What is the SC Joint?
Sternoclavicular Joint Reconstruction:
Contemporary Stabilization Procedures and Rehabilitative Care with Case Report
Sternoclavicular Joint Background:
Acute and chronic sternoclavicular (SC) dislocations are rare. Due to the rarity, consistent assessment and treatment experience among medical providers is lacking. Recognizing the type and extent of injury to the SC joint requires a high index of suspicion, a comprehensive evaluation, and proper imaging studies. Many disorders of the SC joint can be treated non-operatively. However, surgical treatment may be indicated for irreducible dislocations and symptomatic, chronic instability that fails non-operative physical therapy. The purpose of this paper is to provide a comprehensive update on the current surgical techniques supported by anatomic, biomechanical, and outcome data that a rehabilitation specialist can expect to encounter.
Case Description:
This case details the physician assessment, surgical procedure, physical therapy treatment, and outcome of an active, 15 year-old male with atraumatic SC joint instability. A criterion-based rehabilitation guideline, in conjunction with the author’s clinical decision making, manual therapy intervention, and an understanding of the surgical technique, served as the framework for the patient’s post-operative progression. The patient returned to full-participation in sports at 7 months and he remained symptom free without functional limitations at 1 year following surgery.
Discussion:
The rarity of SC joint instability may create a gap in a physical therapists ability to recognize, treat, and post-operatively manage these patients successfully. The figure-of-8 graft reconstruction technique may be recommended more frequently due to recent favorable biomechanical and outcome research. Additional biomechanical research and stratified outcome studies will be needed to better understand adaptations in the shoulder girdle that a physical therapist may expect to find when working with these patients.
“Elevation and depression occur between the clavicle and SC disk, whereas protraction and retraction occur between the disk and the manubrium. The ligaments that stabilize the SC joint are essential for its 50° of clavicular rotation, 35° of elevation, and 35° of anterior-posterior glide.”
SC Joint Dislocations:
Sternoclavicular joint dislocations are rare injuries, representing only 2-3% of the injuries of the upper limb.1 Although rare, such injuries deserve rapid diagnosis and effective treatment to avoid future complications. Motor vehicle collisions and sports participation are the top two causes of traumatic SC joint injury.2,3,4 The injury can be classified on the basis of anatomy in posterior or anterior dislocation, etiology into direct trauma, indirect trauma, or atraumatic injuries, and to the degree of ligamentous injury.2,5 In 1967, Allman classified SC joint injuries based on the degree of ligamentous disruption. Type 1 describes a simple sprain of the SC ligaments and capsule without subluxation or dislocation. Type 2 injuries involve a disruption of the SC ligaments and capsule and result in a subluxation of the medial clavicle without dislocation. Type 3 injuries entail a rupture of all supporting ligaments with complete anterior or posterior dislocation.6
Anatomy and Biomechanics of the SC Joint
The development of the clavicle is unique compared to other bones in the body. Although it is the first long bone to ossify in the womb during the fifth gestational week, its physis is the last to close at nearly 25 years of age. As such, many SC joint dislocations in younger patients may be the result of injury to a non united epiphysis rather than ligamentous disruption.7,8,9
Figure 1. Osseoligamentous anatomy of the sternoclavicular joint.
