Sterno-clavicular joint problems – instability, arthritis
What are Sterno-clavicular joint problems?
Sterno-clavicular (SC) joint is formed between the clavicle (collar bone) and the sternum (breast bone) and connects the upperlimb to the body. SCJ, like any other joint is covered by cartilage (a slippery substance) that helps in the movement of the bones over each other and stabilised by ligaments (a band of connective tissue) that provide strength and stability to the joint. Among the sternoclavicular joint problems, the most common problem is SC arthritis. It is a slow degenerative disease of the SC joint that occurs after the age of 50 years, commonly in post-menopausal women. SC instability is a condition in which
the joint is unstable and clicky, this could be following injury or in some cases spontaneous. The instability usually occurs following injuries to SC joint in high energy collision sports like rugby, football, motor vehicle accidents etc.
What are the symptoms of Sterno-clavicular joint problems?
The symptoms of SC joint problems are pain and swelling in the SC joint. The patients often complain of the limited range of motion in the arm and crepitus with movements. The pain is felt with any activity of hand especially overhead activities. It increases with the time so that it is felt even at rest and at night. Swelling, stiffness and deformity are also common. In inflammatory conditions like rheumatoid arthritis, pain and swelling are also felt in other joints of the body.
Patient with SC instability feels weak and loose in SC joint. They often have mild pain in the shoulder with the uncomfortable feeling of clicking of the joint on movement.
How is it diagnosed?
Your surgeon will diagnose the SC problems with your complete medical history which includes a history of injury to the SC joint. He will perform a physical examination to check your range of motion and other shoulder problems. X-ray usually provides very little information, usually your surgeon asks for a CT scan or MRI scan to determine the extent of the damage and differentiate with dislocation or a fracture.
What happens if nothing is done?
If these problems are left untreated, it may cause persistent pain with restricted range of motion and cosmetic deformity.
How is it treated?
It can be treated with both conservative and surgical methods. Majority of SCJ problems could be treated conservatively, that includes rest, immobilization, ice application, activity modification, medications and physiotherapy.
Surgery is indicated in
- Failure of conservative treatment
- Chronic instability
- Severe symptoms
- Progressive joint subluxation
- Vascular damage
- Nerve involvement
- Arthritis resulting in significant disability
- Type II, III SC joint instability
What are the non-operative treatments?
- Rest and activity modification– the patient is encouraged to take proper rest and avoid any activity that provokes pain like lifting a load.
- Ice packs- Use of ice packs is helpful to reduce pain and inflammation. application of ice 20- 30 minutes twice or thrice a day is advised.
- Immobilization- A shoulder Sling is applied to restrict the movement of the arm and allow healing, the period of immobilization depends on the severity of your SC problems.
- Physiotherapy- physical exercises are necessary to ease the pain and strengthen the muscles. The exercises should be performed with arm below the shoulder level. These exercises are programmed to strengthen the shoulder blade and rotator cuff muscles. The exercises begin with a gentle range of motion and slowly progressing to strenuous exercises under the supervision of a physiotherapist.
What does the operation involve?
The main aim of Surgery in sternoclavicular joint problems is to remove the pathology in the joint and to stabilize the joint.
- Surgery is usually performed as an inpatient under general anaesthesia, considering major blood vessels behind the joint, cardiothoracic surgeons are made aware of the procedure.
- An incision is made in the skin over the affected joint and the affected bones removed and joints stabilised with tendon or synthetic graft. In patients with instability the joint is reduced and stabilised with tendon or synthetic graft.
- The skin is stitched using absorbable sutures and a shoulder sling is applied. The surgical time is usually 1-2hrs and the majority of the patients go home the same day usually after 10 hours of operation.
What happens after surgery?
- The effect of local anaesthesia ends in 4- 10 hours after surgery. The patients are encouraged to take painkillers before they can experience pain usually for 48 hours. In this way, many patients do not report pain.
- The patient is discharged on the same day and advised to take rest and modify his activities based on the procedure. A sling is applied for 2 to 6 weeks to support healing by immobilization.
- Before discharge, the patient is taught set of gentle exercises of the shoulder. These exercises can be started from the day one after the surgery. These exercises are important to reduce stiffness and pain and restore strength and normal range of motion of the shoulder and arm.
- Light activities like using a keyboard or writing are allowed if they don’t cause excessive pain or discomfort.
- The patient is reviewed again after 2 weeks for the check of wound and physiotherapy.
- The wound should be massaged (typically after 2 weeks) using the moisturizing cream by the patient 3 times a day for 3 months once the wound is well healed. This reduces the scar sensitivity and scar-related complications (tenderness; helps scar to mature).
- Physical therapy is advised to ensure rehabilitation. Following SCJ surgery, between 2 and 4 weeks, patients are allowed to do gentle exercises. Full range of movement exercises around 6 weeks and more strenuous exercises are advised around 3 months. Your physiotherapists and surgeon will guide you for the choice and duration of the exercises. The exercises are designed in such a way that you can regain the range of motion of the shoulder with the strength of the arm.
Are there any risks?
- Damage to the nerves, vessels or tendons
- Repair failure
- Recurrence of symptoms
- Persistent of symptoms
- Injury to the major vessels, wind pipe (Trachea) or food pipe (Oesophagus)
- Frozen shoulder
- Hypertrophied scar
What are the results of the operation?
The success rate of surgery in rotator cuff tears is > 80% with fast recovery and minimal complications. However, the results depend on the age of the patient, his profession, duration, the extent of damage to the joint.
When can I return to driving and work?
Depending on your job, you can return to work in 2 weeks (desk job) to few months (manual labour) and start driving after 6 -10 weeks. However, for a full recovery it may take a year or two to regain full functioning of the shoulder. Your surgeon can give you correct advice for this.
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