What are the potential causes and treatments for xiphysternum pain in a patient with a history of chest trauma or surgical procedures?

Xiphysternum Pain: Causes and Treatment After Chest Trauma or Surgery

In patients with xiphysternum pain following chest trauma or surgical procedures, the primary approach is to rule out cardiac causes first, then treat with NSAIDs for 1-2 weeks, with local anesthetic-steroid injection reserved for refractory cases. 1

Diagnostic Approach

Initial Assessment

• The hallmark diagnostic finding is tenderness to palpation directly over the xiphoid process that reproduces the patient's pain 1
• For patients older than 35 years or with cardiac risk factors, obtain an ECG to exclude cardiac etiologies 2
• Patients typically describe pain as stinging or pressing, retrosternal or left-sided, with a tender, hard mass possibly palpable in the epigastric region 1

Imaging Strategy

• Plain radiographs are the first-line imaging modality to identify bone involvement or anatomical variations of the xiphoid process 1
• Ultrasound has high sensitivity and specificity for evaluating soft tissue masses if a palpable mass is present 1
• CT chest may be useful for treatment planning in complex cases, though it provides less anatomic detail of lymphatic structures than MRI 3

Specific Post-Traumatic and Post-Surgical Causes

Post-Sternotomy Complications

• Sternal nonunion and dehiscence occur frequently after cardiac surgery, with sternal gap >3 mm correlating with significantly higher chest pain intensity 3
• Poststernotomy pain affects more than half of patients after cardiac surgery and inversely correlates with the degree of osseous healing 3
• CT with 3-D reconstructions is useful for assessing the degree of healing and residual chest wall deformities 3

Heterotopic Ossification

• Heterotopic ossification of the xiphoid can occur after chest trauma, including chest compressions during CPR 4
• This presents as severe epigastric pain that may persist for years after the initial trauma 4
• CT demonstrates an elongated xiphoid process in these cases 4

Post-Operative Elongation

• Distraction tissue neogenesis can cause xiphoid elongation after median sternotomy, particularly when the xiphoid fractures and separates from the sternum 5
• The xiphoid process can be pulled inferiorly by the rectus abdominis muscles, leading to elongation and reconnection with the sternum 5
• This complication may present 2 years or more after the initial surgery 5

Treatment Algorithm

First-Line Pharmacological Management

• Prescribe NSAIDs for 1-2 weeks as initial therapy 1, 6
• Use acetaminophen as an alternative if NSAIDs are contraindicated 1, 6
• Apply ice packs or heat to the affected area as adjunctive treatment 1, 6

Second-Line Interventions

• Add low-dose colchicine if symptoms persist despite NSAID therapy 1, 6
• Consider topical analgesics such as lidocaine patches for localized pain relief with minimal systemic effects 1, 6
• Local anesthetic-steroid injection is reserved for refractory cases 1

Surgical Management

• Surgical resection of the xiphoid process is indicated when conservative management fails or when heterotopic ossification/elongation is documented 5, 4
• The procedure can be performed under local anesthesia 5
• In cases of fractured or amputated xiphoid process after median sternotomy, the xiphoid should be resected to avoid neogenesis 5
• Xiphoid trigger point injection can be used diagnostically; if it provides temporary relief (even for just days), this confirms xiphoidalgia and supports proceeding with surgical resection 4

Common Pitfalls and Caveats

Diagnostic Challenges

• Comprehensive gastrointestinal workup may be negative despite severe epigastric pain, as the pain originates from the xiphoid rather than intra-abdominal pathology 4
• Symptoms may not appear immediately after trauma or surgery but can develop years later 5
• Histological examination of resected xiphoid typically reveals no neoplastic or malignant changes 5

Anatomical Variations

• The xiphoid process exhibits several morphological variations including bifurcated, trifurcated, deflected, and curved processes, which may complicate diagnostic examinations 7
• These variations should be considered when interpreting imaging studies 7

Post-Radiation Considerations

• In patients who received chest wall radiation, chest CT may identify rib fractures (23.2% incidence) with findings of chest wall edema, osseous cortical thinning, and osteosclerosis usually preceding fractures 3
• Most radiation-related rib fractures occur an average of 21 months after completion of therapy 3