Fractured sternum

 

A fractured sternum is usually indicative of a major impact to the anterior chest wall. Unless the patient is osteoporotic it takes considerable energy to fracture both tables of the sternum. It is not the fracture which matters so much as the concussion/contusion of the heart, pulmonary contusion, and other associated injuries. 

The fracture needs to be  treated for pain as with any chest wall fracture and co-morbidity such as asthma, COAD and cardiac disease need to be taken into consideration. 

The following is an "umbrella" protocol which may not need to be followed line and verse in every case but will allow a period of three days assessment which will cover most eventualities safely:

  1. •Admit

  2. •Monitor ECG for 48 hours

  3. •Daily 12 lead ECG for three days

  4. •Three daily CKMB to exclude cardiac contusion (CK will be unreliable in presence of a fracture). Troponin assessment may be of benefit if available.

  5. •Three daily chest Xrays to exclude other chest injury

  6. •Request echocardiogram

  7. •Pain relief - at least a PCA, consider NSAIDS

  8. •Physiotherapy

  9. •Appropriate bronchodilators etc depending on co-morbidity.


An alternative opinion from Sadaba JR, Oswal D and  Munsch CM in Leeds can be found in the Annals of the Royal College of Surgeons, May 2000. They suggest that "patients, who are otherwise fit and have normal ECG and CXR on presentation, can be safely discharged home on oral analgesics".

If this is the chosen strategy, I would suggest that you let the patient know they have had a significant injury, they will have pain for approximately six weeks from the fracture itself, but that once that has eased, they may be aware of costal cartilage pain which will persist for a considerable period, sometimes years, after injury.

Costal cartilages do not show on Xray and their injury may not be noted at the time. Such pain may be evident on using the pectoral muscles for lifting but is generally "of nuisance value only". However, if not warned of the possibility of CC discomfort it may lead to excessive investigation of "atypical chest pain", spiralling anxiety and medico-legal consequences.