Sternoclavicular Joint Injuries: Types, Diagnosis, Treatments, and Recovery

What is the treatment for sternoclavicular?

Treatment for sternoclavicular (SC) joint injuries varies significantly depending on the type and severity of the injury, ranging from non-surgical approaches like rest, ice, and physical therapy for sprains and stable dislocations, to urgent surgical intervention for severe dislocations, particularly those that are posteriorly displaced.

Understanding the Sternoclavicular (SC) Joint and Its Injuries

The sternoclavicular (SC) joint is a crucial articulation connecting the medial end of the clavicle (collarbone) to the manubrium (upper part of the sternum or breastbone). Though relatively small, it is the only true bony articulation between the upper limb and the axial skeleton, playing a vital role in shoulder and arm movement, stability, and force transmission.

Injuries to the SC joint are uncommon but can range from mild sprains to complete dislocations. They typically result from direct trauma to the front of the chest or an indirect force transmitted through the shoulder, such as a fall onto an outstretched arm or a direct blow during contact sports.

Common SC Joint Injuries:

• SC Joint Sprain: Involves stretching or tearing of the ligaments supporting the joint. Classified into three grades:
  • Grade I: Mild sprain with minimal ligament tearing and no joint instability.
  • Grade II: Moderate sprain with partial ligament tearing, causing some joint laxity but no complete dislocation.
  • Grade III: Severe sprain with complete ligament rupture, resulting in a full dislocation of the clavicle from the sternum.
• SC Joint Dislocation: Occurs when the clavicle completely displaces from the sternum. These are further categorized by the direction of displacement:
  • Anterior Dislocation: The most common type (approximately 90%), where the clavicle displaces forward and superiorly, often visible as a prominent bump.
  • Posterior Dislocation: A rarer but more serious injury where the clavicle displaces backward, behind the sternum. This is considered a medical emergency due to the proximity of vital structures in the mediastinum (e.g., trachea, esophagus, major blood vessels, nerves).

Initial Assessment and Diagnosis

Accurate diagnosis is paramount for determining the appropriate treatment. A healthcare professional will typically conduct:

• Clinical Examination: Assessment of pain, swelling, deformity, range of motion, and stability of the joint. In cases of posterior dislocation, signs of pressure on vital structures (e.g., difficulty breathing or swallowing, hoarseness, upper extremity numbness or tingling) will be evaluated.
• Imaging Studies:
  • X-rays: Often the initial imaging, though standard views can be challenging due to overlapping structures. Specific views (e.g., serendipity view, oblique views) may be used.
  • Computed Tomography (CT) Scan: The gold standard for diagnosing SC joint injuries, providing detailed images of bony alignment and displacement, especially useful for distinguishing anterior from posterior dislocations and assessing the degree of displacement.
  • Magnetic Resonance Imaging (MRI): Useful for evaluating soft tissue damage, such as ligament tears, and assessing for associated injuries or chronic inflammatory conditions.

General Principles of SC Joint Treatment

The overarching goals of SC joint treatment are to reduce pain, restore joint stability, prevent long-term complications, and facilitate a safe return to activity. Treatment approaches are broadly categorized into conservative (non-surgical) and surgical management.

Conservative Management Strategies

Most SC joint injuries, including sprains and stable anterior dislocations, are successfully managed non-surgically.

• Rest and Immobilization:
  • Initial Rest: Avoiding activities that exacerbate pain.
  • Sling or Figure-of-8 Brace: Used to support the arm and shoulder, and to limit movement of the SC joint. The duration of immobilization varies based on the injury's severity, typically from a few days for mild sprains to 3-6 weeks for more severe sprains or stable dislocations.
• Pain and Inflammation Control:
  • Ice Application: Applying ice packs to the affected area for 15-20 minutes several times a day can help reduce swelling and pain.
  • Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Over-the-counter or prescription NSAIDs (e.g., ibuprofen, naproxen) can help manage pain and inflammation.
• Physical Therapy and Rehabilitation:
  • Early Phase (Acute/Protective): Focuses on pain control, reducing inflammation, and maintaining passive range of motion in adjacent joints (elbow, wrist, hand). Gentle, pain-free active range of motion of the shoulder may begin as pain allows.
  • Mid Phase (Sub-acute/Controlled Motion): As pain subsides, the focus shifts to restoring full, pain-free range of motion of the shoulder and SC joint. This includes gentle stretching and early isometric strengthening exercises for the muscles surrounding the shoulder girdle (e.g., scapular stabilizers, rotator cuff).
  • Late Phase (Strengthening/Return to Activity): Progressive strengthening exercises targeting the scapular stabilizers (rhomboids, trapezius, serratus anterior), rotator cuff muscles, and core musculature are introduced. Proprioceptive exercises and sport-specific drills are incorporated to prepare for a safe return to full activity. Emphasis is placed on controlled, pain-free movements to avoid re-injury.

