What is the management approach for sternal fractures?

Management of Sternal Fractures

For isolated sternal fractures with normal ECG and cardiac troponins, conservative management with pain control and early mobilization is appropriate, while complicated fractures with severe pain, respiratory compromise, or cardiac injury require surgical fixation. 1

Initial Assessment and Risk Stratification

The paramount first step is determining hemodynamic stability and excluding life-threatening cardiac injury 1:

• Obtain ECG and cardiac troponin levels immediately in all patients with sternal fractures, as myocardial contusion and malignant ventricular arrhythmias can occur even though sternal fractures are generally considered benign 1
• CT chest without IV contrast accurately detects sternal fractures using sagittal and 3-D reconstructions, and can identify hemothorax or hemopericardium by measuring attenuation 1
• Echocardiography is NOT recommended for isolated sternal fractures when ECG and cardiac troponins are normal 1

Critical Pitfall in Diagnosis

In a multicenter study of 54 patients with suspected sternal fractures, only 72% had baseline ECG performed, 33% had follow-up ECG, and 30% had troponin assessment—yet 6% developed arrhythmias and myocardial contusion 1. This underscores that cardiac monitoring and troponin assessment must be performed systematically, not selectively 1.

Conservative Management (First-Line for Isolated Fractures)

Most sternal fractures can be managed successfully nonoperatively 2, 3:

• Appropriate pain management with regular analgesics should be provided as soon as possible before diagnostic investigations 1
• Sternal bracing provides early pain-free ambulation, satisfactory fracture immobilization, and simplified patient care 4
• Early mobilization should begin as the patient's pain allows 1
• Hospital admission for observation is often unnecessary for isolated sternal fractures with normal cardiac workup 3
• Average hospital confinement for uncomplicated cases is only 4 days 4

Monitoring Requirements

• Hemodynamically stable patients with abnormal ECG findings or rising cardiac troponin levels require cardiac monitoring 1
• Patients with normal ECG and cardiac troponin levels are low probability for cardiac blunt trauma and can be safely discharged 1

Surgical Indications

Surgery should be considered in specific scenarios 2:

• Severe intractable pain despite conservative management 2, 5
• Respiratory failure or dependency on mechanical ventilation 2
• Significant cosmetic deformity 2
• Malunion or disunion 2
• Compression of the heart 2

Surgical Outcomes

Sternal fixation is safe and effective, resulting in 5:

• Pain scores improved by an average of 3.5 points (from 7.08 to 3.54 on a 10-point scale, p=0.001) 5
• Narcotic requirements decreased by 7.59 morphine milligram equivalents (p=0.041) 5
• Total pain medications reduced by 1 medication postoperatively (p=0.002) 5
• Full upper extremity range of motion restored in all but one patient (p<0.001) 5
• No postoperative complications reported in the surgical series 5

Associated Injuries Requiring Attention

Sternal fractures are rarely isolated—98.8% have associated injuries 6:

• Right ventricle is most commonly affected due to its anterior location, followed by left ventricle and right atrium 1
• Hemopericardium and cardiac tamponade can occur when pericardium remains intact and hemorrhage accumulates, requiring immediate intervention 1
• CT chest with IV contrast identifies the source of bleeding and is complementary to chest radiography and transthoracic echocardiography 1
• Most common associated injuries include extremity fractures, brain injury, lung contusion, and intraabdominal injuries 6

Critical Distinction

The causes of death in patients with sternal fractures are usually NOT related to the sternum fracture itself, but to associated injuries 6. Therefore, intrathoracic injuries, especially life-threatening cardiopulmonary injuries, warrant resuscitation and active treatment 6.

Complicated vs. Isolated Fractures

• Isolated sternal fractures (1.2% of cases): Short-term pain relief is sufficient 6
• Complicated sternal fractures (98.8% of cases): Most require surgical treatment by sternal fixation 6
• Surgical treatment was utilized in 59.5% of all sternal fracture patients, conservative management in 39.7%, and staged approach in 0.8% 6