What is the appropriate management for an 86-year-old female patient presenting with a xiphoid process fracture?

From the Guidelines

For an 86-year-old female patient presenting with a xiphoid process fracture, I recommend conservative management with pain control using intravenous acetaminophen every 6 hours as the first line treatment in a multimodal analgesic approach. This approach is based on the strong recommendation from the 2023 WSES guidelines on the management of trauma in elderly and frail patients 1. The guidelines suggest that acetaminophen is a suitable first-line treatment for acute trauma pain in the elderly, with a strong recommendation based on high-quality evidence.

Key Considerations

• The patient's age and potential comorbidities should be taken into account when considering additional pain management options, such as NSAIDs, which may be added if the patient presents with severe pain, but with careful consideration of potential adverse events and pharmacological interactions 1.
• A multimodal analgesic approach, including acetaminophen, gabapentinoids, NSAIDs, lidocaine patches, and opioids only for breakthrough pain, may be implemented to manage pain in elderly patients with trauma 1.
• Non-pharmacological measures, such as immobilizing the affected area and applying ice packs, may be used in conjunction with drug therapy to control acute pain, although the evidence for this is weaker 1.

Monitoring and Follow-up

• The patient should be monitored for complications such as persistent pain, breathing difficulties, or signs of internal injury.
• Imaging may be considered if pain is severe or persists beyond the expected healing time to rule out displacement or other complications.
• Elderly patients may require longer healing periods and should be assessed for fall risk and osteoporosis.

From the Research

Management of Xiphoid Process Fracture

The management of an 86-year-old female patient presenting with a xiphoid process fracture can be approached in the following ways:

• Conservative outpatient treatment may be considered, as seen in a case report of an 86-year-old female with a sternal fracture, where the patient was treated conservatively and referrals were made for fall prevention measures and osteoporosis screening 2.
• Imaging and electrocardiogram (ECG) are essential to rule out concomitant injuries and acute changes, as noted in the case report of an 86-year-old female with a sternal fracture 2.
• Xiphoidectomy may be considered in cases of xiphodynia, a rare musculoskeletal disorder characterized by pain at the lower anterior chest or epigastric region, as studied in a case series where 17 out of 19 patients showed significant improvement in pain scores after xiphoidectomy 3.
• A subxiphoid approach may be used in thoracic surgery, as seen in a case report of a 66-year-old male who underwent a subxiphoid uniportal lung resection, which provided excellent cosmetic outcomes and minimal pain 4.

Considerations for Geriatric Patients

When managing geriatric patients with xiphoid process fractures, the following considerations are important:

• Fall prevention measures and osteoporosis screening should be initiated to prevent future fractures, as recommended in the case report of an 86-year-old female with a sternal fracture 2.
• Hospice care may be considered for patients with multiple chronic conditions and functional decline, as discussed in a review of hospice care for an 86-year-old woman with cardiac cachexia 5.
• Minimally invasive surgical approaches may be considered for geriatric patients, as seen in a case report of an 86-year-old female with mitral regurgitation and significant pectus excavatum who underwent minimally invasive mitral valve repair 6.