Approach Considerations
Although no evidence specifically links sternal fractures to abuse in this age group, [16] such injuries are unusual injuries in children. Just like long bone fractures and rib fractures, sternal fractures should heighten the suspicion of child abuse. Sternal fractures are also more difficult to recognize on radiographs in the pediatric population and should be suspected if deformity, crepitus, and significant pain are present.
Chronic nonunion of sternal fractures is typically treated by osteosynthesis plating with or without autologous bone grafting. [31]
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:
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Supplemental oxygen
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Cardiac monitoring
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Intravenous access
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Consideration of an analgesic
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Trauma care as warranted by protocol for any suspected associated injuries
Emergency Department Care
Clinicians should employ Advanced Trauma Life Support (ATLS) guidelines to manage patients with acute sternal fractures. After the patient's airway, breathing, and circulation have undergone evaluation, a primary survey assessing any life-threatening conditions should follow. [14] 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. [32, 33]
Encouragement of deep breathing decreases pulmonary complications during recovery.
Patients with signs of myocardial contusion require admission for further evaluation and management. Patients with associated intrathoracic injuries, hemodynamically instability, or uncontrolled pain should also be admitted for observation. It is recommended that elderly patients receive close observation, as these patients are at higher risk for respiratory issues. [14]
Consult a trauma surgeon when serious associated injury is diagnosed or suspected.
Consultations
Medical Care
Numerous studies demonstrate that admission for isolated sternal fracture is not generally necessary unless associated injuries or social situations require such considerations. [34, 35, 36, 37]
One 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. [38] 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. 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.
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.
Surgical care
Surgical fixation for sternal fractures is generally unnecessary, although a study has suggested that a more rapid recovery can be made if painful unstable fractures are fixated early rather than allowing them to heal over time. [35, 39, 40, 41] Need for surgical intervention includes severe displacement, severe or persistent pain, nonunion, respiratory failure, or dependency on mechanical ventilation and restricted movement of the trunk. [19]
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. [8]
Chest pain after injury can persist for 8 to 12 weeks. Pain on inspiration can result in atelectasis, pneumonia, and other pulmonary complications. [14]
The elderly may experience prolonged recovery because of pain and osteoporotic bone. These patients should join a physical therapy program to regain their strength and muscle mass. [14]
Cardiac contusion is much less common than once thought; its incidence ranges from 6 to 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 occur when a false joint develops secondary to failed union of a fracture and may require delayed surgical repair. Similarly, 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.
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Posterior surface of the sternum.
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Lateral radiograph shows a complete displaced fracture of the sternum (arrow).
