Sternal Fractures

Case Study:

A 55 year old male is brought into your trauma bay c/o of severe central chest pain thats reproducible on palpation and movement , post being involved in a rear ended MVA at 60kph. The patient was a restrained driver, of an old model car with-out airbags. Paramedics report patient was haemodynamically stable en-route, ECG shows sinus tachycardia, and pain has been relieved by intranasal fentanyl.

You begin your primary and secondary trauma survey, and arrange for a chest x-ray, 12 lead ECG, IV access and bloods including cardiac markers, and ask the friendly ED ultrasound consultant to FAST scan the patient.

Seat belt sign with sternal fracture

Seat belt sign with sternal fracture

 

Sternal Fractures:

  • Sternal fractures result from severe mediastinal trauma, and occur in approximately 3% of blunt chest trauma.
  • Sternal fractures are caused by blunt anterior chest trauma, with 60-90% of cases occurring in motor vehicle accidents by seat belts or by direct impact with the steering wheel. (Incidents are now decreasing with more cars fitted with airbags.)
  • Other causes of sternal fracture are assaults, contact sports, and bone insufficiency
  • Patients over 50 have a higher prevalence and risk of sustaining sternal fractures, with a higher incident in the elderly and women
  • Fractures of the sternum are considering among the most painful thoracic wall injuries
  • 6-12% of patients with sternal fractures will develop an associated myocardial contusion

Image from: www.kidport.com

Emergency Department Assessment:

  • Assess: Airway, breathing, circulation,C-spine, disability and exposure
  • Secondary survey; looking for associated injuries
  • Sternal fractures can result from hyperflexion injuries, also causing spinal column injuries
  • Patients will generally complain of localised pain to the sternum, worse on movement, inspiration and expiration, and is easily reproduced on palpation and coughing
  • Crepitation or displacement is generally not able to be elicited on exam unless the fracture involves significant instability of the sternal bone
  • Around half of patients with sternal fractures will have localised soft tissue swelling and bruising
  • Obtain 12 lead ECG and cardiac monitoring to assess for cardiac contusion, dysrhythmia, conduction disturbances, or ST-segment changes consistent with myocardial injury
  • Cardiac markers (Troponin, Creatine kinase, myoglobin) are required initially to assess for blunt cardiac injury
  • Diagnosis is able to be made clinically however imaging is recommended to assess for associated injuries

Assess for associated injuries:

Radiological Investigations:

X:Ray:

  • Currently remains diagnostic tool of choice, although ultrasound is catching up with promising result being published
  • Standard anteroposterior chest and lateral chest X-ray can reveal fracture, however sternal views are more definitive for detecting injury
Sternum fractureSternum fracture displaced
Sternum fracture buckleSternum fracture oblique
Click image to see full sized version

Ultrasound:

  • A recent study has shown ultrasound to  have a 100% sensitivity and specificity compared to 70.8% for plain radiographs for detecting sternal fractures in blunt chest trauma (abstract)
  • Sonography of sternal fractures may reveal discontinuity of hyperechoic line representing the bony cortex

Transverse Sternal Fracture with displacement

Transverse Sternal Fracture with displacement

CT Scan:

  • Is useful for assessing for associated injuries
  • Newer CT scanners with 3D capabilities have superior sensitivity and specificity however should be used as a last resort after X-ray and ultrasound related to cost and radiation exposure

Emergency Department Management:

  • Initial management involves, supplemental oxygen, cardiac monitoring, analgesia, and imaging.
  • Opiates generally required initially for adequate pain control, then a regular and frequent analgesia regime needs to be provided on discharge to assist in patients managing their pain at home
  • Patients (generally elderly) with isolated sternal fractures generally require short admissions to hospital for pain control
  • Most patients recover completely over a period of 9-12 weeks (average 10.4weeks), with two-thirds only requiring analgesia, most predominant symptom is chest pain during this period.
  • ECG changes and positive cardiac markers require admission for further monitoring
  • Patients with difficulty managing pain and unstable fractures respond better to surgical intervention and fixation over conservative management, with follow up studies demonstrating no significant complication’s in the surgical group when compared to the conservative management group.

