History

In most cases of sternal fracture, 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.^{[1, 2, 3]}

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 in addition to sternal fracture. These may include rib fractures, flail chest, pneumothorax, hemothorax, pulmonary contusion, blunt cardiac injury (manifested by 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, the incidence of sternal fracture 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.^[15]

Effects of airbags on incidence of sternal fractures are not fully known, though literature suggests a decreased incidence when these are deployed.

Differential Diagnoses

Schulz-Drost S, Krinner S, Langenbach A, Oppel P, Lefering R, Taylor D, et al. Concomitant Sternal Fracture in Flail Chest: An Analysis of 21,741 Polytrauma Patients from the TraumaRegister DGU®. Thorac Cardiovasc Surg. 2017 Feb 10. [QxMD MEDLINE Link].
Morgenstern M, von Rüden C, Callsen H, Friederichs J, Hungerer S, Bühren V, et al. The unstable thoracic cage injury: The concomitant sternal fracture indicates a severe thoracic spine fracture. Injury. 2016 Nov. 47 (11):2465-2472. [QxMD MEDLINE Link].
Schulz-Drost S, Oppel P, Grupp S, Taylor D, Krinner S, Langenbach A, et al. The oblique fracture of the manubrium sterni caused by a seatbelt--a rare injury? Treatment options based on the experiences gained in a level I trauma centre. Int Orthop. 2016 Apr. 40 (4):791-8. [QxMD MEDLINE Link].
Khoriati AA, Rajakulasingam R, Shah R. Sternal fractures and their management. J Emerg Trauma Shock. 2013 Apr. 6 (2):113-6. [QxMD MEDLINE Link].
Lahham S, Patane J, Lane N. Ultrasound of Sternal Fracture. West J Emerg Med. 2015 Dec. 16 (7):1057-8. [QxMD MEDLINE Link].
Vioreanu MH, Quinlan JF, Robertson I, O'Byrne JM. Vertebral fractures and concomitant fractures of the sternum. Int Orthop. 2005 Dec. 29(6):339-42. [QxMD MEDLINE Link].
Racine S, Émond M, Audette-Côté JS, Le Sage N, Guimont C, Moore L, et al. Delayed complications and functional outcome of isolated sternal fracture after emergency department discharge: a prospective, multicentre cohort study. CJEM. 2016 Sep. 18 (5):349-57. [QxMD MEDLINE Link].
Schulz-Drost S, Oppel P, Grupp S, Taylor D, Krinner S, Langenbach A, et al. The oblique fracture of the manubrium sterni caused by a seatbelt-a rare injury? Treatment options based on the experiences gained in a level I trauma centre. Int Orthop. 2015 May 10. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Knobloch K, Wagner S, Haasper C, Probst C, Krettek C, Otte D, et al. Sternal fractures occur most often in old cars without any airbag often with concomitant spinal injuries: clinical findings and technical collision variables among 42,055 crash victims. Ann Thorac Surg. 2006 Aug. 82(2):444-50. [QxMD MEDLINE Link].
Weaver AA, Schoell SL, Nguyen CM, Lynch SK, Stitzel JD. Morphometric analysis of variation in the sternum with sex and age. J Morphol. 2014 Nov. 275 (11):1284-99. [QxMD MEDLINE Link].
Hechter S, Huyer D, Manson D. Sternal fractures as a manifestation of abusive injury in children. Pediatr Radiol. 2002 Dec. 32(12):902-6. [QxMD MEDLINE Link].
Ferguson LP, Wilkinson AG, Beattie TF. Fracture of the sternum in children. Emerg Med J. 2003 Nov. 20(6):518-20. [QxMD MEDLINE Link].
Fichtel I, Fernandez FF, Wirth T. [Sternal fracture in growing children : A rare and often overlooked fracture? Documentation of four cases]. Unfallchirurg. 2016 Jul. 119 (7):570-4. [QxMD MEDLINE Link].
Karangelis D, Bouliaris K, Koufakis T, Spiliopoulos K, Desimonas N, Tsilimingas N. Management of isolated sternal fractures using a practical algorithm. J Emerg Trauma Shock. 2014 Jul. 7 (3):170-3. [QxMD MEDLINE Link].
Jin W, Yang DM, Kim HC, Ryu KN. Diagnostic value of sonography for assessment of sternal fractures compared with conventional radiograaphy and bone scans. J Ultrasound Med. 2006. 25:
Racine S, Drake D. BET 3: Bedside ultrasound for the diagnosis of sternal fracture. Emerg Med J. 2015 Dec. 32 (12):971-2. [QxMD MEDLINE Link].
Miller PR, Croce MA, Bee TK, et al. ARDS after pulmonary contusion: accurate measurement of contusion volume identifies high risk patients. J Trauma. 2001. 51:223:
Terry NL, Watts JR Jr, Sonavane SK, Beasley TM, Munden R, Nath PH, et al. Improved identification of sternal injuries with multidetector computed tomography (MDCT): sagittal reconstructions. Clin Imaging. 2016 Jul-Aug. 40 (4):739-44. [QxMD MEDLINE Link].
