Wednesday, January 5, 2011

The SC joint injuries: A mini Review for Physiotherapists in acute care

Parts of SC joints:

The sternoclavicular articulation is a double arthrodial joint. The joint is made out of following boby articulating parts sternal end of the clavicle, the upper and lateral part of the manubrium sterni, and the cartilage of the first rib. The articular surface of the clavicle is much larger than that of the sternum, and is invested with a layer of cartilage, which is considerably thicker than that on the latter bone. Important parts (ligaments & disc) of this joint are:

1. The Articular Capsule
2. The Anterior Sternoclavicular ligament
3. The Posterior Sternoclavicular ligament
4. The Interclavicular ligament
5. The Costoclavicular ligament
And the
6. The Articular Disk

According to a retrospective analysis articular disk injuries were seen in 80% of patients. Injuries of the anterior, posterior, interclavicular and costoclavicular ligaments were seen in 73%, 39%, 29% and 14% of patients, respectively (10).

Movements possible in this joint- This articulation admits of a limited amount of motion in nearly every direction—upward, downward, backward, forward, as well as circumduction. Sternoclavicular joint too, the ligamentous stability is of the utmost importance. The sternoclavicular ligament limits the ante- and retroversion of the clavicle, while the costoclavicular ligament limits the upward movement (11).

Types of SC joint injuries:

Instability & dislocation of the sternoclavicular joint is a rare diagnosis (1, 2, 3, 4, 5 & 6) and will mostly be found after motor vehicle accidents or sports injuries. Echlin et al have described an adolescent butterfly swimmer with recurrent bilateral sternoclavicular subluxation associated with pain and discomfort (6).

SC joint injuries accorging to Echlin et al can be organised by degree (subluxation, dislocation), timing (acute, chronic, recurrent, congenital), direction (anterior, posterior), and cause (traumatic, atraumatic) (6). Severity of SC joint luxations is classified in association with Allmann I-III grades (7).

Anterior dislocation & posterior dislocation: The anterior forms, which are more frequent and benign, are different from the posterior forms, which are emergency cases due to the proximity of the aero-digestive and cardiovascular elements (9).

Use of radiograph in diagnosis of anterior dislocation & posterior dislocations of SC:
Although computed tomography is the ideal method of demonstrating the sternoclavicular joint, some specialized plain film projections are often useful (1). However, routine radiographs of the sternoclavicular joint are often difficult to interpret and may falsely appear normal. Following two views are very helpful for diagnostic purposes.

1. Serendipity view: A specialized view, known as the serendipity view and described by Rockwood (1975), may reveal the medial clavicle position. For this technique, the beam is tilted to 40° from vertical and directed cephalad through the manubrium of the patient while in a supine position. Normal clavicles should appear in the same horizontal plane, while anterior and posterior dislocations appear above and below the plane, respectively.

2. Hobbs view: In the Hobbs view, the patient sits at the radiography table and leans forward so that the anterior chest is in contact with the film cassette and the flexed elbows straddle the cassette and support the patient. The x-ray beam is aimed directly down through the cervical spine, projecting the sternoclavicular joints onto the film cassette.

Conservative maneuvers for SC joint injury:

Depending on the severity of the trauma open reduction is rarely required, and most cases will be treated successfully with conservative management (4,5). Conservative management consists of benign neglect and closed or percutaneous reduction and immobilization. If the injury is treated acutely, conservative management often produces good long-term results (13). According to Kiter et al good functional results may be achieved with conservative treatment of the anterior dislocation of the SCJ even without a reduction maneuver (12). Rehabilitation medicine plays a crucial role in cases sought without reduction. Even sports injury cases chosen for benign neglect & rehabilitation are found to produce good result to the treatment (6).

Closed reduction of anterior dislocation of SC:

Patient arrangement:
1. Supine lying: Shoulder at the edge of the couch.
2. Towel roll placed along the spine between the medial borders of the scapula.

Sports therapist & doctor do the following:
3. Abduct the GH to 90 degree
4. Apply long axis traction through the humerus & maintaining the traction go for a horizontal abduction of 20-30 degrees. Hold it till the SC joint pops back to it’s position & the size of the bump at the SC joint reduces.

Posterior dislocation of SC: Emergency procedure. Reduction not discussed here. However it consists of pulling the clavicle anteriorly. But it is generally treated by open reduction & internal fixation techniques.

Surgical options:
Open recuction should only be performed in cases of persistent posterior luxation, because of the numerous complications that are possible in such cases (11). Primary open reduction and fixation with Kirschner wires and/or fascia lata or PDS is recommended in the treatment of acute traumatic luxations of the sternoclavicular joint (5). Ligamentoplasty is better option than osteo-synthesis (9). A warning is given that, because of the risk of fatal complications, Kirschner wiring should not be used for retention of the reduction unless the K-wires are reliably secured (7).

Rehabilitation options:
Pain reduction with modalities (Cryotherapy in acute cases, Laser therapy, PEME, TENS etc), Mobilization for pain reduction by maitland techniques.
ROM exercises of shoulder & strengthening.

1. Cope R et al; J Orthop Trauma. 1991;5(3):379-84. (Dislocations of the sternoclavicular joint: anatomic basis, etiologies, and radiologic diagnosis.)
2. Cope R; Skeletal Radiol. 1993;22(4):233-8. (Dislocations of the sternoclavicular joint.)
3. Friedman RJ; Orthopade. 1998 Aug;27(8):567-70. (Instability of the sternoclavicular joint)
4. Franck WM et al; Unfallchirurg. 2000 Oct;103(10):834-8. (Traumatic sternoclavicular instability. A therapeutic alternative.)
5. Kahle M et al; Aktuelle Traumatol. 1990 Apr;20(2):83-6. (Luxations in the sternoclavicular joint.)
6. Echlin PS et al; Br J Sports Med. 2006 Apr;40(4):e12. (Adolescent butterfly swimmer with bilateral subluxing sternoclavicular joints.)
7. Sons HU et al; Z Orthop Ihre Grenzgeb. 1992 Jan-Feb;130(1):22-30. (Diagnosis and therapy of sternoclavicular joint dislocation.)
9. Sy MH et al; Dakar Med. 2004;49(3):211-4. (Sternoclavicular dislocations: clinical and therapeutic study. A report of 9 cases.)
11. Haas N et al; Orthopade. 1989 Aug;18(4):234-45; discussion 246. (Injuries of the acromio- and sternoclavicular joint--surgical or conservative treatment?.)
12. Kiter E et al; Ulus Travma Acil Cerrahi Derg. 2003 Jul;9(3):199-202. (Short-term results of conservative treatment without reduction maneuver of the anterior sternoclavicular joint dislocation.)
13. Yeh GL et al; Orthop Clin North Am. 2000 Apr;31(2):189-203. (Conservative management of sternoclavicular injuries.)

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