What happened?

2. What happened? • Kickoff • Player down on the field • Pain with neck movement down his arm • Shortness of breath • Chest pain

3. What was his injury

4. Sternoclavicular Joint

5. Sternoclavicular Articulation • is a synovial double-plane joint composed of two portions separated by an articular disc.

6. Sternoclavicular Articulation • The parts entering into its formation are the sternal end of the clavicle, the upper and lateral part of the manubrium sterni (clavicular notch of the manubrium sterni), and the cartilage of the first rib, visible from the outside as the suprasternal notch.

7. Sternoclavicular Articulation • 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.

8. Sternoclavicular Articulation • The sternoclavicular joint allows movement of the clavicle in three planes, predominantly in the anteroposterior & vertical planes, although some rotation also occurs.

9. Sternoclavicular Articulation • is supported superiorly by the interclavicular ligament that connects the superomedial portions of each clavicle.

10. Interclavicular Ligament

11. Sternoclavicular Articulation • Muscles don't directly act on this joint, although all almost all actions of the shoulder girdle or the scapula will cause some motion at this articulation.

12. Sternoclavicular Articulation • The unique double-hinged articular disk found at the junction of the clavicular head and manubrium allows for movement between the clavicle and the disk during elevation and depression of the scapula.

13. Sternoclavicular Articulation • This disk also allows motion between the sternum (manubrium) and itself during protraction and retraction of the scapula.

14. Sternoclavicular Articulation • A freely moveable synovial joint links the upper extremity to the torso, with the sternoclavicular joint (SCJ) participating in all movements of the upper extremity. • The SCJ is a saddle-type joint that provides free movement of the clavicle in nearly all planes.

15. Concave – Convex Rule?

16. Sternoclavicular Joint • The ability to thrust the arm and shoulder forward requires sound function of the SCJ.

17. Sternoclavicular Joint • Because only about 50% of the medial end of the clavicle articulates with the manubrium, the SCJ has little inherent stability. • Most of the SCJ's strength and stability originates from the joint capsule and supporting ligaments.

18. Sternoclavicular Joint • The capsule surrounding the joint is weakest inferiorly, while it is reinforced on the superior, anterior, and posterior aspects by the various ligaments. • These include the interclavicular, anterior and posterior sternoclavicular, and costoclavicular ligaments.

19. Sternoclavicular Joint Dislocation • Whether the SCJ subluxes or dislocates depends on the extent of the damage to the supporting ligaments and capsule.

20. Sternoclavicular joint injuries (SJIs) are graded into 3 types. What are they?

21. A first-degree injury • simple sprain, constitutes an incomplete tear or stretching of the sternoclavicular and costoclavicular ligaments. • Discomfort is mild, and no instability is present. • This is the most common type of SJI.

22. A Second-Degree Injury • the clavicle undergoes an anterior or posterior subluxation from its manubrial attachment, signifying a complete breach of the sternoclavicular ligament but at most, only a partial tear of the costoclavicular ligament.

23. A Third-Degree Injury • complete rupture of the sternoclavicular and costoclavicular ligaments permits the clavicle to completely dislocate from the manubrium. • A significant direct or indirect force to the shoulder region can cause a traumatic dislocation of the SCJ.

24. Anterior Dislocation • of the SCJ are much more common (by a 9:1 ratio • indirect mechanism such as a blow to the anterior shoulder that rotates the shoulder backward and transmits the stress to the joint.

25. Posterior Dislocations • Traumatic contact driving the shoulder forward can cause posterior dislocations of the SCJ, as can direct impact to the superior sternal or medial clavicular surfaces.

26. Dislocations

27. Frequency • The ligaments and capsule of the SCJ contribute enough stability to make this one of the least dislocated joints in the body.

28. Sternoclavicular Dislocations • are uncommon, accounting for only 3% of a series of 1603 shoulder girdle injuries. • Posterior dislocations are considerably less common than anterior dislocations. • Only 1 patient in the cited series of 1603 shoulder girdle injuries had a posterior dislocation.

29. Mortality/Morbidity • occur infrequently with anterior dislocations of the SCJ. • Problems are usually related to issues of physical appearance as well as pain and functional limitations for persons with an active lifestyle.

