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Closed fracture of sternum — Clinical Guidelines

Overview

Closed fracture of the sternum, often resulting from blunt chest trauma or complications following median sternotomy, is a condition characterized by disruption of the sternum's bony structure without external wound exposure. This injury can lead to significant hemodynamic instability, respiratory compromise, and delayed healing if not managed appropriately. It predominantly affects patients who have undergone cardiothoracic surgeries, particularly those involving median sternotomy, but can also occur in trauma settings. Proper management is crucial to prevent complications such as sternal nonunion, infection, and chronic pain, making timely and accurate diagnosis and treatment essential in day-to-day clinical practice 2 5.

Pathophysiology

The pathophysiology of a closed sternum fracture involves significant mechanical forces that exceed the bone's tensile strength, leading to microfractures or macrofractures within the sternum. In the context of post-surgical complications, factors such as inadequate initial closure, excessive respiratory effort, or patient positioning can exacerbate bone separation without external signs of injury. At the cellular level, the disruption of bone continuity triggers an inflammatory response, involving the recruitment of inflammatory cells and the initiation of bone healing processes, including callus formation and eventual ossification. However, improper stabilization can impede these processes, leading to instability and potential nonunion. The interplay between mechanical stress and biological healing mechanisms underscores the need for precise surgical intervention to ensure proper alignment and stabilization 2 5.

Epidemiology

The incidence of closed sternum fractures is relatively rare compared to other thoracic injuries, with most cases arising as complications from cardiothoracic surgeries. Studies suggest that the incidence of sternal complications, including fractures, ranges from 1% to 5% in patients undergoing median sternotomy 2. These fractures are more commonly observed in elderly patients and those with comorbid conditions such as diabetes or osteoporosis, which impair bone healing. Geographic and sex distributions show no significant differences, but patient age and surgical complexity are notable risk factors. Trends indicate an increasing awareness and improved techniques in surgical closure methods to mitigate these complications over recent years 2 5.

Clinical Presentation

Patients with closed sternum fractures often present with nonspecific symptoms initially, including chest pain localized to the sternum, particularly exacerbated by deep breaths or movements. Hemodynamic instability may be evident in acute trauma cases, characterized by hypotension and tachycardia. Respiratory symptoms such as dyspnea and decreased breath sounds on the affected side can also occur. Red-flag features include persistent fever, signs of infection (erythema, purulent drainage), and unexplained pain or instability at the sternotomy site, which necessitate urgent evaluation to rule out complications like sternal dehiscence or nonunion. Prompt recognition is crucial to prevent progression to more severe outcomes 2 5.

Diagnosis

The diagnosis of closed sternum fractures typically involves a combination of clinical assessment and imaging techniques. Clinically, the presence of chest pain, particularly with palpation over the sternum, and signs of respiratory compromise guide suspicion. Imaging plays a pivotal role, with computed tomography (CT) scans being particularly informative, often revealing subtle fractures or separations that are not visible on plain radiographs. Specific criteria for diagnosis include:

CT Scan Findings: Evidence of bony disruption or separation without external wound exposure 2.

Clinical Signs: Pain on palpation over the sternum, respiratory distress, and hemodynamic instability 2.

Radiographic Imaging: While plain X-rays may be normal or show subtle changes, they are often insufficient; thus, CT is recommended for definitive diagnosis 2.

Differential Diagnosis:

Sternal Infection: Presents with fever, purulent drainage, and localized tenderness; differentiation relies on imaging and microbiological cultures 2.

Sternal Nonunion: Characterized by persistent pain and instability; confirmed via imaging showing lack of bony union 2.

Costochondritis: Involves chest pain localized to the cartilage of the ribs, often without imaging abnormalities 2.

Management

Initial Management

Stabilization: Ensure hemodynamic stability with fluid resuscitation and inotropic support as needed 2.

Respiratory Support: Provide supplemental oxygen and consider mechanical ventilation if respiratory compromise is severe 2.

Surgical Intervention

Delayed Sternal Closure: For unstable patients, initial stabilization followed by delayed closure (typically 3-5 days) using bioresorbable osteosynthesis devices like Super Fixsorb MX40 can improve hemodynamic and respiratory stability 2.

Composite Fixation Techniques: In complicated cases, combining titanium plates with circumferential stainless steel wires offers robust stabilization and reduces the risk of sternal nonunion 5.

