eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Fracture, Sternal: Follow-up

Author: Mark S Slabinski, MD, FACEP, FAAEM, Vice President, EMP Medical Group
Contributor Information and Disclosures

Updated: Aug 12, 2009

Follow-up

Further Inpatient Care

  • Numerous studies demonstrate that admission for isolated sternal fracture is not generally necessary unless associated injuries or social situations require such considerations.
  • Consider admission for cardiac monitoring when ECG abnormalities are found or serum markers indicate cardiac injury.
  • A recent study suggests that patients with pain that is difficult to control with outpatient analgesics should be considered for admission and be given a continuous infusion of an anesthetic via a subperiosteal catheter. Improved respiratory function was noted with this technique; however, it may not be readily available at most sites.
  • Consider at least an observation admission for elderly persons with chest wall fractures because these patients are at increased risk for respiratory compromise and atelectasis.

Further Outpatient Care

  • Follow-up outpatient care is suggested to ensure adequacy of analgesia and to monitor healing; however, no specific interventions or diagnostic testing are indicated in the outpatient care of patients with isolated sternal fractures.

Inpatient & Outpatient Medications

  • Sternal fractures take weeks to heal and provisions must be made for limited physical activity and adequate pain control during this recovery period.
  • Medications include NSAIDs, opiates, or opiate and nonopiate combinations in the usual doses unless specific patient conditions contraindicate their usage.

Transfer

  • Since most patients with isolated sternal fracture are candidates for discharge from the ED, no indications for transfer exist unless associated injuries dictate otherwise.

Deterrence/Prevention

  • Sternal fractures are more prevalent now with the increased use of seat belt restraints; however, the injuries that such restraints prevent more than support their continued usage at all times in motor vehicles. Proper positioning of these restraints is important.

Complications

  • Complications may arise from associated injuries. During evaluation of these patients, carefully assess for cardiac, pulmonary, mediastinal, and thoracic spine injuries, as well as associated injuries unrelated to chest trauma.
  • Cardiac contusion is much less common than once thought; its incidence currently ranges from 6-18% based on severity of trauma.
  • Traumatic aortic injury occurs in fewer than 2% of sternal fractures, a rate similar to that in patients with blunt chest trauma without sternal fracture.
  • Nonunion of sternal fractures is very rare. Painful pseudoarthroses or overlap deformities may require delayed surgical repair.
  • A posttraumatic mediastinal abscess is very uncommon. Risk factors include the presence of a large hematoma, intravenous drug abuse, and another source of a staphylococcal infection. Treatment is open debridement.

Prognosis

  • The prognosis is excellent for isolated sternal fractures. Most patients recover completely over a period of several weeks.
  • In rare cases of nonunion and chronic sternal pain, surgical fixation can be considered.

Patient Education

  • Although seat belts contribute to sternal fractures, they prevent more serious injuries. Reinforce their use.

Miscellaneous

Medicolegal Pitfalls

  • Failure to consider and treat other associated injuries
  • Failure to provide adequate analgesia

Special Concerns

  • Pregnant patients
    • During pregnancy, shield the abdomen and pelvis with a lead apron prior to obtaining required chest radiographs.
    • NSAIDs for analgesia are contraindicated outside the first trimester, though several category B opiate combinations exist for pain management.
  • Older patients: In older people, provide adequate analgesia; however, consider that a patient's baseline level of independent function may be compromised by adequate analgesics. Consider appropriate arrangements for assistance. Consideration for admission is supported by current trauma literature.
  • Children: No specific pediatric concerns are noted. While unusual injuries in children, no evidence exists that can specifically link sternal fractures to abuse in this age group.
 


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References
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Further Reading

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Keywords

sternal fracture, sternal fractures, sternum fracture, sternum fractures, sternum stress fractures, rib fractures, fracture of the sternum, chest trauma, sternal injury, cardiac contusion

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Contributor Information and Disclosures

Author

Mark S Slabinski, MD, FACEP, FAAEM, Vice President, EMP Medical Group
Mark S Slabinski, MD, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Ohio State Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Michelle Ervin, MD, Chair, Department of Emergency Medicine, Howard University Hospital
Michelle Ervin, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, National Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

David B Levy, DO, FACEP, FAAEM, Chairman, Department of Emergency Medicine, St Elizabeth Health Center; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine
David B Levy, DO, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Informatics Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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