What is the initial management for a closed displaced fracture of the sternum?

Management of Closed Displaced Fracture of Sternum

For a closed displaced fracture of the sternum, the initial management should focus on pain control and conservative treatment, with surgical fixation reserved only for cases with severe displacement, intractable pain, or respiratory compromise.

Initial Assessment and Management

• Evaluate for associated injuries, particularly:

  • Cardiac contusion/injury
  • Pulmonary contusion
  • Thoracic spine injury
  • Rib fractures
  • Vascular injuries (especially with first rib fractures)

• Pain management is the cornerstone of initial treatment:

  1. Regular administration of intravenous acetaminophen (1 gram every 6 hours) as first-line treatment 1
  2. Consider NSAIDs with caution, especially in elderly patients
  3. Opioids at lowest effective dose for shortest possible period (hydromorphone preferred over morphine) 1
  4. Regional anesthesia techniques for moderate to severe pain:
     • Thoracic epidural
     • Paravertebral blocks
     • Erector spinae plane blocks
     • Serratus anterior plane blocks

• Apply ice therapy:

  • Use ice and water surrounded by a damp cloth
  • Apply for 20-30 minutes, 3-4 times daily
  • Avoid direct ice-to-skin contact 1

Imaging

• CT scan of the chest is mandatory to evaluate:
  • Degree of displacement
  • Presence of associated injuries
  • Planning for potential surgical intervention 1
  • Consider contrast-enhanced CT if high-energy mechanism or suspicion of intrathoracic injury

Indications for Surgical Management

Surgical fixation should be considered in the following scenarios:

1. Severely displaced fracture causing:

   • Intractable pain despite optimal medical management 2, 3
   • Respiratory compromise or impaired ventilation 2
   • Sternal instability with bony crepitus 2
   • Deformity of the chest wall 4

2. Patients with underlying respiratory disease or poor functional respiratory status

3. Elderly patients with significant displacement (due to increased risk of respiratory compromise)

Surgical Approach

When surgical fixation is indicated:

• T-shaped plate fixation is preferred over longitudinal plate fixation (42.9% of longitudinal plates showed loosening vs. 0% of T-plates) 2
• Open reduction and internal fixation (ORIF) provides better stability than wire fixation 5
• Surgery should be performed by a thoracic surgeon or surgeon experienced in sternal fixation

Admission Criteria

• Patients with isolated, minimally displaced sternal fractures without significant pain or respiratory compromise can often be managed as outpatients 6

• Consider hospital admission for:

  • Severely displaced fractures
  • Significant associated injuries
  • Complex analgesic requirements
  • Important comorbidities
  • Inadequate domestic support 6
  • Age >60 years with respiratory compromise 1

Follow-up

• Initial follow-up within 1-2 weeks of discharge
• Clinical evaluation of:
  • Pain control
  • Respiratory function
  • Functional status
  • Need for additional imaging 1

Complications to Monitor

• Respiratory failure requiring ventilatory support
• Pneumonia
• Pneumothorax
• Hemothorax
• Chronic pain
• Nonunion (rare but may require delayed surgical intervention) 3, 7

Most sternal fractures heal well with conservative management, with surgical intervention required in only a minority of cases (approximately 4% in one series) 6. The decision for surgical intervention should be based on the degree of displacement, presence of respiratory compromise, and severity of pain despite optimal medical management.