Lung

Sternal Fracture

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Sternal Fracture, Fractured Sternum, Sternum Fracture

  • Epidemiology
  1. Uncommon injury associated with Blunt Chest Trauma
  2. Typical patient is an older male
  • Pathophysiology
  1. Mid-sternal Body and Manubrium are most common sites of Sternal Fracture
  • Causes
  1. High Energy Blunt Chest Trauma (typically Motor Vehicle Accident)
  2. Military combat
  3. Sports Injury
    1. Ball sports (e.g. baseball)
    2. Contact Sports
  • Signs
  1. Pain at Sternum
  2. Focal crepitation over Fracture site
  3. Impaired inspiration (Splinting respirations)
  • Precautions
  1. Sternal Fracture is a marker of significant, high energy blunt force to the chest
  • Imaging
  1. Chest XRay
    1. Poor Test Sensitivity for Sternal Fracture
  2. Lateral Sternal XRay
    1. Evaluate for displaced Fracture
  3. CT chest
    1. Sternal Fractures may be difficult to identify even on CT and requires careful inspection to detect
  • Labs
  1. Troponin
    1. Obtain at 4-6 hours after Sternal Fracture (3 hours may be sufficient in High Sensitivity Troponin)
    2. First line study in all Sternal Fractures
  • Diagnostics
  1. Electrocardiogram (EKG)
    1. First line study in all Sternal Fractures (esp. displaced Sternal Fractures)
    2. See Cardiac Contusion for specific findings
  2. Echocardiogram
    1. Echocardiogram is only needed in specific cases (not in all Sternal Fractures)
      1. However initial Bedside Ultrasound FAST Scan may offer global contractility impression
    2. Indications: Sternal Fracture (esp. displaced) AND
      1. Abnormal EKG (e.g. Arrhythmia) or Troponin elevation
      2. Hypotension (or other signs hemodynamic instability)
  • Complications
  1. Rib Fracture
  2. Pulmonary Contusion
  3. Pneumothorax
  4. Hemothorax
  5. Cardiac Contusion or Blunt Cardiac Injury (rare, but potentially life threatening)
    1. Right Ventricle is most commonly injured chamber in Sternal Fracture
    2. Structural injury (Myocardium or valvular injury)
    3. Dysrhythmia
      1. Occurs within first 8-24 hours of injury and typically resolves spontaneously
      2. Atrial Fibrillation is most common
  • Evaluation
  1. Normal Troponin, EKG, hemodynamic and cardiac monitoring in Emergency Department
    1. Unlikely to have significant cardiac injury related to Sternal Fracture
  2. Abnormal Troponin, EKG or hemodynamic and cardiac monitoring (esp. in displaced Sternal Fracture)
    1. Obtain Echocardiogram to evaluate for structural injuries
    2. Monitor on telemetry for Dysrhythmia
  • Management
  • Acute Management
  1. See Primary Trauma Survey
  2. See Secondary Trauma Survey
  3. Cardiovascular monitoring with Oxygen Saturation
  4. Aggressive pain management (prevent respiratory Splinting)
  5. Sternal Fracture uncommonly requires surgical management
  6. Primary attention in Sternal Fractures are to the associated injuries from severe blunt force Chest Trauma
  • Management
  • Surgery
  1. Acute Surgical Management Indications
    1. Overlapping Sternal Fracture edges
    2. Impacted Ventilation
  2. Chronic Surgical Management Indications
    1. Nonunion Sternal Fracture or Pseuodarthrosis resulting in Chronic Pain and dysfunction (esp. athletes)
  • Management
  • Disposition
  1. Stable Sternal Fractures
    1. See Rib Fracture (similar approach to home management)
    2. Treat with pain management and incentive Spirometry
    3. Expect recovery over 8-12 weeks
    4. Follow-up with sports medicine to evaluate for longer term complications (Chronic Pain, dysfunction)
      1. Nonunion Sternal Fracture or Pseuodarthrosis
      2. Consider surgical referral (as above)
  • References
  1. Dreis (2020) Crit Dec Emerg Med 34(7):3-21
  2. Herbert and Inaba in Herbert (2014) EM:Rap 14(11): 1-15