What is the recommended care for a patient with a sternal fracture?

Management of Sternal Fractures

Most sternal fractures can be managed conservatively with appropriate pain control, activity modification, and monitoring for potential cardiac complications, while surgical fixation should be considered for displaced, unstable, or severely painful fractures that limit respiratory function or upper extremity movement. 1, 2

Initial Assessment and Diagnosis

• CT chest without IV contrast is the preferred imaging modality for accurate detection of sternal fractures through sagittal and 3-D reconstructions 1
• All patients with sternal fractures should undergo ECG monitoring and cardiac troponin assessment to evaluate for potential cardiac injury, as myocardial contusion can occur even with seemingly benign fractures 1
• Hemodynamically stable patients with normal ECG and cardiac troponin levels are generally considered low risk for cardiac complications and can be safely discharged with appropriate follow-up 1

Conservative Management

• For isolated, non-displaced sternal fractures (which represent 90-95% of cases), conservative management is the standard of care 3
• Conservative treatment includes:
  • Appropriate pain management with analgesics 1
  • Activity modification to reduce pain and prevent displacement 1
  • Bracing may be considered for symptomatic relief 1
  • Regular follow-up to monitor healing and detect potential complications 3

Surgical Management

• Surgical fixation should be considered in the following scenarios:

  • Displaced or comminuted fractures causing instability 3
  • Severe pain unresponsive to conservative management 2
  • Respiratory failure or dependency on mechanical ventilation 4
  • Cosmetic deformity or chest wall deformity 4
  • Malunion or nonunion 4
  • Compression of the heart 4

• Plate fixation is a suitable method for stable osteosynthesis in complicated sternal fractures 3

• Surgical fixation has been shown to:

  • Significantly improve pain scores (average improvement of 3.5 points on pain scale) 2
  • Reduce narcotic requirements 2
  • Improve upper extremity range of motion 2
  • Shorten duration of mechanical ventilation in ventilator-dependent patients 3

Rehabilitation

• An appropriate rehabilitation program should consist of early post-fracture introduction of physical training and muscle strengthening 1
• Long-term continuation of balance training and multidimensional fall prevention is important, especially in elderly patients 1
• Physical therapy focusing on upper extremity range of motion is beneficial for recovery 2

Monitoring and Follow-up

• Patients with sternal fractures should be evaluated systematically for the risk of subsequent fractures, particularly in those over 50 years of age 1
• Evaluation should include review of clinical risk factors, DXA of spine and hip in older patients, and identification of secondary osteoporosis 1
• Patient education about the injury, expected recovery timeline, and warning signs of complications is essential 1

Special Considerations

• Elderly patients with sternal fractures may benefit from orthogeriatric comanagement to improve functional outcomes and reduce length of hospital stay 1
• Concomitant injuries are common with sternal fractures and must be carefully evaluated, including rib fractures, lung contusions, and intraabdominal injuries 5
• The mortality associated with sternal fractures is usually not related to the fracture itself but to associated injuries, particularly cardiopulmonary complications 5

Pitfalls and Caveats

• Isolated sternal fractures are often over-treated with unnecessary hospitalization when patients have normal cardiac evaluations 6
• Misdiagnosis rates with standard X-rays can be up to 5.5%, so CT imaging should be considered when clinical suspicion is high 5
• Delayed complications can occur in a small number of patients, so appropriate follow-up is important even after initial conservative management 5
• While surgical fixation shows promising results for certain fracture types, patient selection is crucial to avoid unnecessary procedures 2, 3