What is the treatment for a sternal fracture?

Treatment of Sternal Fractures

Most sternal fractures can be managed successfully with conservative treatment, including multimodal pain management and monitoring for potential cardiac complications. 1, 2, 3

Evaluation and Diagnosis

• Initial Assessment:

  • CT scan of the chest is the recommended imaging modality of choice 1
  • Superior to X-ray (which has a 5.5% misdiagnosis rate) 3
  • Allows accurate assessment of:
    • Fracture pattern and displacement
    • Associated cardiac or vascular injuries
    • Concomitant rib fractures or thoracic injuries

• Cardiac Evaluation (essential due to risk of associated cardiac injury):

  • ECG monitoring
  • Cardiac troponin assessment
  • Approximately 6% of patients with sternal fractures may develop arrhythmias and myocardial contusion 1, 2
  • Note: Echocardiography is not recommended for isolated sternal fractures with normal ECG and cardiac troponins 1

Treatment Approach

1. Conservative Management (for most patients)

• Pain Control:

  • Multimodal analgesia (NSAIDs, acetaminophen, and if necessary, short-term opioids)
  • Local anesthetic blocks may be considered for severe pain

• Respiratory Support:

  • Incentive spirometry to prevent atelectasis
  • Deep breathing exercises
  • Early mobilization to prevent pulmonary complications

• Monitoring:

  • Most isolated sternal fractures (ISF) do not require hospitalization 4, 5
  • Hospitalization should be reserved for:
    • High-impact trauma
    • Severely displaced fractures
    • Significant associated injuries
    • Complex analgesic requirements
    • Important co-morbidities
    • Inadequate home support 5

2. Surgical Management (for select cases)

• Indications for surgical fixation 6, 3:

  • Severe pain unresponsive to conservative management
  • Respiratory failure or dependency on mechanical ventilation
  • Cosmetic deformity
  • Malunion or nonunion
  • Compression of the heart
  • Severely displaced fractures in patients with complex comorbidities

• Surgical Techniques:

  • Various fixation methods are available:
    • Steel wire
    • Rigid plate fixation
    • Compression/distraction devices for reduction 6
  • Rigid sternal fixation has shown benefits in improving sternal healing and reducing complications 1

Follow-up Care

• Patients who undergo surgical stabilization: initial follow-up within 1-2 weeks of discharge 2
• All patients: follow-up in clinic within 2-3 weeks to evaluate:
  • Pain control
  • Respiratory function
  • Functional status
  • Need for additional imaging 2

Special Considerations

• Isolated vs. Polytrauma Sternal Fractures:

  • Isolated sternal fractures (26.4% of cases) typically have better outcomes 4
  • Polytrauma sternal fractures (73.6% of cases) often require more intensive care 4
  • Mortality in sternal fracture patients is usually related to associated injuries, not the sternal fracture itself 3

• Associated Injuries:

  • Evaluate for concomitant injuries, particularly rib fractures, which may compound respiratory issues 2
  • Common associated injuries include extremity fractures, brain injury, lung contusion, and intra-abdominal injuries 3

Treatment Algorithm

1. Diagnosis: CT scan of chest + cardiac evaluation (ECG, troponin)
2. Assess for surgical indications: Severe displacement, respiratory compromise, intractable pain
3. If no surgical indications: Conservative management with pain control and respiratory support
4. If surgical indications present: Proceed with appropriate fixation technique
5. Follow-up: Within 2-3 weeks to assess healing and functional status

Remember that the mortality from sternal fractures is typically not from the fracture itself but from associated injuries, making thorough evaluation for concomitant injuries crucial to management.