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.
- 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
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:
- 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
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- 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
- 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.
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