Both PSF and ISF commonly result from blunt chest trauma sustained in motor vehicle accidents or falls [1]. Less frequently, patients present with SF after other forms of accidents or assault. About 75% of those cases correspond to PSF, only 25% to ISF. Besides blunt trauma, distinct pathologies may lead to SF. In detail, osteoporosis and severe thoracic kyphosis predispose for this lesion [3]. Postmenopausal women, elder patients as well as those receiving long-term corticosteroid therapy are at particularly high risks [4]. In this context, ISF is much more common than PSF.

Midline chest pain is the single most important symptom of any SF. It may be the only symptom, especially in ISF patients [4]. SF may be accompanied by retrosternal or mediastinal hematoma, and affected individuals may experience symptoms of blood loss and hemodynamic instability. Hematomas may also compress vital structures in the thoracic cavity, thereby interfering with heart and lung function [5].

Few SF are palpable.

PSF patients may additionally suffer from symptoms associated with:

• Rib fractures
• Flail chest
• Pulmonary contusion
• Pneumothorax
• Blunt cardiac injury
• Aortic rupture and other vascular injuries
• Hemothorax
• Ruptured diaphragm

• Swelling

  When the bone starts to heal there will be a dull continuous ache from the swelling and healing process that will last weeks to months. [clinic-hq.co.uk]

  Symptoms could be slight or severe, ranging from swelling, bruising and pain to difficulty in using after an injury. To diagnose a break or fracture it may be necessary for your phy ... sician to obtain x-rays and occasionally a CT scan or MRI. [sharecare.com]

  Gently icing the sternum in the initial phase of injury (first 72 hours) can assist in reducing pain and swelling. [find-a-physio.com]

  Swelling and / or bruising may also be evident. In severe sternal fractures with bony displacement, an obvious deformity may be present. [athleticedge.biz]

  If sternal fractures were accompanied by osteolysis and adjacent soft-tissue swelling, pathologic fracture must be considered 4 ). [kjim.org]

• Chest Wall Pain

  During workup, the patient complained of midline chest pain, and left chest wall pain. [westjem.com]

• Painful Cough

  The patient will feel tenderness at the front of the chest over the bone and breathing may be painful. Coughing and sneezing are also likely to reproduce pain and bruising may appear later. [sportsinjuryclinic.net]

• Hematochezia

  Haug Browse recently published Learning/CME Learning/CME View all learning/CME CME Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis Case 4-2019: An 18-Year-Old Man with Abdominal Pain and Hematochezia Bridging the Gap Challenge Yourself [nejm.org]

• Chest Pain

  Acute surgical therapy is indicated for debilitating chest pain usually associated with fracture displacement. We report a case of debilitating chest pain associated with a chronic sternal fracture. [ncbi.nlm.nih.gov]

  Case presentation An 80-year-old female patient presented to the Emergency Department with chest pain. Patient described the pain as a sudden onset sharp pain radiating through the chest. [jeccm.amegroups.com]

  […] completely ossify before age 18, physeal injury must be suspected with chest pain in a young athlete. [healio.com]

  Her chest pain and dyspnea were declined by the administration of calcitonin and analgesics. [kjim.org]

• Osteoporosis

  They found that all cases had osteoporosis as suspected and 13 cases had thoracic vertebral fractures. [jeccm.amegroups.com]

  We report a case of a spontaneous sternal fracture secondary to idiopathic osteoporosis in a man in his late forties. His restrictive lung disorder from thoracic kyphoscoliosis was exacerbated by surgery to repair the sternal fracture. [ncbi.nlm.nih.gov]

  In addition, the underlying causes for osteoporosis should be recognized and specifically treated. [kjim.org]

  Stress fractures are occasionally seen in athletes such as wrestlers, but they can also occur in women with osteoporosis and kyphotic thoracic spines. [emedicine.com]

  In detail, osteoporosis and severe thoracic kyphosis predispose for this lesion. Postmenopausal women, elder patients as well as those receiving long-term corticosteroid therapy are at particularly high risks. [symptoma.com]

• Sternal Tenderness

  Localized sternal tenderness was present in 68 (97.1%), external signs of contusion/ecchymosis in 33 (47.1%), and dyspnea in 10 (14.3%) patients. The mechanism of injury was motor vehicle crash in 64 (91.4%) patients, with 46 of these restrained. [ncbi.nlm.nih.gov]

  tenderness and pain who were discharged after normal lateral sternal radiography had such fractures. [emj.bmj.com]

Anamnestic data usually imply a patient to have sustained thoracic trauma. In such cases, extensive injuries may indicate the need to assure proper ventilation and cardiovascular function before taking diagnostic measures to assess the integrity of the sternum. Distinct imaging techniques may be applied to this end:

• Sonography has been shown to yield reliable results, is readily available and cost-effective [6].
• While anterior-posterior chest radiographs are of low sensitivity regarding the detection of SF, lateral sternal views often allow for the respective diagnosis [7]. Lucent fracture lines indicate the site of the lesion; displacement of bone fragments may be observed.
• Computed tomography may be required to depict SF that cannot be visualized by means of plain radiography and according to recent studies, this applies to the majority of minor SF [8]. However, computed tomography scans are associated with considerable exposure to ionizing radiation. Distinct algorithms have been developed to aid in the decision of whether blunt trauma evaluation should or should not comprise computed tomography scans [9] [10].