30. Posterior Dislocations • has an estimated 25% complication rate. • Complications from posterior displacement of the clavicle have included pneumothorax, laceration of the superior vena cava, occlusion of the subclavian artery or vein, and disruption of the trachea. • These and other complications can cause significant disability and even death.

31. Sex and Age • Overall incidence of sternoclavicular joint injury is higher in males than in females, probably because of the activities (eg, motor vehicle crash, contact sports) associated with the injury. • However, recurrent atraumatic anterior subluxation of the SCJ (usually associated with overall joint laxity) though rare, occurs more frequently in young girls.

32. History • Sternoclavicular joint (SCJ) dislocations may follow direct trauma to the anteromedial aspect of the clavicle that drives it backward and causes a posterior dislocation.

33. History • More commonly, dislocations arise from an indirect force applied to the anterolateral or posterolateral shoulder that compresses the clavicle down toward the sternum. • The direction the shoulder is driven determines the type of dislocation.

34. Posterior Dislocation • When overwhelming compression propels the shoulder forward, the force directed toward the clavicle produces a posterior dislocation of the sternoclavicular joint.

35. Anterior Dislocation • If the shoulder is pressed and rotated backward, the force directed down the clavicle produces an anterior dislocation of the sternoclavicular joint. • AtraumaticSCJ dislocations can occur rarely.

36. Physical Exam • Patients commonly complain of chest and shoulder pain exacerbated by arm movement or by assuming a supine position. • Pain tends to be more severe with posterior dislocations. • Additional symptoms may be caused by associated injuries or by compression of adjacent structures by a posterior SCJ dislocation and may include the following: • Dyspnea • Dysphagia • Paresthesias

37. Physical Exam • Check vital signs, especially respirations. Tachypnea, stridor, and other signs of respiratory distress (posterior dislocations) may be present. • Verify adequacy of circulation. • Venous congestion of the head, neck, and/or affected arm may result from posterior dislocations.

38. Physical Exam • Generally, edema and tenderness are present over the SCJ. • Pain manifests with any range of motion testing that affects the SCJ and becomes more severe when a lateral compressive force is applied to the shoulders.

39. Physical Exam • Palpation reveals a medial protrusion.

40. In a "pile-on" in football, the shoulder off the ground may be rolled backward, causing an anterior dislocation, or rolled forward, causing a posterior dislocation.

41. Falls (eg, a person falling on an outstretched abducted arm, driving the shoulder medially) are also responsible.

42. Differentials • Fractures, Clavicle • Fractures, Rib • Fractures, Scapular • Fractures, Sternal

43. X-rays • Routine radiographs of the sternoclavicular joint are often difficult to interpret and may falsely appear normal. • 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.

44. CT scan • is an excellent technique to study problems of the sternoclavicular joint. • Request inclusion of both sternoclavicular joints and the medial half of both clavicles on the CT scan so the injured side can be compared with the noninjured side. • In addition to revealing the position of the medial clavicle, CT scan provides important information about the vital tissues of the superior mediastinum, which may be concomitantly injured.

45. Treatment • sternoclavicular joint injuries (SJIs) may incur severe and life-threatening additional injuries. • Foremost, address the ABCs during prehospital care, with rapid transport to an appropriate trauma care facility. • For patients with seemingly isolated SJI, immobilization of the affected upper extremity with a sling stabilizes the joint and minimizes pain.

46. Treatment • Sprains of the SCJ require only symptomatic treatment (ie, immobilization with a sling, ice for 24-48 h, analgesics, and anti-inflammatory medications).

47. Treatment • Acute anterior dislocations usually can be treated nonoperatively, but interposition of the joint capsule or the ligaments can make the joint irreducible. Additionally, maintaining reduction of anterior dislocations often is difficult

48. Treatment • Treatment options for recurrent/unreduced anterior SCJ dislocations may include open reduction and internal fixation, or acceptance of some degree of permanent instability, depending on the patient's characteristics and functionality.

49. Acute Posterior Dislocations • are a more serious injury because of their association with vascular injuries to the intrathoracic and superior mediastinal structures and are typically reduced in an operating room with the patient under general anesthesia • The treatment of associated injuries and/or complications may take priority over the SCJ dislocation. • Treatment options for unreduced posterior SCJ dislocations may include open reduction and internal fixation, or acceptance of some degree of permanent instability, depending on the patient's characteristics and functionality.

50. Physiatric Prescription?