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Sternal Fracture

Fractured Sternum

Sternal fracture refers to the disruption of the physical integrity of the breastbone. Most sternal fractures result from blunt thoracic trauma, often sustained in motor vehicle accidents.


Presentation

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:

Intravenous Drugs
  • Three patients, all with a history of intravenous drug abuse and requiring central venous access in the emergency room, developed methicillin resistant Staphylococcus aureus mediastinitis.[ncbi.nlm.nih.gov]
  • Risk factors include the presence of a large hematoma, intravenous drug abuse, and another source of a staphylococcal infection. Treatment is open debridement. Schulz-Drost S, Krinner S, Langenbach A, Oppel P, Lefering R, Taylor D, et al.[emedicine.medscape.com]
Respiratory Distress
  • The patient complained of sternal pain and respiratory distress. However, neurologically he was completely normal. His pain and respiratory distress improved, so he refused spinal stabilization, and was discharged 20 days after the injury.[ncbi.nlm.nih.gov]
  • distress, tachycardia, distended neck veins, cyanosis, asymmetry of chest wall motion - Tracheal deviation away from pneumothorax - Percussion hyperresonnance - Unilateral absence of breath sounds, hypotension - Non-radiographic diagnosis - large bore[fprmed.com]
  • The patient was not in acute respiratory distress, and had the following vital signs: temperature 37 C, heart rate 84, blood pressure of 150/64, respiratory rate 18, and oxygen saturation of 97% on two liters of oxygen.[westjem.com]
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]
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]
  • […] 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]
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]
Back Pain
  • Given the success of vertebroplasty in patients in treating back pain, the authors used a similar technique in a 56-year-old woman with chronic obstructive pulmonary disease and an acute comminuted sternal fracture refractory to conservative management[ncbi.nlm.nih.gov]
  • Feb 2019 Acute Nontraumatic Back Pain: Infections and Mimic...[ctisus.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]
Stroke
  • […] hemodynamics, circulatory support, hazards of excessive fluid resuscitation, lasix drips, respiratory monitoring, post-extubation care, weaning from ventilators, sedation, use of opiates, new drugs, emergency room interventions for myocardial infarction, stroke[books.google.com]
  • […] influenced by associated injuries (pulmonary contusions, other thoracic fractures), complications (cardiac arrest, pulmonary embolism, acute respiratory distress syndrome), comorbidities (currently on or requiring dialysis, residual neurologic deficit from stroke[ncbi.nlm.nih.gov]

Workup

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].

Non Specific ST-T Changes
  • Electrocardiography (n 52) was abnormal in four patients--old myocardial infarction (n 1), non-specific ST-T changes (n 3). Cardiac enzymes (creatine-kinase-MB, n 42) were pathologically elevated in five patients.[ncbi.nlm.nih.gov]

Treatment

  • Chest wall fractures, including injuries of the sternum, usually heal spontaneously without specific treatment. However sometimes, they need surgical treatment.[ncbi.nlm.nih.gov]
  • Fractures that are very painful or extremely out of place can be operated on to fix the bone fragments into place, but in most cases treatment consists mainly of reducing pain and limiting movement.[en.wikipedia.org]

Prognosis

  • 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]
  • ISF patients have an excellent prognosis and usually, recover within weeks.[symptoma.com]

Etiology

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

  • 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 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]
  • 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]
Sex distribution
Age distribution

Pathophysiology

  • 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 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]

Prevention

  • 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]
  • 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 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]

Summary

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].

References

Article

  1. Odell DD, Peleg K, Givon A, et al. Sternal fracture: isolated lesion versus polytrauma from associated extrasternal injuries--analysis of 1,867 cases. J Trauma Acute Care Surg. 2013;75(3):448-452.
  2. de Oliveira M, Hassan TB, Sebewufu R, Finlay D, Quinton DN. Long-term morbidity in patients suffering a sternal fracture following discharge from the A and E department. Injury. 1998;29(8):609-612.
  3. Horikawa A, Miyakoshi N, Kodama H, Shimada Y. Insufficiency fracture of the sternum simulating myocardial infarction: case report and review of the literature. Tohoku J Exp Med. 2007;211(1):89-93.
  4. Wong JJ, Drew B, Stern P. Sternal insufficiency fracture related to steroid-induced osteoporosis: A case report. J Can Chiropr Assoc. 2013;57(1):42-48.
  5. Crestanello JA, Samuels LE, Kaufman MS, Thomas MP, Talucci R. Sternal fracture with mediastinal hematoma: delayed cardiopulmonary sequelae. J Trauma. 1999;47(1):161-164.
  6. Lahham S, Patane J, Lane N. Ultrasound of Sternal Fracture. West J Emerg Med. 2015;16(7):1057-1058.
  7. Mavridis IN. Imaging techniques in the assessment of sternal fracture patients. Eur J Radiol. 2013;82(1):200.
  8. Perez MR, Rodriguez RM, Baumann BM, et al. Sternal fracture in the age of pan-scan. Injury. 2015;46(7):1324-1327.
  9. Brink M, Deunk J, Dekker HM, et al. Criteria for the selective use of chest computed tomography in blunt trauma patients. Eur Radiol. 2010;20(4):818-828.
  10. Rodriguez RM, Anglin D, Langdorf MI, et al. NEXUS chest: validation of a decision instrument for selective chest imaging in blunt trauma. JAMA Surg. 2013;148(10):940-946.
  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.

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Last updated: 2019-07-11 21:43