eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Fracture, Sternal

Mark S Slabinski, MD, FACEP, FAAEM, Vice President, EMP Medical Group

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.

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.

Differential Diagnoses

Costochondritis
Dissection, Aortic
Fractures, Rib
Sternoclavicular Joint Injury

Other Problems to Be Considered

Cardiac tamponade
Flail chest
Cardiac contusion
Pulmonary contusion
Thoracic spine injury

Workup

Laboratory Studies

• In general, laboratory studies are not indicated for evaluation of isolated sternal injuries, though consider appropriate laboratory studies in evaluation of potential associated injuries.
• Creatine kinase (CK)-MB index and other enzyme markers of cardiac injury are helpful if cardiac contusion is suspected. However, the routine use of this test is not indicated. Remember that total CK may be elevated from other noncardiac muscle injuries.

Imaging Studies

• Radiographs
  • Plain radiography remains the diagnostic tool of choice.
  • Although standard posteroanterior and lateral chest radiographs may reveal fracture, sternal views are necessary if injury is suspected from physical examination.
  • Be aware of normal ossification centers that normally close by the late teenage years, though sternomanubrial and sternoxiphoid centers may never fuse in 10-30% of patients.
  • Sternal views enhance visualization of the sternum, since they change the angle and focus of the exposure. Obtain these views if highly suspicious for injury and no fracture is seen on chest radiograph.
• Ultrasonography: Ultrasonography demonstrates sternal fractures with as much sensitivity as plain radiography, although this should not be considered the imaging test of first choice.
• Computed tomography
  • CT scanning may reveal this injury yet is less sensitive than plain radiography, as the fracture may be positioned between image cuts.
  • CT scans may demonstrate retrosternal hematoma; although its specificity is high, its sensitivity is poor.
  • Suspicion for other chest injuries warrants CT scans.

Other Tests

• Obtain an ECG in all patients with significant blunt injury to chest. Findings indicative of cardiac contusion include dysrhythmia, conduction disturbances, or ST-segment changes consistent with myocardial injury.
• Perform cardiac monitoring as workup proceeds until making a disposition decision for the patient.
• Obtain pulse oximetry on all patients during their evaluation.
• Do not routinely consider echocardiography in patients with isolated sternal injury. Studies have shown that up to 25% of patients with sternal fracture have small pericardial effusions, yet, in the absence of hemodynamic compromise, this requires no further intervention.

Procedures

• No procedures are indicated in patients with isolated sternal fracture, yet consider interventions for associated injuries.

Treatment

Prehospital Care

• Initiate basic or advanced trauma care based on the level of training of the ambulance crew and initial assessment.
• Care should include the following steps:
  • Supplemental oxygen
  • Cardiac monitoring
  • Intravenous access
  • Consideration of an analgesic
  • Trauma care as warranted by protocol for any suspected associated injuries

Emergency Department Care

• After immediate stabilization, evaluate the patient by obtaining a complete history and physical examination.
• Taping or splinting of sternal fractures is contraindicated, as restriction of normal chest expansion during respiration can lead to atelectasis and pulmonary insufficiency.
• Adequate analgesia is the treatment of choice, both during initial care and subsequently during the recovery period.

Consultations

• Consult a trauma surgeon when serious associated injury is diagnosed or suspected.
• Surgical fixation for sternal fractures is generally unnecessary, although a recent study suggests that a more rapid recovery can be made if painful unstable fractures are fixated early rather than allowing them to heal over time.

Medication

Primary treatment is adequate analgesia with nonsteroidal anti-inflammatory drugs and opiates. Select these on the basis of relative indications and contraindications for each patient and administer in standard doses and routes. Since sternal fractures can take weeks to heal, do not hesitate to offer adequate analgesia for this recovery period. No other pharmacologic therapies are indicated specifically for treatment of sternal fractures.

Nonsteroidal anti-inflammatory agents (NSAIDs)

These agents are most commonly used for relief of mild to moderately severe pain. Effects of NSAIDs in the treatment of pain tend to be patient specific, yet ibuprofen is usually the drug of choice for initial therapy. Other options include fenoprofen, flurbiprofen, ketoprofen, and naproxen.

Ibuprofen (Ibuprin, Advil, Motrin)

Usually DOC for treatment of mild to moderately severe pain if no contraindications. Inhibits inflammatory reactions and pain, probably by decreasing activity of enzyme cyclooxygenase, which inhibits prostaglandin synthesis.

Dosing

Adult

200-400 mg PO q4-6h prn; not to exceed 3.2 g/d

Pediatric

<6 months: Not established
6 months to 12 years: 20-40 mg/kg/d PO divided tid/qid
>12 years: 200-400 mg PO q4-6h prn; not to exceed 3.2 g/d

Interactions

Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants (monitor PT closely and instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; may increase phenytoin levels

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy

Ketoprofen (Oruvail, Orudis, Actron)

Used for relief of mild to moderately severe pain and inflammation. Administer small dosages initially to patients with small bodies, older persons, and those with renal or liver disease. Doses higher than 75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe for response.

Dosing

Adult

25-50 mg PO q6-8h prn; not to exceed 300 mg/d

Pediatric

<3 months: Not established
3 months to 12 years: 0.1-1 mg/kg PO q6-8h
>12 years: 25-50 mg q6-8h prn; not to exceed 300 mg/d

Interactions

Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants (monitor PT closely and instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; may increase phenytoin levels

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy

Naproxen (Anaprox, Naprelan, Naprosyn)

Used for relief of mild to moderately severe pain. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, which inhibits prostaglandin synthesis.