The SC joint is an incongruous, diathrodial saddle joint composed of the medial clavicle, sternum, and first rib.10 The surfaces of the SC joint are covered with fibrocartilage and are highly incongruent. Osseous stability of the SC joint is among the lowest of the major joints in the body because less than half of the medial clavicle articulates with the superior angle of the sternum.11 As a result, this incongruity requires stability from its surrounding ligamentous supports. The SC joint articulation is held in place by the SC capsular ligaments, the costoclavicular ligament, and the interclavicular ligament (Figure 1). A fibrocartilaginous disc acts primarily as a restraint against medial displacement of the proximal clavicle and blends with the fibers of the capsular ligament anteriorly and posteriorly.10
The anatomy of the joint surfaces and ligaments dictates the functional movement at the SC joint. The arthrokinematic motion is similar whether the shoulder girdle moves actively or passively. During scapular elevation, the medial clavicle glides inferiorly on the sternum. Depression of the scapula elicits a superior glide of the medial clavicle on the sternum. The medial clavicle moves posteriorly with scapular protraction and anteriorly with scapular retraction. When the clavicle moves in one direction, the capsular ligaments on the side of the motion become lax. Ligaments on the opposite side of the joint become taut, limiting the movement.12 The axis of motion lies lateral to the joint at the costoclavicular ligament. The location of the axis so far from the joint accentuates the intra-articular motion with elevation-depression and protraction-retraction.13
Elevation and depression occur between the clavicle and SC disk, whereas protraction and retraction occur between the disk and the manubrium.14 The ligaments that stabilize the SC joint are essential for its 50° of clavicular rotation, 35° of elevation, and 35° of anterior-posterior glide. The anterosuperior and posterior aspects of the capsular ligament provide the primary support for the SC joint, with greater strength provided by the posterior component. In 1967, Bearn demonstrated that the capsular ligament is the most important structure preventing superior displacement of the medial clavicle and inferior descent of the distal clavicle.15 More recently Spencer et al. performed a cadaveric biomechanical study to demonstrate that the posterior SC joint capsule is the most important structure for preventing both anterior and posterior translation of the SC joint, with the anterior capsule acting as an important secondary stabilizer.16 Dennis et al. also found that it took 50% more force to dislocate the clavicle posteriorly, compared to anteriorly, in cadavers.17
Mechanism of Injury
Anterior dislocation is three to twenty times more common than posterior dislocation.2,18 Posterior dislocation, which is rare, may cause serious complications due to compression of prime central structures by the medial clavicle (Figure 2). Respiratory discomfort, lesions of the brachial plexus, and arterial insufficiency are some of the harmful consequences of this type of dislocation.19,20,21,22 The high rate of complications and their severity emphasize the importance of an accurate diagnosis and treatment plan.
Some of the factors contributing to SC joint stability include the particular collagen makeup of the patient’s ligaments, the arrangement of the SC ligaments and their method of attachment, and the variation in osseous anatomy of this saddle type joint. This small, incongruous joint is subject to practically every motion of the upper extremity, however the ligamentous support and design make it one of the least dislocated in the body.10
The direction of direct force to the clavicle often determines the type of dislocation.
When a force is applied directly to the anteromedial aspect of the clavicle, the clavicle is pushed posteriorly behind the sternum and into the mediastinum. This may occur in a variety of ways: for example, when an athlete is jumped on while lying on their back, the contact is directly on the medial end of the clavicle; when a kick is delivered to the front of the medial clavicle; when a person is run over by a vehicle; or when a person is pinned between a vehicle and a wall or the ground.
An indirect force can be applied to the SC joint from either the anterolateral or posterolateral aspect of the shoulder. If the shoulder is compressed and rolled backward, the anterolateral applied force produces an anterior dislocation of the SC joint as the underlying first rib acts as a fulcrum to lever the sternal end of the clavicle anteriorly.10 By contrast, a posterolateral compression on the shoulder moves it forward and the force directed toward the clavicle produces a posterior dislocation.23
Spontaneous atraumatic anterior subluxation of the SC joint is less likely to occur compared to indirect or direct trauma of the clavicle. When it does occur, it is most commonly seen in teenagers and young adults who have ligamentous laxity. The subluxation often occurs either during routine overhead activities or during overhead sports activities.5
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Contributing Authors, Collaborators, & Colleagues:
Mark Bouma, PT, DPT, OCS,COMT,FAAOMPT,CSCS
Heidi Biehl, PT, DPT, OCS, CSCS, CFSC
Matt Sato, PT, TPIc, SFMA
Benjamin Wobker, PT, MSPT, CSCS, SFMA
Joe nance, PT, MPT, OCS, COMT, FAAOMPT, ATC
DR. Samuel Koo, MD
DR. Jamie Antoine, MD
Dr. Vincent Santoro, MD
Dr. Camile Clinton, MD
Dr. Bob AdamS, DO
Dr. Christian Peterson, DO
DR. Chris Wahl, MD
Dr. Dayne Mickelson, MD
DR. Tyler Nathe, MD
Dr. Thomas CastLe,MD
Dr. Michael Sailer, MD
Dr. Greg Komenda, MD
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