What medications can be given for a suspected sternum (sternal) fracture in the outpatient setting, and is prednisone a suitable option?

Medications for Suspected Sternal Fracture in Outpatient Setting

Do not give prednisone for a sternal fracture—corticosteroids are contraindicated as they increase the risk of pathological fractures and impair bone healing. 1

Pain Management Approach

Start with acetaminophen (paracetamol) as first-line therapy unless contraindicated, then add opioids as needed for breakthrough pain. 2

First-Line Analgesic Options

• Acetaminophen 650-1000 mg every 6 hours is the safest initial choice for most patients with sternal fractures 2
• Document pain scores at rest and with movement before and after medication administration 2

Second-Line Options (If Acetaminophen Insufficient)

• Add short-acting opioids (e.g., oxycodone 5-10 mg every 4-6 hours) for moderate to severe pain 2
• Exercise caution with opioids if renal function is unknown, as approximately 40% of trauma patients have moderate renal dysfunction 2

NSAIDs: Use With Extreme Caution

Avoid NSAIDs (ibuprofen, naproxen, diclofenac) if renal function has not been assessed, as they are relatively contraindicated in patients with impaired kidney function 2, 3

• If renal function is normal and there are no contraindications, NSAIDs can be considered for short-term use (less than 10 days) 3
• NSAIDs carry risks of gastrointestinal bleeding, cardiovascular events, and renal toxicity that increase with longer use 3
• The combination of ibuprofen 200-400 mg plus acetaminophen 500-1000 mg provides superior analgesia (NNT 1.6-2.5) compared to either agent alone 4

Why Prednisone Is Contraindicated

Corticosteroids significantly increase fracture risk and impair bone healing:

• Chronic corticosteroid use is a well-documented cause of spontaneous sternal fractures in patients with underlying lung disease 1
• Prednisone doses ≥2.5 mg/day for ≥3 months substantially increase vertebral and hip fracture risk 5
• Very high-dose corticosteroids (≥30 mg/day prednisone) increase vertebral fracture risk 14-fold and hip fracture risk 3-fold 5
• Glucocorticoids cause rapid bone loss and impair fracture healing through multiple mechanisms 5

Supportive Measures for Outpatient Management

Ensure adequate calcium and vitamin D supplementation to support bone healing:

• Calcium 1000-1200 mg/day (dietary plus supplementation if needed) 5, 2, 6
• Vitamin D 800 IU/day (target serum level ≥20 ng/mL) 5, 2, 6
• Vitamin D supplementation with adequate calcium reduces non-vertebral fractures by 15-20% 5, 6

Encourage early mobilization as pain allows, typically within 24-48 hours, as this improves outcomes and prevents complications 2, 6

Critical Safety Monitoring

Before discharge, ensure:

• ECG and cardiac troponin levels are normal (to exclude myocardial contusion) 2, 7, 6
• Pain is adequately controlled with oral medications 7
• Patient understands warning signs requiring immediate return (chest pain, shortness of breath, hemodynamic instability) 2, 7
• Reliable follow-up is arranged within 1-2 weeks 7

Common Pitfalls to Avoid

• Never prescribe corticosteroids for pain management in fracture patients—they worsen outcomes 1
• Do not use NSAIDs without checking renal function first 2
• Avoid long-term NSAID use (>10 days) due to cardiovascular and gastrointestinal risks 3
• Do not discharge patients with abnormal ECG or elevated troponins without cardiac monitoring 2, 7, 6