Perez MR, Rodriguez RM, Baumann BM, Langdorf MI, Anglin D, Bradley RN, et al. Sternal fracture in the age of pan-scan. Injury. 2015 Jul. 46 (7):1324-7. [QxMD MEDLINE Link].
Chiu WC, D'Amelio LF, Hammond JS. Sternal fractures in blunt chest trauma: a practical algorithm for management. Am J Emerg Med. 1997 May. 15(3):252-5. [QxMD MEDLINE Link].
Wright SW. Myth of the dangerous sternal fracture. Ann Emerg Med. 1993 Oct. 22(10):1589-92. [QxMD MEDLINE Link].
Raza I, Narayanan M, Venkataraju A, Ciocarlan A. Bilateral Subpectoral Interfascial Plane Catheters for Analgesia for Sternal Fractures: A Case Report. Reg Anesth Pain Med. 2016 Sep-Oct. 41 (5):607-9. [QxMD MEDLINE Link].
Thomas KP, Sainudeen S, Jose S, Nadhari MY, Macaire PB. Ultrasound-Guided Parasternal Block Allows Optimal Pain Relief and Ventilation Improvement After a Sternal Fracture. Pain Ther. 2016 Jun. 5 (1):115-22. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Gallo DR, Lett ED, Conner WC. Surgical repair of a chronic traumatic sternal fracture. Ann Thorac Surg. 2006 Feb. 81(2):726-8. [QxMD MEDLINE Link].
Schulz-Drost S, Oppel P, Grupp S, Schmitt S, Carbon RT, Mauerer A, et al. Surgical fixation of sternal fractures: preoperative planning and a safe surgical technique using locked titanium plates and depth limited drilling. J Vis Exp. 2015 Jan 5. e52124. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Peek GJ, Firmin RK. Isolated sternal fracture: an audit of 10 years' experience. Injury. 1995 Jul. 26(6):385-8. [QxMD MEDLINE Link].
Sadaba JR, Oswal D, Munsch CM. Management of isolated sternal fractures: determining the risk of blunt cardiac injury. Ann R Coll Surg Engl. 2000 May. 82(3):162-6. [QxMD MEDLINE Link].
Duncan MA, McNicholas W, O'Keeffe D, O'Reilly M. Periosteal infusion of bupivacaine/morphine post sternal fracture: a new analgesic technique. Reg Anesth Pain Med. 2002 May-Jun. 27(3):316-8. [QxMD MEDLINE Link].
Athanassiadi K, Gerazounis M, Moustardas M, Metaxas E. Sternal fractures: retrospective analysis of 100 cases. World J Surg. 2002 Oct. 26(10):1243-6. [QxMD MEDLINE Link].
Holcomb JB, McMullin NR, Kozar RA, Lygas MH, Moore FA. Morbidity from rib fractures increases after age 45. J Am Coll Surg. 2003 Apr. 196(4):549-55. [QxMD MEDLINE Link].
Lederer W, Mair D, Rabl W, Baubin M. Frequency of rib and sternum fractures associated with out-of-hospital cardiopulmonary resuscitation is underestimated by conventional chest X-ray. Resuscitation. 2004 Feb. 60(2):157-62. [QxMD MEDLINE Link].
Lin KH, Ponampalam R. Sternum insufficiency fracture presenting as acute chest pain: a case report and review of the literature. Eur J Emerg Med. 2006 Apr. 13(2):122-4. [QxMD MEDLINE Link].
Miller LA. Chest wall, lung, and pleural space trauma. Radiol Clin North Am. 2006. 44 (2):213-244.
Perron AD. Chest pain in athletes. Clin Sports Med. 2003 Jan. 22(1):37-50. [QxMD MEDLINE Link].
Rashid MA, Ortenwall P, Wikstrom T. Cardiovascular injuries associated with sternal fractures. Eur J Surg. 2001 Apr. 167(4):243-8. [QxMD MEDLINE Link].
Velissaris T, Tang AT, Patel A, Khallifa K, Weeden DF. Traumatic sternal fracture: outcome following admission to a Thoracic Surgical Unit. Injury. 2003 Dec. 34(12):924-7. [QxMD MEDLINE Link].
Wiener Y, Achildiev B, Karni T, Halevi A. Echocardiogram in sternal fracture. Am J Emerg Med. 2001 Sep. 19(5):403-5. [QxMD MEDLINE Link].

Media Gallery

Posterior surface of the sternum.
Lateral radiograph shows a complete displaced fracture of the sternum (arrow).

of 2

Author

Scott Felten, MD, FACEP Residency Director for Emergency Medicine Physicians, Attending Physician, Emergency Medicine Physicians, St Francis Medical Center

Scott Felten, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Mark S Slabinski, MD, FACEP, FAAEM Vice President, USACS Central

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, Ohio State Medical Association

Disclosure: Nothing to disclose.

Mark B Sigler, MD Resident Physician, Department of Emergency Medicine, University of Oklahoma College of Medicine, Tulsa

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

David B Levy, DO, FAAEM Senior Consultant in Emergency Medicine, Waikato District Health Board, New Zealand; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine

David B Levy, DO, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, Fellowship of the Australasian College for Emergency Medicine, American Medical Informatics Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Acknowledgements

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.