What is the diagnosis and treatment for a fracture of the body of the sternum with a possible infected hematoma in a patient who has already undergone a computed tomography (CT) scan of the thorax?

From the Guidelines

For a sternal fracture with a possible infected hematoma in a patient who has already had a CT thorax, immediate orthopedic and infectious disease consultation is recommended, with consideration of further imaging using [¹⁸F]FDG hybrid PET to assess for infection and inflammation, as outlined in the recent guideline by the European Association of Nuclear Medicine and the Society of Nuclear Medicine and Molecular Imaging 1.

Diagnosis and Treatment Approach

The patient's condition requires a comprehensive approach to diagnose and treat the possible infected hematoma and sternal fracture.

• Immediate consultation with orthopedic and infectious disease specialists is crucial to determine the best course of action.
• Treatment may involve surgical debridement of the infected hematoma, culture-guided antibiotic therapy, and possible sternal fixation depending on fracture stability.
• Initial empiric antibiotic therapy should include coverage for common skin flora such as Staphylococcus aureus; options include vancomycin 15-20 mg/kg IV every 12 hours or daptomycin 6-8 mg/kg IV daily, plus piperacillin-tazobactam 4.5g IV every 6-8 hours for broader coverage until culture results are available, as suggested by general principles of infectious disease management.
• The use of [¹⁸F]FDG hybrid PET, as recommended by the recent guideline 1, can help in identifying patterns of infection such as osteomyelitis, fracture-related infection, and distinguishing these from non-infectious patterns, which is critical for guiding treatment decisions.

Imaging and Monitoring

• Additional imaging such as MRI may be necessary to fully evaluate the extent of infection and to assess the fracture stability.
• Close monitoring for respiratory compromise, mediastinitis, or osteomyelitis is essential, given the significant morbidity associated with sternal fractures and infections.
• The patient's pain management is also a priority, with acetaminophen 1000mg every 6 hours and possibly opioids for breakthrough pain, considering the potential for significant discomfort and the need to balance pain control with the risk of opioid use.

Outcome Prioritization

The primary goal in managing this patient is to prioritize morbidity, mortality, and quality of life outcomes.

• Aggressive management with a multidisciplinary approach is essential for optimal outcomes, given the risk of spreading infection to adjacent vital structures.
• The recent guideline 1 provides a framework for using [¹⁸F]FDG hybrid PET in the diagnosis of infection and inflammation, which can guide treatment decisions and improve patient outcomes.

From the Research

Diagnosis of Body of Sternum Fracture with Possible Infected Haematoma

• The patient has already undergone a CT thorax, which is a common diagnostic tool for traumatic sternal fractures 2.
• The CT scan can help identify the location and severity of the fracture, as well as any potential complications such as haematoma or infection.
• Clinical evaluation and biochemical tests, including microbiology studies, may also be necessary to diagnose and manage potential infections 3.

Treatment of Body of Sternum Fracture with Possible Infected Haematoma

• Isolated sternal fractures can often be managed conservatively in an outpatient setting, but polytrauma patients with sternal fractures require careful screening for associated injuries 2.
• Surgical stabilization of sternal fractures may be necessary in cases of unstable fractures, severe displacement, symptomatic malunion or non-union 2.
• Antibiotic therapy may be necessary to manage potential infections, and topical application of antibiotics such as vancomycin and gentamicin may be effective in reducing sternal wound infection rates 4.
• In cases of infected haematoma, surgical debridement and reconstruction with soft tissue flap coverage may be necessary 3.

Management of Possible Infected Haematoma

• The diagnosis of infected haematoma typically consists of three main stages: clinical, biochemical including microbiology studies, and imaging studies 3.
• Computed tomography (CT) and magnetic resonance imaging (MRI) can be valuable in defining mediastinal abnormalities and identifying the source of infection 3.
• Management of infected haematoma may involve antibiotic therapy, surgical debridement, and reconstruction with soft tissue flap coverage 3.
• Ceftriaxone, a third-generation cephalosporin, may be effective in managing community-acquired and nosocomial infections, including those caused by Streptococcus pneumoniae and Haemophilus influenzae 5.