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Imaging in Sternal Fractures

  • Author: David A Fisher, MD; Chief Editor: Felix S Chew, MD, MBA, MEd  more...
 
Updated: Jan 11, 2016
 

Overview

Sternal fractures are often seen in association with deceleration injuries and/or direct blows to the chest, and they occur in approximately 3% of patients suffering blunt chest trauma, such as in motor vehicle accidents, which account for the majority of sternal fractures (see the following images).[1] The introduction of seat-belt legislation has resulted in an increased frequency of these types of injuries.[2, 3, 4]

Lateral radiograph demonstrates complete dislocati Lateral radiograph demonstrates complete dislocation at the sternal angle. (Also see next image.)
Upright frontal radiograph in the same patient as Upright frontal radiograph in the same patient as in the previous image shows mild widening of the superior mediastinum after blunt trauma to the chest.

Most sternal fractures occur in the midbody, and they are typically transverse (see the first image above). Manubrial fractures are the next most common. Stress fractures are occasionally seen in athletes such as wrestlers, but they can also occur in women with osteoporosis and kyphotic thoracic spines.

These injuries can have an associated mortality rate of less than 1%[5, 6] as a result of associated chest injuries, such as cardiac contusion, aortic rupture, pulmonary contusion, and thoracic spine compression fractures.

Anatomy

The sternum has 3 parts: the manubrium, the body (corpus), and the xiphoid process (tip) (see the images below).

(Click Image to enlarge.) Posterior surface of the (Click Image to enlarge.) Posterior surface of the sternum.
(Click Image to enlarge.) Lateral border of the st (Click Image to enlarge.) Lateral border of the sternum.

The manubrium lies at the level of the third (T3) and fourth thoracic (T4) vertebrae. Along the superior margin of the manubrium is the suprasternal or jugular notch. Both the clavicle and the first rib articulate with the manubrium, and the sternal head of the sternocleidomastoid muscle inserts onto this portion of the sternum.

The joint between the manubrium and the body, the manubriosternal joint, forms the sternal angle, which is at the level of the second rib. In older people, this joint tends to be fused.

The xiphoid process is cartilaginous in younger people and ossified in older people

Preferred examination

The routine radiologic study of the sternum consists of a lateral projection and frontal views, which are obtained with the patient prone and rotated slightly off the midline in each direction. Normal anatomic variants, such as nonunited ossification centers, may sometimes cause a diagnostic dilemma. Initially, computed tomography (CT) scan studies were less sensitive than plain radiographs. However, the newer generation of multidetector-row CT (MDCT) scanning units now allow for multiplanar and 3-dimensional (3-D) reconstruction, which greatly improve accuracy. CT scanning provides superior sensitivity and specificity but at greater cost and with increased radiation exposure. Ultrasonography has been proven to be as accurate as radiography in diagnosing sternal fractures. However, lateral radiographs remain the standard means of demonstrating the grade of sternal displacement.[3, 7, 8, 9, 10, 11]

Trauma to the aorta and cardiac and/or pulmonary contusions are part of the differential diagnosis.

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Radiography

The lateral radiograph is usually the most valuable view for detecting sternal fractures and for determining the degree of displacement (see the following images).[12]

Lateral radiograph of the normal sternum. Lateral radiograph of the normal sternum.
Frontal radiograph of the normal sternum. Frontal radiograph of the normal sternum.
Lateral radiograph demonstrates complete dislocati Lateral radiograph demonstrates complete dislocation at the sternal angle. (Also see next image.)
Upright frontal radiograph in the same patient as Upright frontal radiograph in the same patient as in the previous image shows mild widening of the superior mediastinum after blunt trauma to the chest.
Supine frontal radiograph after significant blunt Supine frontal radiograph after significant blunt trauma to the anterior chest wall shows marked mediastinal widening. (Also see next image.)
Lateral radiograph shows a complete displaced frac Lateral radiograph shows a complete displaced fracture of the sternum (arrow) (same patient as in the previous image above).

