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

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Media Gallery

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

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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.