Instability of the sternoclavicular joint

Current concepts in classification, treatment and outcomes

M. D. Sewell, N. Al-Hadithy, A. Le Leu, S. M. Lambert

Abstract

The sternoclavicular joint (SCJ) is a pivotal articulation in the linked system of the upper limb girdle, providing load-bearing in compression while resisting displacement in tension or distraction at the manubrium sterni. The SCJ and acromioclavicular joint (ACJ) both have a small surface area of contact protected by an intra-articular fibrocartilaginous disc and are supported by strong extrinsic and intrinsic capsular ligaments. The function of load-sharing in the upper limb by bulky periscapular and thoracobrachial muscles is extremely important to the longevity of both joints. Ligamentous and capsular laxity changes with age, exposing both joints to greater strain, which may explain the rising incidence of arthritis in both with age. The incidence of arthritis in the SCJ is less than that in the ACJ, suggesting that the extrinsic ligaments of the SCJ provide greater stability than the coracoclavicular ligaments of the ACJ.

Instability of the SCJ is rare and can be difficult to distinguish from medial clavicular physeal or metaphyseal fracture-separation: cross-sectional imaging is often required. The distinction is important because the treatment options and outcomes of treatment are dissimilar, whereas the treatment and outcomes of ACJ separation and fracture of the lateral clavicle can be similar. Proper recognition and treatment of traumatic instability is vital as these injuries may be life-threatening. Instability of the SCJ does not always require surgical intervention. An accurate diagnosis is required before surgery can be considered, and we recommend the use of the Stanmore instability triangle. Most poor outcomes result from a failure to recognise the underlying pathology.

There is a natural reluctance for orthopaedic surgeons to operate in this area owing to unfamiliarity with, and the close proximity of, the related vascular structures, but the interposed sternohyoid and sternothyroid muscles are rarely injured and provide a clear boundary to the medial retroclavicular space, as well as an anatomical barrier to unsafe intervention.

This review presents current concepts of instability of the SCJ, describes the relevant surgical anatomy, provides a framework for diagnosis and management, including physiotherapy, and discusses the technical challenges of operative intervention.

Cite this article: Bone Joint J 2013;95-B:721–31.

Footnotes

  • The authors would like to thank Anatomy Atlases (www.anatomyatlases.org) for their kind permission to use Figure 1, and also to Springer Science+Business Media for their kind permission to use Figure 3.

    No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

    This article was primary edited by D. Rowley and first-proof edited by J. Scott.

  • Supplementary material. Intra-operative photographs showing the surgical technique for reconstruction of the sternoclavicular joint with the sternocleidomastoid tendon are available alongside the electronic version of this article on our website www.bjj.boneandjoint.org.uk

  • Received October 8, 2012.
  • Accepted February 21, 2013.
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