Sternal fractures in blunt chest trauma: A practical algorithm for management

doi:10.1016/S0735-6757(97)90007-3

The American Journal of Emergency Medicine

Volume 15, Issue 3, May 1997, Pages 252-255

https://doi.org/10.1016/S0735-6757(97)90007-3 Get rights and content

Abstract

A retrospective review of the medical records of blunt trauma patients with sternal fracture admitted to a level 1 trauma center from June 1990 to June 1993 was undertaken to determine the relationship between sternal fractures and clinically significant myocardial injury, and to assess the usefulness of cardiac evaluation and monitoring in these patients. Of 33 patients with sternal fracture, 31 were in motor vehicle crashes and 2 were pedestrians struck. All had Glasgow Coma Scale score = 15. No patient had a severe, life-threatening, associated injury (Abbreviated Injury Score of >3). No electrocardiogram or echocardiogram showed evidence of acute injury or ischemia. No arrhythmias requiring treatment were noted. No CPK-MB fraction was >5%. These results show that sternal fracture is not a marker for clinically significant myocardial injury. The management of sternal fracture patients should be directed toward the treatment of associated injuries.

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Cited by (44)

Thoracic trauma: Clinical and paleopathological perspectives
2022, International Journal of Paleopathology
Although trauma is one of the most significant areas of study in paleopathology, most studies focus on fractures of single anatomical elements. Paleopathological research on regional trauma, such as of the thorax, is rare. This paper explores the causes, complications, and consequences of adult thoracic trauma using clinical data in order to inform paleopathological research.
Trends in paleopathological thoracic trauma literature were assessed by evaluating publications from Bioarchaeology International, International Journal of Osteoarchaeology, International Journal of Paleopathology, and American Journal of Biological Anthropology. Clinical publications on thoracic trauma throughout time were also assessed through a PubMed search, and modern prevalence data was found through trauma databases such as the National Trauma Databank.
Consideration of thoracic trauma involving concomitant injuries is a recent trend in clinical literature and patient care, but paleopathological research on thoracic trauma has been limited. Since thoracic fractures tend to occur in conjunction with other injuries, assessing them together is critical to the interpretation of trauma in the past.
Clinical research into thoracic fractures and concomitant injuries provides valuable data for paleopathological research. Evaluating the likelihood and consequences of concomitant injury in skeletal remains provides a more robust understanding of trauma in the past and its impact on past lifeways.
This paper provides a review of current clinical and paleopathological literature on thoracic trauma and demonstrates the importance of moving beyond the analysis of fractures or trauma of single anatomical elements.
Thoracic bones are often taphonomically altered and differentially preserved leading to difficulty in identifying and interpreting fractures.
Practical application of the data presented here to archaeological samples will help to advance paleopathological understandings of thoracic trauma.
Comment on: Perforation of the right cardiac ventricle as a late complication of a displaced sternal fracture following blunt trauma
2022, American Journal of Emergency Medicine
Sternal fractures caused by blunt chest trauma are associated with an increased incidence of cardiac injury. Reports of the incidence of cardiac injury associated with sternal fracture range from 18% to 62%. Delayed cardiac tamponade is a rare phenomenon that appears days or weeks after injury. Moreover, after nonpenetrating chest trauma, cardiac tamponade is very rare and occurs in less than 1 of 1000. To date, we read with great interest an article by Dr. S. Vanwynsberghe and colleagues for sharing their first case report of perforation of the right cardiac ventricle due to direct mechanical effect of the sharp, bony sternal fragment as a late complication of a displaced sternal fracture following blunt trauma, which occurred 5 days after blunt chest trauma. Fortunately, the patient recovered after aggressive surgical intervention and critical care.
National risk factors for blunt cardiac injury: Hemopneumothorax is the strongest predictor
2019, American Journal of Surgery
Blunt cardiac injury (BCI) can occur after chest trauma and may be associated with sternal fracture (SF). We hypothesized that injuries demonstrating a higher transmission of force to the thorax, such as thoracic aortic injury (TAI), would have a higher association with BCI.
We queried the National Trauma Data Bank (NTDB) from 2007-2015 to identify adult blunt trauma patients.
BCI occurred in 15,976 patients (0.3%). SF had a higher association with BCI (OR = 5.52, CI = 5.32–5.73, p < 0.001) compared to TAI (OR = 4.82, CI = 4.50–5.17, p < 0.001). However, the strongest independent predictor was hemopneumothorax (OR = 9.53, CI = 7.80–11.65, p < 0.001) followed by SF and esophageal injury (OR = 5.47, CI = 4.05–7.40, p < 0.001).
SF after blunt trauma is more strongly associated with BCI compared to TAI. However, hemopneumothorax is the strongest predictor of BCI. We propose all patients presenting after blunt chest trauma with high-risk features including hemopneumothorax, sternal fracture, esophagus injury, and TAI be screened for BCI.
