Sternoclavicular Joint Injection

Patients usually respond well to one steroid injection. See Pourcho et al for a free access review.. The topics of sternoclavicular joint pain and sternoclavicular joint anatomy are addressed elsewhere.
==Anatomy==
The sternoclavicular joint has a small meniscus which can be injured. The joint line runs obliquely laterally superiorly to inferiorly. It can be identified by asking the patient to protract and retract the shoulder, and palpating the joint at the medial end of the clavicle.Malanga, Gerard A., and Kenneth R. Mautner. Atlas of ultrasound-guided musculoskeletal injections. New York: McGraw-Hill Education Medical, 2014
==Indications==
Injection can be considered for those with persistent SCJ pain that is unresponsive to non-interventional management. It can also be used for diagnostic purposes if there is clinical uncertainty.
==Contraindications==
==Pre-procedural Evaluation==
==Equipment==
==Technique==
===Ultrasound Guided===
Ultrasound guided injection is highly accurate. In the presence of an intact intra-articular disc, most of the injectate tends to go to the clavicular side of the joint, rather than the sternal side. Most osteoarthritic changes occur on the clavicular side. 
*Joint visualisation
**Find the joint by direct palpation. Normally the clavicle lies superficial to the manubrium, creating a step-off. Passive shoulder motion can be used to aid in palpation.
**Visualise the SCJ in its long axis, perpendicular to the joint line, using a high-frequency linear array transducer
**The disc may be visualised as a hypoechoic intra-articular structure. Try increasing the gain setting to accentuate its appearance.
**Pathological changes include cortical irregularity, widening or instability when examined dynamically, and joint effusion.
*Position the patient seated or supine, with the arm adducted in neutral rotation
*Consider a gel standoff, where additional gel is placed, especially if there is a large step-off deformity.
*In plane technique version 1
**Probe position in anatomic sagittal oblique plane over the anterior aspect of the SCJ
**Direct needle in an anterior to posterior direction targeting the anterior SCJ
*In plane technique version 2
**Probe position anatomic coronal oblique plane over the medial aspect of the SCJ
**Needle approach medial to lateral targeting the medial SCJ
*Avoid inserting the needle beyond the posterior capsule where it may injury retrosternal structures.
===Fluoroscopy Guided===
===Landmark Guided===
The accuracy of landmark guided injections has been evaluated to be 78%.
*Patient sitting supported with arm is slight external rotation
*Identify the mid-point of the joint line.
*Insert needle perpendicularly through the joint capsule
*Inject solution as a bolusSaunders, Stephanie, Steve Longworth, and Elaine Hay. Injection techniques in musculoskeletal medicine : a practical manual for clinicians in primary and secondary care. Edinburgh: Churchill Livingstone/Elsevier, 2012.
==Complications==
==Aftercare==
Rest for a week then do progressive mobilisation.
==Videos==
See pourcho et al's free access videos - out of plane and in plane.
==See Also==
*Sternoclavicular Joint Pain and Instability
*Sternoclavicular Joint Anatomy
==External Links==
==References==
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