Do patients with sternal fractures require follow-up radiographs (x-rays) if they are clinically improving?

From the Guidelines

Patients with sternal fractures who are clinically improving do not require follow-up radiographs (x-rays) unless there is a concern for complications or clinical deterioration. The management of sternal fractures primarily focuses on pain control and monitoring clinical progress, rather than repeated imaging, as most uncomplicated sternal fractures heal within 6-12 weeks with conservative management 1.

Key Considerations

• Pain management is crucial and usually involves oral analgesics such as acetaminophen or NSAIDs like ibuprofen for mild to moderate pain, with opioids reserved for severe pain.
• The decision to obtain follow-up imaging should be individualized and primarily considered if there is clinical deterioration, new symptoms, or concern for complications such as nonunion.
• Clinical assessment is more valuable than radiographic healing in determining recovery, and sternal fractures themselves rarely require surgical intervention.
• Patients should be advised to gradually increase activity as tolerated while avoiding heavy lifting or strenuous activities that exacerbate pain during the healing period.

Rationale

The use of CT chest without IV contrast, as discussed in the study 1, can accurately detect sternal fractures and is important in the initial diagnosis, especially when evaluating for associated cardiac injuries. However, once the initial diagnosis is established and associated injuries are ruled out, the focus shifts to clinical management and monitoring.

Clinical Approach

• Initial diagnosis and assessment for associated injuries are critical.
• Pain control and monitoring of clinical progress are key components of management.
• Follow-up imaging is not routinely necessary unless clinically indicated.
• Patient education on gradual increase in activity and avoidance of exacerbating factors is important for recovery.

From the Research

Sternal Fractures and Follow-up Radiographs

• Patients with sternal fractures who are clinically improving may not require follow-up radiographs, as the primary concern is the exclusion of concomitant injuries and monitoring of vital parameters 2.
• A study found that 88% of patients with traumatic sternal fractures did not require parenteral analgesia or any other procedure that would necessitate admission to hospital, and follow-up revealed no significant complications 3.
• The management of sternal fractures is often conservative, with surgical intervention indicated in cases of deformity, severe pain, and ventilatory complications 4, 5.
• In cases where surgical fixation is necessary, follow-up radiographs may be used to assess the integrity of the sternal bone structure and the success of the surgical procedure 4, 6.
• The decision to perform follow-up radiographs should be based on the individual patient's clinical progress and the presence of any complications or concerns 2, 3.

Indications for Follow-up Radiographs

• Severe displacement of the fracture
• Complex co-morbidities
• Significant associated injuries
• Inadequate domestic support
• Clinical deterioration or worsening of symptoms

Clinical Judgment and Patient Assessment

• Clinicians should use their judgment to determine the need for follow-up radiographs based on the patient's clinical presentation and progress 2, 3.
• A detailed survey of the patient and a three-dimensional reconstructed computed tomography may be used to assess the fracture's morphology and guide surgical treatment 5.