What are the management and complications of sternal fracture?

Management and Complications of Sternal Fractures

CT scan of the chest is the recommended imaging modality for initial assessment of sternal fractures, allowing accurate evaluation of fracture pattern, displacement, and associated injuries. 1

Initial Assessment and Diagnosis

• Imaging:

  • CT scan is superior to X-ray (X-ray has a 5.5% misdiagnosis rate) 2
  • Allows visualization of:
    • Fracture pattern and displacement
    • Associated cardiac or vascular injuries
    • Concomitant rib fractures or thoracic injuries

• Cardiac Evaluation:

  • ECG monitoring and cardiac troponin assessment are essential due to risk of cardiac injury 1
  • Approximately 6% of patients develop arrhythmias and myocardial contusion 1
  • Echocardiography is not recommended for isolated sternal fractures with normal ECG and cardiac troponins 1

Types of Sternal Fractures

• Isolated sternal fractures: Comprise only 1.2% of cases 2
• Complicated sternal fractures: Account for 98.8% of cases with associated injuries 2

Management Approach

Conservative Management (39.7% of cases) 2

• Appropriate for:

  • Stable, non-displaced fractures
  • Absence of respiratory compromise
  • Manageable pain with oral analgesia
  • No significant associated injuries

• Pain Control:

  • Multimodal pain management approach
  • Short-term pain relief is sufficient for isolated fractures 2

• Monitoring:

  • Cardiorespiratory monitoring for 24-48 hours in cases with potential cardiac involvement
  • Median hospital stay is typically 2 days (range 1-15 days) 3
  • 88% of patients do not require parenteral analgesia or procedures necessitating admission 3

Surgical Management (59.5% of cases) 2

• Indications for surgical fixation:

  • Severe pain unresponsive to conservative management
  • Respiratory failure or dependency on mechanical ventilation
  • Cosmetic deformity
  • Malunion or disunion
  • Compression of the heart 4
  • Severely displaced fractures 3

• Fixation Techniques:

  • Rigid sternal fixation improves healing and reduces complications 1
  • Methods include:
    • Plate fixation (used in majority of cases)
    • Steel wire fixation
    • Novel compression/distraction devices for reduction prior to fixation 4

• Post-surgical Follow-up:

  • Initial follow-up within 1-2 weeks of discharge
  • Clinic evaluation within 2-3 weeks to assess:
    • Pain control
    • Respiratory function
    • Functional status
    • Need for additional imaging 1

Complications

Immediate Complications

1. Cardiac Injuries:

   • Myocardial contusion
   • Arrhythmias (6% of patients) 1
   • Cardiac tamponade (rare)

2. Pulmonary Complications:

   • Respiratory insufficiency
   • Pneumothorax
   • Hemothorax
   • Pulmonary contusion

3. Vascular Injuries:

   • Aortic or great vessel injury (rare but life-threatening)

Associated Injuries

• Extremity fractures
• Traumatic brain injury
• Lung contusion
• Intraabdominal/intraperitoneal injuries 2
• Rib fractures (may compound respiratory issues) 1

Delayed Complications

• Small number of patients develop fracture-related delayed complications 2
• May include:
  • Chronic pain
  • Nonunion
  • Malunion
  • Sternal instability
  • Most require surgical treatment but generally have good outcomes 2

Prognosis

• Mortality is usually not related to the sternal fracture itself but to associated injuries 2
• Isolated sternal fractures have excellent prognosis with appropriate pain management
• Hospital admission is not necessary for every patient with sternal fracture 3
• Admission should be reserved for:
  • High-impact trauma
  • Severely displaced fractures
  • Significant associated injuries
  • Complex analgesic requirements
  • Important co-morbidities
  • Inadequate domestic support 3

Special Considerations

• Precordial thump can cause sternal fracture, osteomyelitis, stroke, and rhythm deterioration in adults 5
• Patients with sternal fractures from CPR or precordial thump require the same evaluation as traumatic fractures