Sternoclavicular joint (SCJ) injections under image guidance ensure precise delivery of an injectate into the joint and importantly that needle depth is under direct visualization.
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Indications
pain
arthropathy, e.g. osteoarthritis
diagnostic injection
Contraindications
Absolute
anaphylaxis to contrast/injectates
active local/systemic infection
Relative
recent musculoskeletal steroid injection
unable to remain still for the procedure
young age
Procedure
The general principles of SCJ injections are to:
cannulate the joint
confirm an intra-articular position with imaging
administer intra-articular injectate, usually a corticosteroid and a small amount of longer-acting local anesthetic, e.g. ropivacaine; the SCJ is a small joint, therefore, the injectate volume should reflect this
Pre-procedural evaluation
Relevant imaging should be reviewed, and the details of the patient confirmed. The patient should have an opportunity to discuss the risks and benefits and consent obtained. Targeted ultrasound is usually performed.
Risks:
infection
bleeding
allergic reaction to injectate components
focal fat necrosis or skin hypopigmentation at the injection site (if injectate is in the subcutaneous tissue) 2
steroid flare
Equipment
ultrasound machine, sterile probe cover and a skin marker
skin cleaning product
sterile drape
sterile field and tray for sharps
syringe selection i.e. 5 mL and 3 mL
larger bore drawing up needle
needle to administer local anesthetic i.e. 30 or 25-gauge needle
needle to cannulate the joint i.e. 25 or 27-gauge needle
injectants i.e. local anesthetics, iodinated contrast, corticosteroid preparation
sterile gauze
adhesive dressing
Syringe selection
Using a Luer lock syringe for the injectate will mean the needle and syringe will not disconnect as the joint is often under pressure.
A suggested syringe and injectate selection for an ultrasound-guided SCJ anesthetic arthrogram injection:
5 mL syringe: 3 mL of local anesthetic, e.g. 1% lidocaine
3 mL syringe (Luer lock), e.g. 40 mg triamcinolone acetonide (40 mg/1 mL) and 1 mL 0.5% ropivacaine
Needle selection
Smaller gauge needles can be less painful but are less stiff and can bend when trying to cannulate a joint.
SCJ: 25 or 27-gauge needles
Technique
Ultrasound
check for allergies and if on blood thinners
consent
optimize patient positioning by laying them supine on the bed at 45 degrees for anterior access
identify the joint in a transverse plane; perpendicular to the clavicle, optimize imaging and mark skin entry point
clean skin and draw up appropriate medications
consider local anesthesia along the proposed needle path
under careful ultrasound guidance using anterior access, insert the needle in-plane with the probe into the SCJ, taking extreme care not to insert the needle too deep by keeping the tip in constant view
administer arthrogram injectate under direct visualization
remove the needle and apply dressing/ band-aid as required
Complications
Steroid flare is a relatively common side effect that will settle after 1 -2 days. The most serious complication is an infection causing septic arthritis. Steroid-containing injections should be postponed if there are signs and/or symptoms of local and/ or systemic infection. Possible fat necrosis causing skin dimpling and skin discolouration can occur due to steroid leaking into the surrounding soft tissues, and this should be included in the consent, for this procedure especially in this visible area 1.