Sternal fracture

 1. Search strategy

A literature search was conducted using pubmed and web of knowledge. The following search terms were used separately and in combination: sternal fracture, sternal pain, epidemiology, physical therapy

2. Definition/Description

The sternum or breastbone can be broken by a blunt anterior chest trauma, like the impact of a steering wheel in a car accident. Fractures usually occur at the body or the manubrium.
Sternal fracture also can be caused by severe flexion of the thoracic vertebrae , particularly in the upper and middle body of the sternum.12

3. Clinically Relevant Anatomy

The sternum is a flat bone, located in the center of the anterior thoracic wall. It consists of three segments; the manubrium (uppermost part), the body (middle part) and the xiphoid process (lowest part).13,14

4. Epidemiology/etiology

Isolated sternal fracture (ISF) can be defined as a sternal fracture without any other known thoracic injuries like rib fracture, pneumothorax, heamothorax, etc. Its incidence is now seen with increasing frequency mainly following road traffic accidents1, because of the imported seat belt legislation2

Sternal fracture is considered to be caused by a high energy injury2 and may be associated with intrathoracic injuries1; like cardiac injury. That’s why traditionally management of sternal fracture also consists of hospital admission for close monitoring2. There have been recent reports, however, which have suggested that isolated sternal fracture is a benign injury1.

Most sternal fractures are caused by blunt anterior chest trauma. Stress fractures have been noted in golfers, weight lifters, and other participants in noncontact sports. Insufficiency fractures caused by abnormally decreased bone density or weakened bone can occur spontaneously in patients with osteoporosis or osteopenia (particularly in older persons, especially women), those on long-term steroid therapy, or those with severe thoracic kyphosis. Cardiopulmonary resuscitation commonly causes rib and sternal fractures.3

5. Clinical presentation

Case studies report complaining of substernal chest pain that increases with inspiration shortness of breath, cough, or hemoptysis. There can be pain to palpation of the anterior chest wall over the sternum with slight bruising across the sternal area.4

Most patients complain of violent localized sternal pain due to a direct trauma. There is tenderness, bruising and sometimes a stair-step palpable at the fracture line.6

Patients with spontaneous fractures are a greater diagnostic challenge, because the symptoms often resemble other serious conditions. Their pain may be more diffuse. These fractures tend to occur in the elderly population, especially in postmenopausal women.5

Dyspnea is present in 15-20% of these patients and may indicate associated cardiopulmonary contusion.5

Palpitations may be noted only if dysrhythmia occurs, which is unusual in isolated sternal injury without associated cardiac contusion.5

6. Differential diagnosis

Costochondritis
Ribfractures
Sternoclavicular Joint Injury
Aortic dissection

Pain may be more diffuse in patients with insufficiency fractures and may lead to a more extensive differential diagnosis for chest pain in an older population.5

7. Diagnostic procedures

Manubrial fractures may be associated with aortic and brachiocephalic vessels injuries, while the depresses sternal body fractures may determine myocardial effects in 1,5-6% of patients. So echocardiography, CT and other cardiac tests are recommended to rule out pericardial effusion or other signs of myocardial injury in case of depressed, displaced sternal fractures.6

A CTscan is used most commonly to diagnose sternal fractures. But is less sensitive than plain radiography.7

Sternal fractures need to be detected with lateral views or other special radiographic projections of the sternum. Sternal fractures can only be detected in a frontal chest plain film when it is associated with significant tansverse displacement. A CT scan identifies almost all sternal fractures, displacements, internal thoracic injuries and retrosternal haematomas.6


8. Outcome measures

9. Examination

A stair-step can be palpable at the fracture line of the sternal bone.

10. Medical management

Most patients only need to be treated conservatively if the fracture is not displaced. They need to avoid provocative movement for four to six week.16

It is contraindicated to tape or splint sternal fractures, because it causes a restriction of normal chest expansion during respiration and can lead to atelectasis and pulmonary insufficiency. Encouragement of deep breathing decreases pulmonary complications during recovery. If this is to painful, analgesia need to be prescribed.

Surgical fixation for sternal fractures is generally unnecessary, although a recent study suggests that a more rapid recovery can be made if painful unstable fractures are fixated early rather than allowing them to heal over time.8

11. Physical therapy management

Once serious conditions have been ruled out and the sternal fracture has been confirmed as minor and non-displaced, treatment can be commenced.