Additional studies are indicated to identify the underlying disease in patients presenting with pathological SF [3] [4] [11] [12].

• Atelectasis

  Taping or splinting of sternal fractures is contraindicated, as restriction of normal chest expansion during respiration can lead to atelectasis and pulmonary insufficiency. [emedicine.medscape.com]

  They need to avoid provocative movement for four to six week.16 It is contraindicated to tape or splint sternal fractures, because it causes a restriction of normal chest expansion during respiration and can lead to atelectasis and pulmonary insufficiency [physio-pedia.com]

  Consider at least an observation admission for elderly persons with chest wall fractures because these patients are at increased risk for respiratory compromise and atelectasis. [emedicine.com]

Chest wall fractures, including injuries of the sternum, usually heal spontaneously without specific treatment. However sometimes, they need surgical treatment. [ncbi.nlm.nih.gov]

Treatment Treatment of a sternum fracture which has not been displaced generally involves rest and the use of painkillers or anti-inflammatory medications. [sportsinjuryclinic.net]

A more formal approach to rehabilitation, analgesia and a letter to the general practitioner outlining prognosis will improve their standard of care. [ncbi.nlm.nih.gov]

Prognosis for a sternum fracture Although the morality rate is high due to other traumatic injuries, the prognosis is fairly good for most people who have sternum or breastbone fractures. [rosenfeldinjurylawyers.com]

[…] and multiple body system manifestations due to the underlying etiology. [icd10data.com]

Conclusions It is important to remember that sternum fracture with unidentified etiology is one of the rare causes of chest pain. [jeccm.amegroups.com]

[…] frequent of which are rib fractures (22% to 32% when an associated injury has occurred). 12,14 The injury pattern describing stress fractures of the sternum consistent with repetitive microtrauma has far fewer comorbidities than some of the mentioned etiologies [healio.com]

Epidemiology Uncommon injury associated with Blunt Chest Trauma Typical patient is an older male IV. Precautions Sternal Fracture is a marker of significant blunt force to the chest V. [fpnotebook.com]

LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level II. [ncbi.nlm.nih.gov]

Epidemiology of sternal fractures. Am Surg 2009;75(5):401-4 [socmob.org]

Epidemiology of sternal fractures. Am Surg. 2009 May. 75(5):401-4. [Medline]. Knobloch K, Wagner S, Haasper C, Probst C, Krettek C, Otte D, et al. [emedicine.com]

The authors succinctly explain the pathophysiology underlying clinical disorders and the key principles of diagnosis and patient management, emphasizing cost-effective approaches. [books.google.com]

Principles of Pathophysiology and Emergency Medical Care. Albany, N.Y: Delmar Thomson Learning. ISBN 978-0-7668-2548-2. Retrieved 2008-06-14. ^ a b c Johnson I, Branfoot T (March 1993). "Sternal fracture--a modern review". [en.wikipedia.org]

Principles of Pathophysiology and Emergency Medical Care. Albany, N.Y: Delmar Thomson Learning. ISBN 0-7668-2548-5. Retrieved 2008-06-14. 1 2 3 Johnson I, Branfoot T (March 1993). "Sternal fracture--a modern review". [ipfs.io]

Pathophysiology Most sternal fractures are caused by blunt anterior chest trauma, although stress fractures have been noted in golfers, weight lifters, and other participants in noncontact sports. [emedicine.com]

To relieve the sternal pain and prevent further displacement the patient now agreed to stabilization of the sternal fracture by minimal invasive flexible intramedullary nailing. [ncbi.nlm.nih.gov]

The use of protective padding or chest guards may be required when returning to contact sports or ball sports following a sternal fracture to prevent further injury. [find-a-physio.com]

Prevention The majority of sternum fractures are caused due to traffic collisions. Wearing seat belts can prevent breastbone fractures in such situations. [steadyhealth.com]

The sternum is commonly referred to as the breastbone and forms part of the thoracic wall. It is located in the center of the chest with its most cranial portion, the manubrium forming the sternoclavicular joints with the clavicles. Along the sternum's body, a total of fourteen sternocostal articulations connects the breastbone with seven true ribs on either side. Finally, the inferior portion of the sternum, the xiphoid process, constitutes the site of insertion of the costoxiphoid ligaments, tendons of the diaphragm, and determined abdominal muscles. Either part of the sternum may succumb to the impact of mechanical forces that exceed the maximal resistance of the breastbone, and the respective patient sustains a sternal fracture (SF).

As a whole, the rib cage provides mechanical protection to major blood vessels, mediastinal organs and vital thoracic organs like lungs and heart. Its physical integrity may be disrupted if a patient sustains thoracic trauma and due to the afore-described proximity of the sternum to other bones and organs, an individual suffering from SF commonly presents with additional fractures or lesions of internal organs. This condition may be referred to as polytrauma sternal fracture (PSF) and differs largely from the isolated sternal fracture (ISF) regarding clinical presentation, workup, and treatment [1].

In PSF patients, the outcome largely depends on the severity of accompanying injuries. ISF patients have an excellent prognosis and usually, recover within weeks [2].

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11. Latzin P, Griese M, Hermanns V, Kammer B. Sternal fracture with fatal outcome in cystic fibrosis. Thorax. 2005;60(7):616.
12. Reuling EM, Jakma TS, Schnater JM, Westerweel PE. Spontaneous sternal fracture due to multiple myeloma requiring extensive surgical repair. BMJ Case Rep. 2015.