are rare, by 20 to 1 (Ernberg). |
Source: Medical Disability Advisor
History: A thorough history including any trauma prior to the injury, the mechanism of injury, history of prior SC joint dislocation(s), underlying medical conditions, and medications should be obtained. The individual may report trauma to the chest or shoulder area. Shoulder or chest pain is worse with arm movement, especially elevation of the arm and with lying flat on the back (supine). The individual may also have weakness of the shoulder/arm on the affected side and may report having heard or felt a "popping" at the time of the injury. Individuals with a posterior sternoclavicular dislocation may experience shortness of breath (dyspnea), difficulty swallowing (dysphagia), or tingling in the arm (paresthesia). These symptoms should prompt further investigations to determine their cause. Physical exam: Observation of the individual may reveal that the head is tilted toward the injured side and the affected arm is held across the chest. Vitals signs should be obtained with particular attention to signs of respiratory distress (i.e., rapid respiratory rate [tachypnea], harsh high-pitched wheezing [stridor]), and any signs of circulatory problems in the head, neck, and upper extremities. On physical examination, the affected shoulder usually appears shortened and thrust forward. There may be visible swelling or deformity, and palpation of the joint may reveal tenderness. Individuals often have pain with normal shoulder range of motion and shrugging of the shoulders. Posterior dislocations may be less apparent, especially if there is soft tissue swelling. Tests: A CT scan of the upper thorax centered over the sternum will show the position of the clavicle and allow comparison with the normal clavicle on the uninjured side. CT scan also can reveal any concomitant injuries to the chest. MRI may be used to evaluate soft tissue injuries. Angiography or esophagoscopy may be necessary if other injuries to the chest from a posterior dislocation are suspected. |
Source: Medical Disability Advisor
Treatment of sternoclavicular joint dislocations depends upon the type of dislocation (i.e., anterior or posterior) and the severity of the injury (i.e., first-, second-, or third-degree). First-degree dislocations are treated nonsurgically (conservatively) with anti-inflammatory medications (NSAIDs) to relieve pain and inflammation, rest of the affected arm and shoulder, ice (cold therapy), and placement of the affected arm in a sling.
With second-degree dislocations, a figure-8 harness usually is added to this regimen for 7 to 10 days. With a third-degree injury, the joint must be restored to its normal position (reduced), either with manipulation/traction under sedation (closed reduction) or with surgery and general anesthesia (open reduction). The treatment regimen for a second-degree injury is followed after reduction. In cases requiring surgical reduction, longer periods of immobilization will be necessary. Posterior dislocations are usually reduced surgically under general anesthesia because of the higher incidence of associated vascular and chest injuries. Pins are not used to stabilize the joint due to the possibility of pin migration into the chest region. Posterior dislocations may require emergency treatment of associated injuries and/or complications. |
Source: Medical Disability Advisor
| First- and second-degree dislocations have a good to excellent outcome following appropriate conservative treatment. Prognosis for third-degree dislocations is more guarded and depends on complications from associated injuries. Anterior dislocations that do not require reduction or that are easily reduced via closed reduction have a better outcome than those that require open reduction. Posterior dislocations usually require open reduction and may have a poorer outcome due to associated injuries. |
Source: Medical Disability Advisor
Rehabilitation of a sternoclavicular joint dislocation depends greatly on the direction and extent of the dislocation, and the associated soft tissue injury (Lemos). As a result of the proximity of vital organs and structures to this joint, the therapist must be cautious, primarily with posterior dislocations, and observe the individual for any unusual signs and symptoms (Rudzki).
The primary focus of rehabilitation is to control pain and regain function. The degree of immobility following the injury will determine the amount of supervised exercise needed to resume pre-injury activities. When indicated by the treating physician, mobilization of the shoulder may be initiated.
The therapist may use cold or warm modalities throughout rehabilitation to control inflammation and pain (Salter). Rehabilitation of a sternoclavicular dislocation begins with range of motion exercises to the shoulder in all pain-free movements. Individuals may progress to strengthening exercises using pain as a guide, but should avoid motions that may compromise the integrity of the joint. Care should be taken to strengthen all muscles surrounding the shoulder and scapula. The individual may be instructed to continue a daily home exercise program in conjunction with supervised treatment.
Ligaments and soft tissues surrounding the sternoclavicular joint may take up to 12 weeks to heal. During this time, depending on the severity and direction of the dislocation, heavy loading of the involved arm through activities such as heavy lifting or contact sports might be restricted. After healing has occurred, more aggressive strengthening exercises can be added until the resumption of pre-injury functional levels. |
FREQUENCY OF REHABILITATION VISITS | | Nonsurgical ‡ | |
| Physical or Occupational Therapist | | Up to 12 visits within 6 weeks | | | | | | | | Surgical ‡ ‡ | |
| Physical or Occupational Therapist | | Up to 8 visits within 4 weeks | |
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‡ Note on Nonsurgical Guidelines: Exercise may not be initiated until after 6 to 8 weeks of immobilization.
