eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Fracture, Sternal

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

Updated: Aug 12, 2009

Introduction

Background

Sternal fractures were once thought to be high-morbidity injuries, with a mortality rate of 25-45% from associated injuries. Recent literature reveals that the morbidity rate may be lower, yet caution is warranted when evaluating and treating patients with this injury.

Pathophysiology

Most sternal fractures are caused by blunt anterior chest trauma, although stress fractures have been noted in golfers, weight lifters, and other participants in noncontact sports. Insufficiency fractures can occur spontaneously in patients with osteoporosis or osteopenia (particularly in older persons), those on long-term steroid therapy, or those with severe thoracic kyphosis. Cardiopulmonary resuscitation commonly causes rib and sternal fractures, something that must be considered during the recovery process from the illness that lead to the cardiac arrest.

Posterior surface of the sternum.

Posterior surface of the sternum.

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Posterior surface of the sternum.

Posterior surface of the sternum.

Frequency

United States

Motor vehicle collisions account for 60-90% of sternal fractures.1 Most of these are in older vehicles in which a seat belt is used but no airbag deploys. Those who were unrestrained generally sustained injury from ejection from the vehicle or impact with the steering wheel or dashboard. Direct impact sports, falls, vehicle-to-pedestrian accidents, and assaults account for most of the rest. Spontaneous fractures and stress fractures are rare.

Mortality/Morbidity

The mortality rate from isolated sternal fracture is extremely low. Death and morbidity are related almost entirely to associated injuries such as aortic disruption, cardiac contusion, and pulmonary contusion, or unrelated injuries to the abdomen or head sustained in the accident.

Race

No racial predilection is known.

Sex

Sternal fractures are slightly more common in females than in males, possibly because of shoulder restraint positioning; however, the difference is small.

Age

Sternal fractures are more common in patients older than 50 years, possibly because of a weaker or inelastic bony thorax. Because of the elasticity of their chest walls, children less commonly have sternal fractures; however, when present, the underlying injuries may be more severe.

Clinical

History

  • In most cases, consider the diagnosis based on the mechanism of injury. Direct trauma is the most common cause of injury due to mechanisms such as motor vehicle accidents, sports, and falls. Hyperflexion injuries can lead to sternal fractures, often in association with spinal column injuries.
  • The symptoms in a patient with spontaneous insufficiency or stress fracture create a greater diagnostic challenge unless the diagnosis is considered carefully, because the symptoms often resemble other serious conditions. These fractures tend to occur in the elderly population, especially in postmenopausal women.
  • Almost all patients complain of localized sternal pain. Pain may be more diffuse in patients with insufficiency fractures and may lead to a more extensive differential diagnosis for chest pain in an older population.
  • Dyspnea is present in 15-20% of these patients and may indicate associated cardiopulmonary contusion.
  • Palpitations may be noted only if dysrhythmia occurs, which is unusual in isolated sternal injury without associated cardiac contusion.

Physical

  • Carefully assess for signs of other potentially associated injuries. These may include rib fractures, flail chest, pneumothorax, hemothorax, pulmonary contusion, blunt cardiac injury (dysrhythmias or murmurs), pericardial tamponade, or vascular injury, as well as head, neck, abdominal, or extremity trauma.
  • Pain usually is localized over the fracture site and readily reproducible, though patients with insufficiency fractures may have more diffuse pain.
  • Crepitation or displacement is not often palpable unless the sternum is disrupted completely with significant instability of the fragments.
  • Only 40-55% of patients have overlying soft-tissue edema or ecchymosis.
  • Patients with insufficiency fractures usually exhibit an exaggerated dorsal kyphosis.

Causes

  • With increased use of seat belts and shoulder restraints, incidence has increased, but overall severity of injuries has decreased.
  • Presumably, incidence has increased because all of the deceleration forces are concentrated into a nonelastic 2-inch strap that transmits this force directly to the sternum.
  • Effects of airbags on incidence of sternal fractures are not fully known, though literature suggests a decreased incidence when these are deployed.

More on Fracture, Sternal

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Follow-up: Fracture, Sternal
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References
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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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