Overhead lifting, pushing, pulling, and lifting objects that weigh more than 2 to 3 kilograms and activities which place large amounts of stress through the sternum, particularly lying face down and applying direct pressure or impact to the chest, should be avoided until the fracture has healed.

The goal of rehabilitation is to decrease pain, prevent respiratory complications, and restore function. Local application of heat or cold may provide temporary relief of discomfort, in conjunction with pain relieving medication. The therapist will instruct patients in deep-breathing exercises to promote full lung expansion, relieve muscle spasm, and mobilize lung secretions. To relieve discomfort, promote chest expansion and functional shoulder mobility, and improve posture when the fracture is stable, shoulder and trunk stretching exercises may be used.9

Once the fracture has healed, there can be a gradual return to normal activities, provided there is no increase in pain and other symptoms. This should take place over a period of weeks to months. Ignoring symptoms is likely to cause further damage and may slow healing or prevent healing of the sternal fracture altogether.9

To prevent stiffness and weakness, exercises to improve posture, flexibility and strength should also be performed.9

In the final stages of rehabilitation, a gradual return to activity or sport can occur as provided symptoms do not increase. When returning to contact sports or ball sports, the use of protective padding or chest guards may be required to prevent further injury.

Patients with more severe sternal fractures, particularly those which require surgical correction, or when other structures have been involved, will usually require a prolonged period of management over many months before recovery can take place.10

12. Key research

13. References

1) JR Sadaba, 2000, “Management of isolated sternal fractures: determining the risk of blunt cardiac injury”, The Royal College of Surgeons of England
Level of evidence: 3
2) Vasileios K, 2012, “Isolated sternal fractures treated on an outpatient basis”, American Journal of Emergency Medicine
Level of evidence: 2
3) Scott Felten, American College of Emergency Physicians, 2012, Medscape, “Sternal fracture”, (http://emedicine.medscape.com/article/826169-overview#a0104)
Level of evidence: 5
4) Karen Mulloy Restifo, Gabor D. Kelen,1994, “Case report: sternal fracture from a seatbelt”, The Journal of Emergency Medicine, Volume 12, Issue 3, May–June 1994, Pages 321-323
Level of evidence: 4
5) Scott Felten, American College of Emergency Physicians, 2012, Medscape, “Sternal fracture”, presentation, history (http://emedicine.medscape.com/article/826169-clinical)
Level of evidence: 5
6) Anne Grethe Jurik, 2007, “Imaging of the Sternocostoclavicular Region”
Level of evidence: 5
7) Scott Felten, American College of Emergency Physicians, 2012, Medscape, “Sternal fracture”, Workup, Imaging studies (http://emedicine.medscape.com/article/826169-workup#a0720)
Level of evidence: 5
8) Scott Felten, American College of Emergency Physicians, 2012, Medscape, “Sternal fracture”, Treatment, Consultations (http://emedicine.medscape.com/article/826169-treatment#a1129)
Level of evidence: 5
9) Seconde referention of MDGuidelines (http://www.mdguidelines.com/fracture-sternum-closed)
Collins, J., 2000, "Chest Wall Trauma.", Journal of Thoracic Imaging 15 2: 112-119.
Salter, Robert, ed., 1999, Textbook of Disorders and Injuries of the Musculoskeletal
System. 3rd ed.
Level of evidence: 4
10) Athletic edge Sports Medicine Orthopedic & Therapeutic Massage Therapy (http://athleticedge.biz/Sternal_Fracture.html)
Level of evidence: 5
11) Nancy D Ciesla, “Chest Physical Therapy for Patients in the Intensive Care Unit”, Physical Therapy . Volume 76 . Number 6 . June 1996
Level of evidence: 1
12) Robert C. Schenck, Athletic Training and sports medicine, 1999, p. 358
Level of evidence: 4
13) Gray’s Anatomy of the Human Body, fig. 115 – anterior surface of sternum and costa cartilages.
Level of evidence: 5
14) A. Iqbal, Human anatomy, sternum, 2001
Level of evidence: 5
15) R.broyles, The location and purpose of the Xiphoid process, 2009.
Level of evidence: 5
16) Second referention: Gregory PL, Biswas AC, Batt ME, ‘Musculoskeletal problems of the chest wall’ Sports Med 2002; 32(4): 235-2507
Level of evidence: 5