‡ ‡ Note on Surgical Guidelines: If surgery is required, this is not an uncomplicated case. |
| The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice. |
Source: Medical Disability Advisor
Anterior sternoclavicular joint dislocations usually do not cause serious complications, but may result in a permanent cosmetic deformity or decreased range of motion. Posterior sternoclavicular joint dislocations, however, have a 25% complication rate including tracheal rupture, pneumothorax, laceration of the superior vena cava, occlusion of the subclavian artery and/or vein, and recurrent dislocations. There may be life-threatening consequences if the diagnosis is missed (Ernberg).
Most surgical complications involve migration of orthopedic hardware into vital structures, which may result in death. This has led to increasing use of alternate techniques that use muscle, tendon, or synthetic materials to reconstruct the sternoclavicular ligaments. Complications after open sternoclavicular procedures have been reported in up to 25% of cases (Canale). |
Source: Medical Disability Advisor
| Use of the affected arm and shoulder, including lifting and overhead work, may be restricted for up to 8 weeks, with a gradual increase use of the affected arm. Following successful rehabilitation, the majority of individuals are able to resume their full work load. Medication may be needed to control pain. Company policy on medication usage should be reviewed to determine if pain medication use is compatible with job safety and function. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- What was the mechanism of injury?
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Was dislocation congenital or the result of developmental, degenerative, or inflammatory processes?
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Was individual's dislocation anterior or posterior?
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Was individual's dislocation first-, second-, or third-degree?
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Did individual have CT or MRI? Was additional testing such as angiography or esophagoscopy necessary?
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Were conditions with similar symptoms ruled out?
Regarding treatment:
- Is individual following the prescribed conservative treatment regimen of NSAIDs, rest, and ice?
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Is individual wearing a figure-8 harness or sling as directed?
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Was a closed or open reduction done?
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Does individual require physical therapy?
Regarding prognosis:
- Is individual active in physical therapy? Does individual participate in a home exercise program?
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Can individual's employer accommodate any necessary work restrictions?
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Does individual have any conditions that may affect recovery?
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Did individual have any complications that would affect recovery?
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Did individual experience additional injuries that would delay recovery?
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Source: Medical Disability Advisor
| CitedErnberg, L. A., and H. G. Potter. "Radiographic Evaluation of the Acromioclavicular and Sternoclavicular Joints." Clinics in Sports Medicine 22 2 (2003): 255-275. MD Consult. Elsevier, Inc. 15 Sep. 2008 <http://home.mdconsult.com/das/journal/view/41337842-2/N/13094193?sid=287642244&source=MI>.Bicos, J., and G. P. Nicholson. "Treatment and Results of Sternoclavicular Joint Injuries." Clinics in Sports Medicine 22 2 (2003): 359-370. MD Consult. Elsevier, Inc. 15 Sep. 2008 <http://home.mdconsult.com/das/journal/view/41337842-2/N/13094201?sid=287642244&source=MI>. Rudzinski, John P., and Nicholas Kunio. "Sternoclavicular Joint Injury." eMedicine. Eds. Daniel J. Dire, et al. 25 Jan. 2007. Medscape. 12 Jan. 2009 <http://emedicine.medscape.com/article/828642-overview>. Canale, S. Terry, and James H. Beatty, eds. "Sternoclavicular Joint." Campbell's Operative Orthopaedics. 11th ed. Philadelphia: Mosby Elsevier, 2007. |
| RehabilitationLemos, M. J., and E. T. Tolo. "Complications of the Treatment of the Acromioclavicular and Sternoclavicular Joint Injuries, Including Instability." Clinics in Sports Medicine 22 2 (2003): 371-385. National Center for Biotechnology Information. National Library of Medicine. 15 Sep. 2008 <PMID: 12825537>.Rudzki, J. R., M. J. Mataya, and G. A. Paletta. "Complications of Treatment of Acromioclavicular and Sternoclavicular Joint Injuries." Clinics in Sports Medicine 22 2 (2003): 387-405. National Center for Biotechnology Information. National Library of Medicine. 15 Sep. 2008 <PMID: 12825538>. Salter, Robert, ed. Textbook of Disorders and Injuries of the Musculoskeletal System. 3rd ed. Philadelphia: Lippincott, Williams & Wilkins, 1999. |
Source: Medical Disability Advisor
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