Surgical Intervention

Surgery for SC joint injuries is less common but may be indicated in specific circumstances, particularly for irreducible or unstable dislocations, or those posing a threat to vital structures.

• Indications for Surgery:
  • Posterior SC Dislocation: Almost always requires urgent reduction due to the risk of life-threatening complications (e.g., tracheal compression, esophageal rupture, major vessel injury).
  • Irreducible Dislocation: When the joint cannot be put back into place non-surgically.
  • Chronic Instability or Recurrent Dislocation: If conservative measures fail to provide stability and function.
  • Open Dislocation: When the skin is broken, exposing the joint.
  • Associated Fractures: When the clavicle or sternum is also fractured in a way that compromises stability.
• Types of Surgical Procedures:
  • Closed Reduction: For acute dislocations (especially posterior), the surgeon attempts to manipulate the clavicle back into place without an incision. This is often performed under general anesthesia.
  • Open Reduction: If closed reduction is unsuccessful or contraindicated, an incision is made to directly visualize and reposition the joint.
  • Ligament Reconstruction/Stabilization: For chronic instability or severe acute injuries, the damaged ligaments may be repaired or reconstructed using grafts (e.g., hamstring tendon) or internal fixation (e.g., sutures, plates, screws) to stabilize the joint.
  • Medial Clavicle Resection: In rare cases of chronic pain or degenerative changes resistant to other treatments, a small portion of the medial clavicle may be removed.
• Post-Operative Care: Typically involves a period of immobilization (sling or brace) followed by a structured physical therapy program, similar to conservative management but often with a more gradual progression to protect the surgical repair.

Specific Treatment Approaches by Injury Type

• SC Joint Sprains (Grade I & II):
  • Primarily conservative: rest, ice, NSAIDs, and a brief period of sling immobilization (days to 1-2 weeks).
  • Followed by progressive physical therapy to restore range of motion and strengthen surrounding muscles.
• SC Joint Sprain (Grade III) / Anterior SC Dislocation:
  • Often managed conservatively: closed reduction may be attempted, followed by 3-6 weeks of immobilization in a sling or figure-of-8 brace.
  • Physical therapy is crucial for regaining strength and stability.
  • Surgical intervention may be considered for persistent pain, instability, or if conservative treatment fails.
• Posterior SC Dislocation:
  • Urgent Medical Emergency: Requires immediate evaluation and often urgent reduction due to the risk of life-threatening complications.
  • Closed Reduction: Attempted first under general anesthesia, often with traction and direct manipulation. Thoracic surgery standby may be required.
  • Open Reduction: If closed reduction fails or if there are signs of mediastinal compression, open surgery is performed to reduce the joint and assess for associated injuries.
  • Post-reduction, immobilization for 4-6 weeks is common, followed by a comprehensive rehabilitation program.

Rehabilitation Phases and Return to Activity

Regardless of the initial treatment approach, a structured rehabilitation program is critical for optimal recovery.

• Phase 1: Acute Protection (0-2 weeks post-injury/surgery): Focus on pain and swelling control, protecting the joint, and maintaining mobility in unaffected areas.
• Phase 2: Controlled Motion (2-6 weeks): Gradual restoration of pain-free range of motion. Gentle isometric exercises for shoulder girdle muscles.
• Phase 3: Progressive Strengthening (6-12+ weeks): Introduction of resistance exercises for scapular stabilizers, rotator cuff, and core. Focus on improving strength, endurance, and neuromuscular control.
• Phase 4: Return to Activity/Sport-Specific Training (3-6+ months): Advanced strengthening, power training, agility drills, and sport-specific movements. Gradual return to full activity based on pain, stability, and functional milestones. Contact sports may require longer recovery periods.

Long-Term Outlook and Potential Complications

The prognosis for SC joint injuries is generally good, especially with appropriate management. However, some individuals may experience:

• Chronic Pain: Persistent discomfort, especially with activity.
• Instability or Recurrence: The joint may feel unstable or dislocate again, particularly anterior dislocations.
• Osteoarthritis: Long-term degenerative changes in the joint, potentially leading to pain and stiffness.
• Cosmetic Deformity: A visible bump or asymmetry, especially with anterior dislocations.
• Neurovascular Complications: Rare, but possible with posterior dislocations if not promptly reduced.

When to Seek Medical Attention

It is crucial to seek immediate medical attention if you suspect an SC joint injury, especially if you experience:

• Severe pain or swelling around the sternum/collarbone.
• Visible deformity or a prominent bump near the sternum.
• Difficulty moving your arm or shoulder.
• Any symptoms of nerve or blood vessel compression (e.g., difficulty breathing or swallowing, hoarseness, numbness, tingling, or weakness in the arm or hand).

Early and accurate diagnosis is key to effective treatment and preventing potential long-term complications of sternoclavicular joint injuries.