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Arthrocentesis of the Sternoclavicular Joint

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Authors

Catherine Fairgrieve Appel, DO
Resident Physician
Department of Emergency Medicine
University of Nebraska Medical Center
Omaha, NE

Ross Mathiasen, MD, CAQSM
Associate Professor
Department of Emergency Medicine
University of Nebraska Medical Center
Omaha, NE

Summary

  • Arthrocentesis of the SC joint may be performed safely with ultrasound guidance for injections and/or aspirations.
  • Knowledge of the surrounding anatomy is critical to avoid complications from this procedure.
Long axis view of the SC joint on ultrasound.
Ultrasound guided injection of the SC joint. This video demonstrates a long axis view of the SC joint with in plane approach. This technique would also work for an aspiration.
Ultrasound guided injection of the SC joint. This video demonstrates a long axis view of the SC joint with the out of plane approach. This technique would also work for an aspiration.

Introduction

  • An often overlooked source of shoulder pain, pathology of the sternoclavicular joint (SCJ), can result in clinically significant pain and result in dysfunction of the glenohumeral and scapulothoracic joints.
  • As the only synovial articulation between the upper extremity and axial skeleton the joint is subject to significant acute and chronic mechanical trauma as well as conditions including rheumatoid arthritis, infection, gout, avascular necrosis of the clavicle (Fredrich’s disease), Synovitis-Acne-Pustulosis-Hyperostosis-Osteitis (SAPHO) Syndrome, and other seronegative spondyloarthropathies.[1]Dhawan R, Singh RA, Tins B, Hay SM. Sternoclavicular joint. Shoulder Elbow. 2018;10(4):296-305.
  • While often approached using CT or fluoroscopy guidance, musculoskeletal ultrasound has been demonstrated to be a safe and accurate method for SCJ injection and aspiration.[2]Pourcho AM, Sellon JL, Smith J. Sonographically guided sternoclavicular joint injection: description of technique and validation: Description of technique and validation. J Ultrasound Med. … Continue reading[3]Hansford BG, Stacy GS. Musculoskeletal aspiration procedures. Semin Intervent Radiol. 2012;29(4):270-285.

Anatomy

  • The sternoclavicular joint is a multiaxial, diarthrodial joint composed of the medial clavicle, superolateral manubrium, and superior surface of the first rib costal cartilage.
  • An articular disc rests between these surfaces and the joint is stabilized by a capsule formed from the anterior and posterior sternoclavicular, interclavicular, and costoclavicular ligaments.
  • Knowledge and identification of surrounding anatomy and structures of the superior mediastinum are of particular importance when performing any invasive procedures in this area.
  • Deep to the SCJ lie the great vessels including the common carotid, subclavian artery, and brachiocephalic vein to the left, with the arterial brachiocephalic trunk and brachiocephalic vein on the right.[4]Dhawan R, Singh RA, Tins B, Hay SM. Sternoclavicular joint. Shoulder Elbow. 2018;10(4):296-305.[5]Hansford BG, Stacy GS. Musculoskeletal aspiration procedures. Semin Intervent Radiol. 2012;29(4):270-285.
Sternoclavicular joint anatomy
Anatomy of the Sternoclavicular Joint.[6]O’Sullivan MB, Yang J, Barden B, Singh H, Divenere J, Mazzocca AD. Sternoclavicular Joint Anatomy and Pathology. In: Normal and Pathological Anatomy of the Shoulder. Springer Berlin Heidelberg; … Continue reading
The great vessels under the sternoclavicular joint
The great vessels deep to the sternoclavicular joint.[7]Image courtesy of musculoskeletalkey.com/, “The Sternoclavicular Joint”

Ultrasound Evaluation

  • The patient should be supine
  • A linear transducer is utilized
  • Identify the bony margins of the sternum (manubrium) medially and the clavicle laterally, with the SCJ between these bony landmarks.
  • The anterior sternoclavicular ligament may be visualized.
  • The transducer may then be rotated 90 degrees along the plane of the SCJ, allowing visualization of the vasculature deep and cranial to the joint.
The sternoclavicular joint in long axis with labels. The sternoclavicular joint is outlined, needle placement target is within this area, located between the sternum and clavicle, and deep to the anterior sternoclavicular ligament.
Another view of the sternoclavicular joint in long axis with labels. Note the depth could be decreased in this view to increase resolution of the joint space.[8]Blakeley CJ, Harrison HL, Siow S, Hashemi K. The use of bedside ultrasound to diagnose posterior sterno-clavicular dislocation. Emerg Med J. 2011;28(6):542.
Position of probe placement overlying the sternoclavicular joint in long axis.
Chest US Color doppler showing flow deep to the sternoclavicular joint
Color doppler showing vasculature deep and cranial to the SC joint (oval outline). Note that probe is turned 90 degrees in short axis.
Probe position for identifying the sternoclavicular joint in short axis
Position of probe placement overlying the sternoclavicular joint in short axis.

Procedure

  • Materials
    • 18 gauge draw needle, 23-25 gauge needle for aspiration
    • 3 – 5 cc syringe
    • Local anesthetic
    • Sterile equipment (gauze, skin prep, gloves, probe cover, etc)
  • The joint may be approached via the
    • Out of plane approach (author preference)
    • In plane approach
  • Out of plane approach
    • Identify the SCJ in long axis and identify your needle target
    • Utilize a step down technique (from superficial to deep) until the needle is visualized within the joint, deep to the anterior sternoclavicular ligament.
    • Local anesthetic may be utilized as necessary for needle placement.
    • An approach angle of approximately 25-30 degrees from parallel of the sternum for initial needle insertion will be adequate for safe initial needle visualization.
Out of plane approach. Note the SCJ will be visualized in long axis with the needle out of plane. (click to enlarge)
Sternoclavicular joint arthrocentesis in plane approach
In plane approach. Note the SCJ will be visualized in short axis with the needle in plane. (click to enlarge)
  • Due to the relatively small size of the joint, volumes aspirated and/or injected are low, often not exceeding 1 mL.

Additional Considerations

  • Indications
    • Aspiration for diagnostic evaluation and symptom relief
    • Injections for diagnostic or therapeutic purposes.
  • Relative contraindications
    • Uncooperative patients
    • Coagulopathies
    • Acute clavicle fractures
    • Sternoclavicular dislocation or subluxation
    • Overlying cellulitis or osteomyelitis
    • Findings which increase the likelihood of violating structures of the superior mediastinum such as incomplete or poor visualization of the SCJ, vascular or bony anomalies, or deep effusions.

Pearls & Pitfalls

  • Effusions commonly extend anterior to the joint allowing for aspiration with relatively shallow needle insertion.[9]Lin HM, Learch TJ, White EA, Gottsegen CJ. Emergency joint aspiration: a guide for radiologists on call. Radiographics. 2009;29(4):1139-1158.
  • Typically performed in supine positioning. May elevate head of bed as necessary to displace breast tissue caudally away from the joint.
  • When utilizing the out of plane approach, it is especially important to be aware of the location of the needle tip.

Reference

References[+]