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

Management of Sternal Fracture

For isolated sternal fractures with normal ECG and cardiac troponins, patients can be safely discharged with analgesics and early mobilization, while those with associated injuries, abnormal cardiac markers, or hemodynamic instability require admission and multidisciplinary management. 1, 2

Immediate Assessment and Risk Stratification

Cardiac Evaluation (Critical First Step)

• Obtain baseline ECG and cardiac troponin levels immediately in all patients with sternal fractures 1, 2
• Patients with normal ECG and normal cardiac troponins have low probability for cardiac blunt trauma and can be safely discharged 1, 2
• Approximately 6% of sternal fracture patients develop ECG changes, arrhythmias, or myocardial contusion 1
• Hemodynamically stable patients with abnormal ECG findings or rising cardiac troponin levels require cardiac monitoring and admission 2
• Echocardiography is NOT recommended for isolated sternal fractures when ECG and troponins are normal 1, 2

Imaging

• CT chest without IV contrast is the imaging modality of choice, using sagittal and 3-D reconstructions for accurate detection of sternal fractures 1, 2
• CT can identify hemothorax or hemopericardium by measuring attenuation 2
• X-ray has a 5.5% misdiagnosis rate for sternal fractures 3

Associated Injury Assessment

• The vast majority (73.6-98.8%) of sternal fractures have associated injuries requiring attention 3, 4
• Most common associated injuries include extremity fractures, brain injury, lung contusion, and intraabdominal/intraperitoneal injuries 3
• The right ventricle is most commonly affected in cardiac injuries due to its anterior location, followed by left ventricle and right atrium 2
• Hemopericardium and cardiac tamponade can occur and require immediate intervention 2

Management Based on Fracture Type

Isolated Sternal Fractures (26.4% of cases)

Conservative management is appropriate for isolated sternal fractures: 4

Pain Management

• Provide appropriate analgesics tailored to patient comorbidities as soon as possible, before diagnostic investigations 5, 2
• Short-term pain relief is sufficient for solitary sternal fractures 3

Mobilization and Rehabilitation

• Begin early mobilization and physical training as soon as pain allows 1, 2
• Range-of-motion exercises should start within the first postoperative days, including shoulder, elbow, wrist, and hand motion 1
• Restrict above-chest-level activities until fracture healing is evident 1

Disposition

• Patients with isolated sternal fractures, normal ECG, and normal troponins can be discharged from the emergency department 4
• Average hospital confinement for uncomplicated cases is only 4 days when admission occurs 6

Complicated Sternal Fractures (73.6% of cases)

Most complicated sternal fractures require more intensive management: 3

Indications for Surgical Fixation

Surgery should be considered in cases of: 7

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

Treatment Approach

• 59.5% of sternal fractures are treated surgically, 39.7% conservatively, and 0.8% with staged conservative then surgical approach 3
• Intrathoracic injuries, especially life-threatening cardiopulmonary injuries, warrant resuscitation and corresponding active treatment 3
• Endotracheal intubation, chest tube insertion, or thoracotomy may be required (performed in 16.9% of complicated cases) 4

Special Populations

Elderly Patients (>50 years)

For elderly patients with sternal fractures, additional considerations include: 5

• Assess for underlying osteoporosis and consider calcium (1000-1200 mg/day) and vitamin D supplementation (800 IU/day) 5, 1
• Perform fall risk assessment as part of overall management 1
• Monitor for secondary complications such as deep vein thrombosis in less mobile patients 1
• Consider multidisciplinary geriatric input to address age-related factors affecting recovery 1
• Vitamin D supplementation (800 IU/day) with adequate calcium intake is associated with 15-20% reduction in non-vertebral fractures and falls 5

Patients Requiring Hospitalization

When admission is necessary: 5

• Provide multidisciplinary clinical system with adequate preoperative assessment
• Ensure appropriate pain management and fluid management
• Minimize delirium and avoid complications
• Comprehensive admission assessment should include investigations for malnutrition, electrolyte disturbances, anemia, cardiac or pulmonary diseases

Common Pitfalls to Avoid

• Do not routinely admit all patients with sternal fractures - isolated fractures with normal cardiac workup can be safely discharged 4
• Do not skip cardiac evaluation - ECG and troponins are mandatory in all cases 1, 2
• Do not use echocardiography as a screening tool when ECG and troponins are normal 1, 2
• Do not delay mobilization - early movement improves outcomes 1, 2
• Remember that mortality in sternal fracture patients is usually related to associated injuries, not the sternal fracture itself 3