Almost all patients with sternal fractures complain of localized sternal pain. Therefore, correlation with the clinical presentation is important.

Nonunited ossification centers and failure of bony fusion of the sternomanubrial and sternoxiphoid articulations can simulate fractures; the angulation is variable at both of these sites.

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Computed Tomography

CT scan studies were initially less sensitive than plain radiography.[13] The newer generation of MDCT scanning units now allow for multiplanar and 3-D reconstruction, which greatly improve accuracy. CT scanning provides superior sensitivity and specificity but at a greater cost and with more radiation exposure.

CT scanning is particularly useful to assess patients with sternal fractures for associated injuries such as pulmonary contusion, pneumothorax, or retrosternal hematoma.

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Ultrasonography

Ultrasonography is a useful way to demonstrate fractures of the sternum.[14, 15, 16]  The sensitivity of ultrasonography is comparable to that of plain radiography, but conventional radiography remains the standard means of documenting a sternal fracture.

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Nuclear Imaging

Nuclear bone scanning may be needed if the initial radiographic findings are not definitive (see the following image).

Nuclear bone scan of fractures of the sternum (arr Nuclear bone scan of fractures of the sternum (arrow) and of the ribs on the right side (arrowheads).

Total-body bone scans are sensitive for acute sternal trauma. However, the anatomic detail is limited, and correlation with the results of radiography or CT scanning is often necessary.

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Contributor Information and Disclosures
Author

David A Fisher, MD Consulting Staff, Metropolitan Diagnostic Imaging

David A Fisher, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, Radiological Society of North America

Disclosure: Nothing to disclose.

Specialty Editor Board

Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand

Disclosure: Nothing to disclose.

Theodore E Keats, MD Professor, Departments of Radiology and Orthopedics, University of Virginia School of Medicine

Disclosure: Nothing to disclose.

Chief Editor

Felix S Chew, MD, MBA, MEd Professor, Department of Radiology, Vice Chairman for Academic Innovation, Section Head of Musculoskeletal Radiology, University of Washington School of Medicine

Felix S Chew, MD, MBA, MEd is a member of the following medical societies: American Roentgen Ray Society, Association of University Radiologists, Radiological Society of North America

Disclosure: Nothing to disclose.

Additional Contributors

Leon Lenchik, MD Program Director and Associate Professor of Radiologic Sciences-Radiology, Wake Forest University Baptist Medical Center

Leon Lenchik, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, Radiological Society of North America

Disclosure: Nothing to disclose.

Acknowledgements

David S Gazzaniga, MD Consulting Staff, ProHEALTH Care Associates; Head Orthopedic Surgeon, Hofstra University; Consulting Orthopedic Surgeon, North Shore University Hospital; Head Team Orthopedic Surgeon, New York Islanders; Consulting Orthopedic Surgeon, U S Open; Foot and Ankle Consultant to New York Jets and New York Dragons

David S Gazzaniga, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Orthopaedic Foot and Ankle Society

Disclosure: Nothing to disclose.

Stephen W Lastig, MD Chairman, Department of Radiology, South Nassau Communities Hospital

Stephen W Lastig, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Radiology, and Radiological Society of North America

Disclosure: Nothing to disclose.

References
  1. Brookes JG, Dunn RJ, Rogers IR. Sternal fractures: a retrospective analysis of 272 cases. J Trauma. 1993 Jul. 35(1):46-54. [Medline].

  2. Budd JS. Effect of seat belt legislation on the incidence of sternal fractures seen in the accident department. Br Med J (Clin Res Ed). 1985 Sep 21. 291(6498):785. [Medline]. [Full Text].

  3. Mavridis IN. Imaging techniques in the assessment of sternal fracture patients. Eur J Radiol. 2013 Jan. 82 (1):200. [Medline].

  4. Recinos G, Inaba K, Dubose J, Barmparas G, Teixeira PG, Talving P, et al. Epidemiology of sternal fractures. Am Surg. 2009 May. 75 (5):401-4. [Medline].

