What is the initial management for a patient with a sternal fracture?

Initial Management of Sternal Fractures

The initial management of a patient with a sternal fracture should include adequate pain relief, appropriate fluid management, and comprehensive assessment for associated injuries within a multidisciplinary clinical system. 1

Initial Assessment and Stabilization

• Pain Management:

  • Provide appropriate pain management immediately before starting diagnostic investigations 1
  • Use multimodal analgesia including:
    • Regular paracetamol (acetaminophen) unless contraindicated
    • Cautious use of opioids after reviewing renal function (approximately 40% of trauma patients have renal dysfunction) 1
    • Consider nerve blocks for effective pain control 1
  • Avoid NSAIDs due to relative contraindication in trauma patients 1

• Diagnostic Evaluation:

  • CT scan of the chest is the preferred imaging modality for initial assessment 2
  • Assess for:
    • Fracture pattern and displacement
    • Associated cardiac or vascular injuries
    • Concomitant rib fractures or thoracic injuries

• Cardiac Assessment:

  • ECG monitoring
  • Cardiac troponin measurement
  • Monitor for arrhythmias (occur in approximately 6% of patients) 2
  • Echocardiography is not routinely recommended for isolated sternal fractures with normal ECG and cardiac troponins 2

Management Approach

For Isolated Sternal Fractures

• Most isolated sternal fractures can be managed conservatively 3
• Short-term pain relief is usually sufficient 3
• Routine hospital admission is often unnecessary for patients with:
  • Isolated sternal fracture
  • No significant displacement
  • No associated injuries
  • Adequate pain control with oral medications
  • No significant comorbidities 4

For Complicated Sternal Fractures

• Surgical fixation may be indicated for:
  • Severe pain unresponsive to analgesics
  • Respiratory failure or ventilator dependency
  • Significant displacement causing cosmetic deformity or cardiac compression
  • Malunion or nonunion 5

Associated Injuries

• Carefully evaluate for associated injuries, particularly:
  • Rib fractures (may compound respiratory issues) 2
  • Cardiac injuries (myocardial contusion)
  • Pulmonary contusions
  • Extremity fractures
  • Brain injury
  • Intra-abdominal/intraperitoneal injuries 3

Follow-up Care

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

Important Considerations

• Mortality in sternal fracture patients is typically related to associated injuries rather than the sternal fracture itself 3
• Patients with isolated sternal fractures have excellent prognosis with appropriate pain management
• The decision for surgical versus conservative management should be based on fracture characteristics, associated injuries, and patient factors