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