  5. Bar I, Friedman T, Rudis E, Shargal Y, Friedman M, Elami A. Isolated sternal fracture--a benign condition?. Isr Med Assoc J. 2003 Feb. 5(2):105-6. [Medline].

  6. Potaris K, Gakidis J, Mihos P, Voutsinas V, Deligeorgis A, Petsinis V. Management of sternal fractures: 239 cases. Asian Cardiovasc Thorac Ann. 2002 Jun. 10(2):145-9. [Medline].

  7. Kung JW, Wu JS, Shetty SK, Khasgiwala VC, Appleton P, Hochman MG. Spectrum and detection of musculoskeletal findings on trauma-related CT torso examinations. Emerg Radiol. 2014 Aug. 21 (4):359-65. [Medline].

  8. Scheyerer MJ, Zimmermann SM, Bouaicha S, Simmen HP, Wanner GA, Werner CM. Location of sternal fractures as a possible marker for associated injuries. Emerg Med Int. 2013. 2013:407589. [Medline].

  9. Yeh DD, Hwabejire JO, DeMoya MA, Alam HB, King DR, Velmahos GC. Sternal fracture--an analysis of the National Trauma Data Bank. J Surg Res. 2014 Jan. 186 (1):39-43. [Medline].

  10. Kim EY, Yang HJ, Sung YM, Hwang KH, Kim JH, Kim HS. Sternal fracture in the emergency department: diagnostic value of multidetector CT with sagittal and coronal reconstruction images. Eur J Radiol. 2012 May. 81 (5):e708-11. [Medline].

  11. You JS, Chung YE, Kim D, Park S, Chung SP. Role of sonography in the emergency room to diagnose sternal fractures. J Clin Ultrasound. 2010 Mar-Apr. 38 (3):135-7. [Medline].

  12. Yoganandan N, Pintar FA, Gennarelli TA, Martin PG, Ridella SA. Chest deflections and injuries in oblique lateral impacts. Traffic Inj Prev. 2008 Jun. 9(2):162-7. [Medline].

  13. Huggett JM, Roszler MH. CT findings of sternal fracture. Injury. 1998 Oct. 29(8):623-6. [Medline].

  14. Jin W, Yang DM, Kim HC, Ryu KN. Diagnostic values of sonography for assessment of sternal fractures compared with conventional radiography and bone scans. J Ultrasound Med. 2006 Oct. 25(10):1263-8; quiz 1269-70.

  15. Yoon D, Hoftman N, Ren W, Esmailian F, Schmidt P, Mahajan A. Intraoperative transesophageal echocardiography in chest trauma. J Trauma. 2008 Oct. 65(4):924-6. [Medline].

  16. Zeng Q, Lai JY, Wang XM, Lee JL, Chia ST, Wang CJ, et al. Costochondral changes in the chest wall after the Nuss procedure: ultrasonographic findings. J Pediatr Surg. 2008 Dec. 43(12):2147-50. [Medline].

  17. Gray H. Anatomy of the human body. Available at http://www.bartleby.com/107/. Accessed: February 21, 2007.

 
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Lateral radiograph of the normal sternum.
Frontal radiograph of the normal sternum.
(Click Image to enlarge.) Posterior surface of the sternum.
(Click Image to enlarge.) Lateral border of the sternum.
Nuclear bone scan of fractures of the sternum (arrow) and of the ribs on the right side (arrowheads).
Lateral radiograph demonstrates complete dislocation at the sternal angle. (Also see next image.)
Upright frontal radiograph in the same patient as in the previous image shows mild widening of the superior mediastinum after blunt trauma to the chest.
Supine frontal radiograph after significant blunt trauma to the anterior chest wall shows marked mediastinal widening. (Also see next image.)
Lateral radiograph shows a complete displaced fracture of the sternum (arrow) (same patient as in the previous image above).
 
 
 
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