Reference:

  • Day, C. & Wastson, N. (2006). Emergent chest radiology: chest wall, pleura, lungs and diaphragm. Imaging. 18, 111-121. (abstract)
  • Felton, S. Slabinski, M. & Sigler, M. (2010). Fracture, Sternal. emedicine.medscape.com (full text)
  • Fisher, D. Gazzaniga, D. & Lastig, S. (2008). Imaging in Sternal Fractures. emedicine.medscape.com (full text)
  • Garrel, T. et.al. (2004). The sternal fracture: Radiographic analysis of 200 fractures with special reference to concomitant injuries. The Journal of Trauma, Injury, Infection, and Critical Care. 57(4), 837-844. PMID: 15514539
  • Jones, A. & Dollery, W. (2009). Admission not needed for uncomplicated sternal fractures. bestbets.org (full text)
  • Lee, W. & Lin H. (2010). Severe chest pain after blunt chest trauma. Emergency Medicine Journal. PMID: 20360484
  • Potaris, K. et.al. (2002). Management of Sternal Fractures: 239 Cases. Asian Cardiovascular & Thoracic Annals. 10(2), 145-149. PMID: 12079939
  • Rippey, J. Accessed 04/10/2010. www.ultrasoundvillage.com (full text)
  • Roy-Shapira, A. Levi, I. & Khoda, J. (1994). Sternal fractures: a red flag or a red herring? Journal of Trauma. 37(1), 59-61. PMID: 8028060
  • Summers, A. (2006). The Sternum. Emergency Nurse. 14(4), 19-23. PMID: 16878847
  • Ursic, C. & Curtis, K. (2010). Thoracic and neck trauma. Part Two. International Emergency Nursing. 18,99-108. PMID: 20382371
  • Velissaris, T. Tang, A. Khallifa, K. & Weeden, D. (2003). Traumatic sternal fracture: outcome following admission to a Thoracic Surgical Unit. Injury. 924-927, PMID: 1436736
  • You, JS. et.al. (2010). Role of sonography in the emergency room to diagnose sternal fracture. Journal of Clinical Ultrasound. 38(3), 135-137. PMID:20127877
Print Friendly

Comments

  1. Aaron Sparshott says

    Nice read. Reminds me of the girl in our year who broke her sternum jelly wrestling. Probably not a very common presentation to the ED.

  2. Mitchell3021 says

    I fractured my sternum 17yrs ago in a household accident, (transverse fracture at T4) when I tripped on the edge of a couch in the dark and landed on my chest on the corner of the wooden couch frame.

    I couldn’t breathe and yet the doctors did not bother to do anything more than xray me. There was no follow-up or any other types of assessment done.

    And because the basic xray did not show anything I was told to go home to “rest”.
    Nine weeks later, I had to have a bone scan, after complaining of continued debilitating intense pain… and at the time of the bone scan some 10 wks after the injury, the site was still an active fracture. It hasn’t healed well.

    I went from being an athlete to a couch potato… It’s 17yrs later and I am still seeing chiropractors, because of the instability the damage has caused.

  3. Kim says

    My husband fractured his sternum eight months ago. The doctor diagnosed him with Rib Strain/Sprain and had him on light duty. As the months went by the light duty increased even though he was telling him was physically unable to do these things. He has been in horrible pain even with ever increasing pain meds. Finally after 7 months we convinced Doctor to do a CT Scan which showed the Sternum fracture and numerous ribs and possibly the Clavicle. We are concerned that it has been eight months and CT showed that Sternum was only partially healed. Everything I read says healing is usually complete in 8-10 weeks. Has anyone else gone through this? We’re looking for any type of info or input here. Doctor wanted to send him for a Functional Capacity test but Insurance company will not approve at they say that that test is only for after you are healed to assess disability. Doctor says he’s afraid this is permanent which we do not understand, how can this be permanent? Does this type of fracture not heal? Can’t get any info from the Doctor, he’s a “how are you feeling, so you in four weeks” kind of doctor. Any input anyone has would be really appreciated!

    • Shadoson says

      It depends on the fracture. If the fracture leads to a separation as in my case, it may never heal without surgery. Plus, depending on the age of the subject, the sternum is cartilaginous. As you should know, cartilage doesn’t heal. Again it depends on the extent of the damage and the age of the subject. Also, as time goes on, his body will find a state of homeostasis anyways. It should become a minor inconvenience every once and a while if it never heals. He cannot stop doing everything though. Mine was painful for about 1.5 years. Then maybe once a month or so after that. I never took pain killers for it, but to each their own.

Comments