What is the treatment for sternal fractures?

Treatment of Sternal Fractures

Most sternal fractures can be managed conservatively with pain control and monitoring, while surgical intervention is reserved for specific cases with displacement, instability, or persistent pain. 1

Initial Assessment and Diagnosis

• Imaging: CT scan of the chest is the recommended imaging modality for initial assessment of sternal fractures 1

  • Provides accurate evaluation 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 1

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

Treatment Algorithm

Conservative Management (First-Line)

• Indicated for:

  • Isolated, non-displaced sternal fractures 2, 3
  • Stable fractures without significant associated injuries 4

• Components of conservative management:

  • Pain control with appropriate analgesia
  • Rest
  • Respiratory physiotherapy
  • Monitoring for complications

Surgical Management

• Indications for surgical fixation: 1, 5

  • Significantly displaced fractures
  • Unstable fractures causing respiratory compromise
  • Persistent pain despite conservative management
  • Nonunion
  • Fractures with associated flail chest

• Surgical techniques:

  • Rigid sternal fixation with plates (preferred in most cases) 1, 5
  • Wiring techniques (alternative approach) 5

Management Based on Associated Injuries

• Isolated Sternal Fractures:

  • Generally benign entities 4
  • Can be safely managed with rest and analgesia
  • Routine hospital admission often unnecessary 6, 3
  • Short-term pain relief is usually sufficient 2

• Complicated Sternal Fractures:

  • Associated injuries determine morbidity and mortality 4, 2
  • Common associated injuries include:
    • Rib fractures (most common - 30%) 4
    • Extremity injuries
    • Brain injury
    • Lung contusion
    • Intraabdominal/intraperitoneal injuries

Post-Treatment Follow-up

• Initial follow-up within 1-2 weeks of discharge 1
• All patients should have clinic follow-up within 2-3 weeks to evaluate:
  • Pain control
  • Respiratory function
  • Functional status
  • Need for additional imaging

Special Considerations

• Pain Management: Multimodal approach often required, coordinated with specialists 1
• Hospital Admission Criteria: Should be reserved for: 3
  • High-impact trauma
  • Severely displaced fractures
  • Significant associated injuries
  • Complex analgesic requirements
  • Important co-morbidities
  • Inadequate domestic support

Prognosis

• Mortality is typically not related to the sternal fracture itself but to associated injuries 2
• Isolated sternal fractures have excellent prognosis with conservative management 4
• Most patients with surgically treated sternal fractures have good outcomes 5