Sternal Fracture Workup

Updated: Jul 12, 2017
  • Author: Scott Felten, MD, FACEP; Chief Editor: Trevor John Mills, MD, MPH  more...
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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 (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.

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Imaging Studies

Radiographs

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. [5]

Bedside ultrasonography has been demonstrated in a study to be more effective in diagnosis than conventional radiography. [16]

The diagnosis time may be significantly shortened the use of bedside ultrasonography. [17]

CT scanning

CT is the most common imaging study to make the diagnosis. [18, 19]  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. [20]

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.

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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.

A repeat ECG in 6 hours is recommended and requires no further workup for cardiac injury if the findings are normal. [21, 22]

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