What is the appropriate treatment for a patient presenting with a sternum fracture?

Treatment of Sternal Fracture

Most sternal fractures are managed conservatively with pain control, early mobilization, and monitoring for cardiac complications—hospitalization is only necessary for patients with ECG abnormalities, elevated troponins, severely displaced fractures, or significant comorbidities. 1, 2

Initial Assessment and Risk Stratification

Obtain an ECG and cardiac troponin levels immediately in all patients with sternal fractures, as this determines whether safe discharge is possible or admission is required. 1, 3

• Patients with normal ECG and normal cardiac troponins can be safely discharged without prolonged observation, as they have a low probability for cardiac blunt trauma. 1, 4
• Approximately 6% of sternal fracture patients develop ECG changes or rising troponin levels, requiring monitoring for arrhythmias and myocardial contusion. 1
• Do not routinely order echocardiography if ECG and troponins are normal, as this adds no diagnostic value for isolated sternal fractures. 1, 4, 3

Imaging

• CT chest without IV contrast using sagittal and 3-D reconstructions is the imaging modality of choice for accurately detecting sternal fractures and displacement. 1, 3
• Standard chest radiography can be used initially but may miss fracture details. 5

Conservative Management (Majority of Cases)

88% of sternal fracture patients do not require parenteral analgesia or procedures necessitating hospital admission. 2

Pain Control

• Provide multimodal analgesics tailored to patient comorbidities, as adequate pain control is essential for respiratory mechanics and preventing complications. 1, 3
• Chest pain typically persists for a mean of 10.9 weeks, with significantly prolonged symptoms in patients over age 50. 6

Early Mobilization and Rehabilitation

• Begin early mobilization and physical training as soon as pain allows, typically within 24-48 hours. 1, 3
• Start range-of-motion exercises within the first few days, including shoulder, elbow, wrist, and hand motion. 1
• Restrict above-chest-level activities until fracture healing is evident (typically 6-8 weeks). 1, 4

Indications for Hospital Admission

Admission is reserved for specific high-risk scenarios:

• ECG changes or elevated/rising troponin levels requiring telemetry monitoring for 6-12 hours minimum with serial biomarkers. 1, 3
• Severely displaced fractures requiring potential surgical fixation. 2
• High-impact trauma with concern for associated injuries (rib fractures in 64%, head injury in 48%, thoracic spine injury in 38%). 7
• Manubrium sterni fractures, which are strongly associated with thoracic spine injuries, other chest injuries, and higher ICU admission rates. 7
• Complex analgesic requirements or significant comorbidities. 2
• Inadequate domestic support for safe home care. 2

Surgical Management

Surgical fixation is rarely needed but should be considered for:

• Severely displaced fractures with complex comorbidities (approximately 4% of cases). 2
• Anterior sternal plating using low-profile locking titanium plates provides the best stability when surgery is indicated. 8
• Transverse fractures are plated longitudinally, while oblique manubrium fractures and sternocostal separations require transverse plating from rib to sternum to rib. 8

Special Considerations for Elderly Patients

• Assess for underlying osteoporosis and consider calcium and vitamin D supplementation. 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, 4
• Consider multidisciplinary geriatric input to address age-related factors affecting recovery. 1
• Duration of symptoms is significantly prolonged in patients over age 50. 6

Common Pitfalls to Avoid

• Do not routinely admit all sternal fracture patients for observation—this is unnecessary for isolated fractures with normal cardiac workup. 9, 2
• Do not order routine "trauma panels" beyond initial ECG and troponin for uncomplicated cases. 4
• Do not assume normal vital signs exclude cardiac injury—ECG and troponins are far more sensitive. 4
• Provide specific rehabilitation advice and prognosis information, as current practice shows variable and poor discharge instructions leading to prolonged disability. 6

Follow-Up

• Outpatient follow-up at 6 weeks post-discharge to assess healing and functional recovery. 2
• Inform patients that symptoms typically last 10-12 weeks, with longer duration expected in elderly patients. 6
• Communicate prognosis clearly to the patient's primary care physician. 6