Dosing

Adult

500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d

Pediatric

<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d

Interactions

Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants (monitor PT closely and instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; may increase phenytoin levels

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug

Analgesics

Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained fractures.

Acetaminophen (Tylenol, Panadol, aspirin-free Anacin)

DOC for treatment of pain in patients with documented hypersensitivity to aspirin or NSAIDs or those with upper GI disease or taking oral anticoagulants.

Dosing

Adult

325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d

Pediatric

<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 g PO q4h; not to exceed 5 doses/d

Interactions

Rifampin can reduce analgesic effects; barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity

Contraindications

Documented hypersensitivity; known G-6-PD deficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Hepatotoxicity possible in chronic alcoholics following various dose levels; severe or recurrent pain or high or continued fever may indicate serious illness; acetaminophen is contained in many OTC products and combined use with these products may result in cumulative acetaminophen doses exceeding recommended maximum dose

Acetaminophen and codeine (Tylenol #3)

Drug combination indicated for treatment of mild to moderately severe pain.

Dosing

Adult

30-60 mg/dose based on codeine content PO q4-6h or 1-2 tab q4h; not to exceed 12 tab/d

Pediatric

0.5-1 mg/kg/dose based on codeine content PO q4-6h; 10-15 mg/kg/dose based on acetaminophen content; not to exceed 2.6 g/d of acetaminophen

Interactions

CNS depressants or tricyclic antidepressants increase toxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in patients dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction

Hydrocodone bitartrate and acetaminophen (Vicodin ES)

Drug combination indicated for relief of moderately severe to severe pain.

Dosing

Adult

1-2 tab/cap PO q4-6h prn

Pediatric

<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d of acetaminophen
>12 years: 750 mg acetaminophen PO q4h; single dose not to exceed 10 mg of hydrocodone bitartrate; not to exceed 5 doses/d

Interactions

Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants increase toxicity

Contraindications

Documented hypersensitivity; high-altitude cerebral edema; elevated intracranial pressure

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Tablets contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction

Oxycodone and acetaminophen (Percocet)

Drug combination indicated for relief of moderately severe to severe pain. DOC for aspirin-hypersensitive patients.

Dosing

Adult

1-2 tab/cap PO q4-6h prn

Pediatric

0.05-0.15 mg/kg/dose oxycodone PO q4-6h prn; not to exceed 5 mg/dose of oxycodone

Interactions

Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants increase toxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Duration of action may increase in elderly persons; be aware of total daily dose of acetaminophen patient is receiving; do not exceed 4000 mg/24 h of acetaminophen; higher doses may cause liver toxicity

Morphine sulfate (Duramorph, Astramorph, MS Contin)

DOC for narcotic analgesia because of its reliable and predictable effects, safety, and ease of reversibility with naloxone. Administered IV, may be dosed in a number of ways and commonly is titrated until desired effect obtained.

Dosing

Adult

Starting dose: 0.1 mg/kg IV/IM/SC
Maintenance dose: 5-20 mg/70 kg IV/IM/SC q4h
Relatively hypovolemic patients: Start with 2 mg IV/IM/SC and reassess hemodynamic effects of dose

Pediatric

Neonates: 0.05-0.2 mg/kg IV/IM/SC prn
Children: 0.1-0.2 mg/kg IV/IM/SC q2-4h prn

Interactions

Phenothiazines may antagonize analgesic effects; tricyclic antidepressants, MAOIs, and other CNS depressants may potentiate adverse effects

Contraindications

Documented hypersensitivity; hypotension; potentially compromised airway in which establishing rapid airway control would be difficult

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Avoid in hypotension, respiratory depression, nausea, emesis, constipation, and urinary retention; caution in atrial flutter and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate

Acetylsalicylic acids

These agents are effective in reducing pain and inflammation.

Aspirin (Anacin, Ascriptin, Bayer aspirin)

Used for treatment of mild to moderately severe pain and headache. Blocks prostaglandin synthetase action, which inhibits prostaglandin synthesis and prevents formation of platelet-aggregating thromboxane A2. Also acts on hypothalamus heat-regulating center to reduce fever.

Dosing

Adult

325-650 mg PO q4-6h; not to exceed 4 g/d

Pediatric

10-15 mg/kg/dose PO q4-6h; not to exceed 60-80 mg/kg/d

Interactions

Antacids and urinary alkalinizers may decrease effects; corticosteroids decrease serum levels; anticoagulants may cause additive hypoprothrombinemic effects and increased bleeding times; may antagonize uricosuric effects of probenecid and increase toxicity of phenytoin and valproic acid; doses >2 g/d may potentiate glucose-lowering effects of sulfonylurea drugs

Contraindications

Documented hypersensitivity; liver damage; hypoprothrombinemia; vitamin K deficiency; bleeding disorders; asthma
Because of association with Reye syndrome, do not use in children (<16 y) with flu

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

May cause transient decrease in renal function and aggravate chronic kidney disease; avoid use in patients with severe anemia, in those with history of blood coagulation defects, or in those taking anticoagulants

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.

Multimedia

Media file 1: Posterior surface of the sternum.

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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

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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