What is the recommended treatment for a sternal fracture?

Treatment of Sternal Fracture

Most isolated sternal fractures should be managed conservatively with pain control and early mobilization, while surgical fixation is reserved for displaced/comminuted fractures, chest wall instability, or severe deformity. 1, 2

Initial Assessment and Risk Stratification

The critical first step is determining whether the sternal fracture is isolated or associated with cardiac injury:

• Obtain baseline ECG and cardiac troponin levels immediately in all patients with sternal fractures 1
• Patients with normal ECG and normal cardiac troponins can be safely discharged without prolonged observation, as they are considered low probability for cardiac blunt trauma 1
• CT chest without IV contrast accurately detects sternal fractures using sagittal and 3-D reconstructions and should be the imaging modality of choice 1
• If ECG changes or rising troponin levels are present, monitor for arrhythmias and myocardial contusion as approximately 6% of sternal fracture patients develop these complications 1
• Echocardiography is NOT recommended for isolated sternal fractures when ECG and troponins are normal 1

Conservative Management (90-95% of Cases)

The vast majority of sternal fractures are non-displaced, simple fractures that heal spontaneously 2:

• Provide appropriate analgesics for pain control, tailored to patient comorbidities 3
• Begin early mobilization and physical training as soon as pain allows 1, 3
• Range-of-motion exercises should start within the first postoperative days, including shoulder, elbow, wrist, and hand motion 1
• A sling may be worn for comfort only and discarded as early as pain allows 1
• Restrict above-chest-level activities until fracture healing is evident 1

Surgical Indications (5-10% of Cases)

Operative fixation is indicated for:

• Displaced or comminuted fractures causing instability 2, 4
• Severe chest wall deformity 2, 4
• Intractable pain not responding to conservative management 5
• Flail chest or respiratory compromise requiring mechanical ventilation 2
• Associated cardiovascular injuries requiring urgent intervention 1, 2

Surgical Technique

• Plate fixation is the preferred method for stable osteosynthesis in complicated sternal fractures 2, 4
• Plates were used in 52 of 76 surgically treated cases in systematic review, compared to wiring in 24 cases 4
• Surgical fixation significantly improves pain scores (average reduction of 3.5 points on pain scale), decreases narcotic requirements by 7.59 morphine milligram equivalents, and restores full upper extremity range of motion 5
• No serious postoperative complications were reported in systematic reviews of surgical fixation 4, 5

Common Pitfalls and Caveats

Critical associated injuries to exclude:

• Sternal fractures are more commonly complicated (98.8%) than isolated (1.2%) 6
• Concomitant injuries occur frequently: rib fractures, lung contusion, intra-abdominal injuries, extremity fractures, and brain injury 2, 6
• Patients with comminuted fractures have higher serum troponin-T and myoglobin levels, indicating more severe trauma 2
• Mortality from sternal fractures is usually due to associated injuries, not the sternal fracture itself 6
• The misdiagnosis rate is 5.5% with X-ray alone, emphasizing the need for CT imaging 6

Special Considerations for Elderly Patients

• Assess for underlying osteoporosis and consider calcium (1000-1200 mg/day) and vitamin D (800 IU/day) supplementation 1
• Perform fall risk assessment as part of overall management 3
• Monitor for secondary complications such as deep vein thrombosis in less mobile patients 3
• Consider multidisciplinary geriatric input to address age-related factors affecting recovery 3