Using the National Trauma Data Bank, sternal fracture is more strongly associated with blunt cardiac injury than blunt thoracic aortic injury. However, hemopneumothorax was the strongest predictor.
The Depth of Sternal Fracture Displacement is Not Associated With Blunt Cardiac Injury
2019, Journal of Surgical Research
Citation Excerpt :
Our study confirms and expands on the previous research performed in the investigation of the association of sternal fracture with BCI. For the most part, there has not been a significant association with BCI in the setting of sternal fracture.1,8,10-12 Similarly, we failed to find a significant difference in the rates of BCI among patients with or without sternal fracture displacement.
Background: Little evidence exist associating displaced sternal fractures with blunt cardiac injury (BCI), especially regarding the depth and severity of sternal fracture displacement and risk of BCI. The purpose of this study was to quantify sternal fracture severity by the degree of displacement and to evaluate the association of fracture severity with BCI.
A single institution retrospective review was performed from 2011 to 2014. All adult patients with sternal fracture were identified from the trauma registry, and sternal fracture displacement was quantified as mild (>0 mm, <5 mm), moderate (≥5 mm, <10 mm), or severe (≥10 mm). BCI was diagnosed according to standard AAST grading. Analysis was performed to assess the association of sternal fracture displacement with BCI, which was the primary outcome of interest.
Two hundred thirty-five patients with sternal fractures were included in the study. Forty-five percentage of patients suffered a displaced fracture, and 42.6% were diagnosed with BCI. There was no difference in mean fracture displacement when compared to patients without BCI (2.4 versus 1.6 mm, P = 0.07). There was no significant increase in BCI with sternal fracture displacement when compared to patients with nondisplaced fractures (44.3% versus 41.1%, P = 0.62). Neither fracture displacement (OR 1.10, CI 95% 0.65-1.88) nor severe displacement (OR 2.34, CI 95% 0.64-8.54) was associated with significantly increased risk of BCI.
There is no significant association between the depth of sternal fracture displacement and BCI. Further evaluation and management for BCI should be reserved in the absence of additional symptoms or findings.
Management Issues in Critically Ill Pediatric Patients with Trauma
2017, Pediatric Clinics of North America
Citation Excerpt :
For example, any patient presenting with blunt thoracic trauma severe enough to cause a sternal fracture should undergo an electrocardiogram to evaluate for abnormal findings (arrhythmia, ectopy) and to determine whether echocardiography is needed. A FAST can be used to look for pericardial fluid or obvious abnormalities in heart function.46 Evaluating patients with chest wall injuries requires an understanding of their associated injuries and recognition of their clinical presentations.
Sternal fracture - An analysis of the National Trauma Data Bank
2014, Journal of Surgical Research
Citation Excerpt :
Our results are consistent with previous series reports of SF. The mechanism of injury was MVC in 84%, which is within the 68%–94% reported in the literature [2,4,8,10,11]. Isolated SF were present in 13.2%, which is slightly lower than the 15%47% previously reported, but still within close range [7,8,13].
The clinical significance of sternal fractures (SFs) after blunt trauma is heavily debated. We aimed to test the hypothesis that isolated SF is not associated with significant morbidity or mortality.
The National Trauma Data Bank (NTDB) sets for 2007–2010 were retrospectively examined. Adult subjects with SF were identified by International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes. Data collected included demographics, mechanisms of injury, clinical variables, and in-hospital mortality. The primary outcome measure was in-hospital mortality. Secondary outcome measures included hospital length of stay, intensive care unit days, and ventilator days.
A total of 32,746 subjects with SF were included. Motor vehicle crash (MVC) was the most common mechanism (84%) in this group and SF was present in 3.7% of all patients admitted after MVC. The mean age was 51 y, 66% were males, and most were white (74%). Overall in-hospital mortality was 8.8% and mortality with isolated SF was 3.5%. Increasing thoracic fracture burden (rib fracture, clavicular fracture, and scapular fracture) was associated with increasing hospital length of stay, intensive care unit days, ventilator days, and mortality. On multivariate regression analysis, other significant predictors of mortality were cardiac arrest, acute respiratory distress syndrome, pulmonary embolism, blunt cardiac injury, pulmonary contusion, increasing age, and lack of insurance.
SFs occur in 3.7% of victims after MVC. With isolated SF, the mortality rate is low (3.5%); the tendency for poorer outcomes is most heavily influenced by associated injuries (pulmonary contusions, other thoracic fractures), complications (cardiac arrest, pulmonary embolism, acute respiratory distress syndrome), comorbidities (currently on or requiring dialysis, residual neurologic deficit from stroke), and lack of insurance.

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Brief reportSternal fractures in blunt chest trauma: A practical algorithm for management

Abstract

Ann Emerg Med

Ann Emerg Med

Ann Thorac Surg

The significance of stable patients with sternal fractures

Surg Gynecol Obstet

Sternal fractures: A retrospective analysis of 272 cases

J Trauma

Sternal fractures: A red flag or a red herring?

J Trauma

Brief report
Sternal fractures in blunt chest trauma: A practical algorithm for management