Imaging Studies

Radiographs

Chest radiographs are usually the initial imaging provided for patients with suspected sternal injury.^[14] 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. Ultrasound is not accurate in identifying the degree of displacement of sternal fractures, but it can accurately identify related hematomas and pleural effusions.^[6]

Normal sternal development should be considered when evaluating the sternum in children. Each component of the sternum contains several ossification centers. Their pattern of appearance and configuration may vary greatly with the age of the patient. Since some ossification centers are discernible until adulthood, they may be misinterpreted as a fracture in childhood. Failure of midline fusion may also be confused with a fracture.^[23]

Bedside ultrasonography has been demonstrated in a study to be more effective than conventional radiography in making the diagnosis of sternal fracture.^[24] Diagnosis time may be significantly shortened by the use of bedside ultrasonography.^[25]

CT scanning

CT is the most common imaging study to make the diagnosis.^{[26, 27]} Of 292 patients with sternal fracture in one study, 94% of fractures were visible only on chest CT. Cardiac contusion was identified in 7 of the patients.^[28]

CT scanning may reveal sternal fracture, but it 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

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 (troponin) 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.

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.

A repeat ECG in 6 hours is recommended and requires no further workup for cardiac injury if the findings are normal.^{[29, 30]}

Treatment & Management

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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.