What is the appropriate management for a patient with a sternum fracture, potentially with a history of osteoporosis, and possible associated injuries?

Management of Sternal Fractures

Immediate Assessment and Cardiac Evaluation

All patients with sternal fractures require immediate ECG and cardiac troponin levels to exclude myocardial contusion and malignant ventricular arrhythmias, regardless of mechanism or patient age 1, 2. While sternal fractures are often considered benign, cardiac complications occur in approximately 6% of cases and can be life-threatening 1.

Risk Stratification Based on Cardiac Workup

• Patients with normal ECG and normal cardiac troponins are low probability for cardiac injury and can be safely discharged without routine admission 1, 2
• Patients with abnormal ECG findings or rising troponin levels require cardiac monitoring and should be admitted for observation 1, 2
• Echocardiography is NOT recommended for isolated sternal fractures when ECG and troponins are normal, as it does not change management 1, 2

Imaging Protocol

• CT chest without IV contrast accurately detects sternal fractures using sagittal and 3-D reconstructions and can identify hemothorax or hemopericardium 1, 2
• CT chest with IV contrast should be obtained if hemothorax or hemopericardium is present to identify the source of bleeding and exclude cardiac rupture, as the right ventricle is most commonly injured due to its anterior location 1, 2
• Plain radiographs have a 5.5% misdiagnosis rate and should not be relied upon alone 3

Pain Management Strategy

Start with regular acetaminophen (paracetamol) as first-line analgesia unless contraindicated 2, 4. This is particularly important in elderly patients who may have undiagnosed renal dysfunction.

• Add opioids as needed for breakthrough pain, but exercise caution as approximately 40% of trauma patients have moderate renal dysfunction 2
• Avoid NSAIDs until renal function is confirmed, as they are relatively contraindicated in patients with impaired kidney function 2
• Document pain scores at rest and with movement before and after analgesia administration to guide titration 2
• Provide analgesia as soon as possible before diagnostic investigations to facilitate patient cooperation 2, 4

Conservative Management for Isolated Fractures

Most isolated sternal fractures (88%) can be managed conservatively without hospitalization 5. The key is excluding associated injuries and cardiac complications.

Outpatient Management Criteria

Patients suitable for discharge must have:

• Normal ECG and cardiac troponins 1, 2
• No hemodynamic instability 1
• Adequate pain control with oral analgesics 2, 4
• No severely displaced fractures requiring surgical fixation 5
• Adequate domestic support 5

Conservative Treatment Protocol

• Begin early mobilization as pain allows to prevent complications of immobility 2
• Initiate range-of-motion exercises for shoulder, elbow, wrist, and hand within the first few days 4
• Avoid prolonged bed rest, as it accelerates bone loss, muscle weakness, and increases risk of deep vein thrombosis 4

Admission Indications

Hospitalization is reserved for specific high-risk scenarios 5:

• High-impact trauma mechanism 5
• Severely displaced fractures 5
• Abnormal ECG or rising cardiac troponins requiring monitoring 1, 2
• Hemopericardium or cardiac tamponade requiring immediate intervention 1, 2
• Complex analgesic requirements or inability to tolerate oral medications 5
• Significant associated injuries (extremity fractures, brain injury, lung contusion, intraabdominal injuries) 3
• Important comorbidities or inadequate domestic support 5

Inpatient Management

For admitted patients:

• Provide comprehensive assessment including investigations for malnutrition, electrolyte disturbances, anemia, and cardiac or pulmonary diseases 2
• Ensure appropriate fluid management 2
• Median hospital stay is 2 days for uncomplicated cases 5

Surgical Indications

Surgical fixation is required in only 3-4% of cases 5:

• Severely displaced fractures with complex comorbidities 5
• Fracture-related delayed complications that develop during follow-up 3
• Most complicated sternal fractures requiring surgical treatment have good outcomes 3

Special Considerations for Osteoporosis

Elderly patients with sternal fractures, particularly from low-energy mechanisms, warrant osteoporosis screening and fall prevention measures 6.

Osteoporosis Management

• Ensure adequate calcium intake (1000-1200 mg/day) and vitamin D (800 IU/day) to support fracture healing, as this reduces non-vertebral fractures by 15-20% 2, 4
• Consider bone density evaluation if not previously performed 2, 4
• Implement multidimensional fall prevention programs, which reduce fall frequency by approximately 20% 4
• Address environmental hazards and review medications that may increase fall risk 4

Pharmacological Osteoporosis Treatment

For patients with documented osteoporosis and adequate renal function (GFR ≥30 mL/min):

• First-line treatment with oral bisphosphonates (alendronate or risedronate) reduces vertebral, non-vertebral, and hip fractures 4

For patients with GFR <30 mL/min or oral intolerance:

• Denosumab 60 mg subcutaneously every 6 months has demonstrated efficacy in reducing all fracture types 4

Follow-Up Protocol

• Outpatient follow-up at 6 weeks after discharge to assess healing and identify any delayed complications 5
• Educate patients about osteoporosis burden, fracture risk factors, and importance of medication adherence 4
• Referral to primary care for fall prevention measures and osteoporosis screening in geriatric patients 6

Critical Pitfalls to Avoid

• Do not routinely admit all patients with sternal fractures for observation - this is unnecessary for isolated fractures with normal cardiac workup 7, 5
• Do not miss associated injuries - 98.8% of sternal fractures have concomitant injuries, with extremity fractures, brain injury, and lung contusion being most common 3
• Do not overlook cardiac tamponade - look for the triad of high-attenuation pericardial effusion, peri-portal low attenuation, and distention of the IVC and other veins on CT 1
• Do not assume high-energy mechanism is required - elderly patients with osteoporosis can sustain sternal fractures from minor trauma or even spontaneously with severe kyphosis 6, 8
• Do not start NSAIDs without checking renal function in trauma patients 2