Sternoclavicular joint injection (technique)

Sternoclavicular joint (SCJ) injections under image guidance ensure precise delivery of an injectate into the joint and, importantly, that the needle is under direct visualization.

Indications

• pain

• arthropathy, e.g. osteoarthritis

• diagnostic injection

Contraindications

Absolute

• anaphylaxis to contrast/injectates

• active local/systemic infection 

Relative

• bleeding diathesis

• 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 needle tip position with imaging

• administer intra-articular injectate, usually a corticosteroid and a small amount of long-acting local anesthetic

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 with linear probe: 38 mm probe allows for greater stability ^f

• sterile probe cover and a skin marker

• skin cleaning product

• sterile drape

• sterile field and tray for sharps

• syringe selection

  • Leur lock syringe are less likely to disconnect due to the pressure of the injection

  • 5 mL for local anesthetic

  • 3 mL for injectate

• needles

  • large bore drawing up needle

  • 2 x small bore hypodermic needles, e.g. 25 G

• injectate

  • short-acting local anesthetic for skin and subcutaneous tissues (if using), e.g. 1% lidocaine

  • intra-articular injectate - <2 mL total volume ³, for example

    • 1 mL of steroid, e.g. 40 mg/mL triamcinolone acetonide, 5.7 mg/mL betamethasone

    • 1 mL of long-acting local anesthetic, e.g. 0.5% ropivacaine, 0.5% bupivacaine

• sterile gauze

• adhesive dressing

Technique

Ultrasound

• check for allergies and blood thinners

• consent

• optimize patient positioning by laying them supine on the bed at 45 degrees for anterior access

  • external rotation and 45 degrees arm abduction can help open the anterior aspect of the SCJ ³

• 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

• insert the needle in-plane with the probe at 45 degrees angle to the skin in a medial-lateral approach that may need to be slightly obliqued aiming for the anterior aspect of the SCJ

• administer injectate under direct visualization

• remove the needle and apply dressing 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.