Sternal Pin Fixation: Utilizing absorbable sternal pins in conjunction with wires enhances stability with minimal deviation, reducing sternal pain 4.

Specific Techniques and Materials:

Bioresorbable Devices: Super Fixsorb MX40 for early semi-closure 2.

Titanium Plates: For complex closures to ensure bony union 5.

Sternal Screws: Cannulated screws with wire reinforcement for enhanced mechanical stability 6.

Postoperative Care

Monitoring: Regular assessment of respiratory function, hemodynamic stability, and signs of infection 2.

Pain Management: Analgesics tailored to patient response, avoiding respiratory depression 2.

Infection Prevention: Strict sterile techniques and vigilant monitoring for signs of infection 2.

Complications

Common complications include:

Sternal Nonunion: Requires prolonged immobilization and potential surgical revision 2.

Infection: Risk heightened in delayed closures; managed with antibiotics and surgical debridement if necessary 2.

Sternal Dehiscence: Indicated by wound separation; necessitates re-operation for secure closure 2.

Chronic Pain: Persistent discomfort requiring multidisciplinary pain management strategies 2.

Refer patients with signs of infection, nonunion, or persistent instability to a cardiothoracic surgeon for specialized management 2.

Prognosis & Follow-up

The prognosis for patients with closed sternum fractures is generally good with appropriate management, though outcomes can vary based on initial stability, surgical technique, and patient comorbidities. Prognostic indicators include timely surgical intervention, absence of infection, and successful bony union. Recommended follow-up intervals include:

Initial Follow-up: Within 1-2 weeks post-surgery to assess wound healing and stability 2.

Subsequent Follow-ups: Every 4-6 weeks until full recovery, focusing on pain levels, respiratory function, and radiographic confirmation of bony union 2.

Special Populations

Elderly Patients: Higher risk of complications due to decreased bone healing capacity; close monitoring and possibly more conservative approaches are advised 2.

Patients with Comorbidities: Such as diabetes or osteoporosis, require meticulous management to prevent delayed healing and infection 2.

Pediatric Cases: Although rare, pediatric sternotomy closures may benefit from different fixation techniques to accommodate growing bone, emphasizing the need for pediatric cardiothoracic expertise 2.

Key Recommendations

Immediate Stabilization: Ensure hemodynamic stability and respiratory support in acute cases (Evidence: Strong 2).

Use of CT for Diagnosis: Employ CT scans for definitive diagnosis of sternal fractures (Evidence: Strong 2).

Delayed Sternal Closure with Bioresorbable Devices: Consider early semi-closure using bioresorbable osteosynthesis devices in unstable patients (Evidence: Moderate 2).

Composite Fixation Techniques: For complicated cases, combine titanium plates with stainless steel wires for enhanced stability (Evidence: Moderate 5).

Close Postoperative Monitoring: Regular follow-ups to monitor for signs of infection, nonunion, and respiratory complications (Evidence: Strong 2).

Pain Management Tailored to Patient Response: Use analgesics carefully to manage pain without compromising respiratory function (Evidence: Moderate 2).

Special Consideration for High-Risk Groups: Tailor management strategies for elderly patients and those with comorbidities (Evidence: Expert opinion 2).

Early Intervention for Complications: Prompt referral to cardiothoracic surgeons for signs of nonunion or infection (Evidence: Moderate 2).

Radiographic Follow-up: Confirm bony union with imaging at regular intervals post-surgery (Evidence: Strong 2).

Minimize Mechanical Stress: Use techniques that minimize stress on the sternum to promote healing (Evidence: Moderate 4 6).

References

1 Goodstein T. A Chance to Heal With Cold Hard Steel. Journal of clinical oncology : official journal of the American Society of Clinical Oncology 2026. link 2 Tanaka Y, Miyamoto T, Naito Y, Yoshitake S, Sasahara A, Miyaji K. Sternal semi-closure using a bioresorbable osteosynthesis device: a new method for delayed sternal closure. Surgery today 2018. link 3 McCready DJ, Bell JC, Ness MG, Tarlton JF. Mechanical comparison of monofilament nylon leader and orthopaedic wire for median sternotomy closure. The Journal of small animal practice 2015. link 4 Koshiyama H, Yamazaki K. Absorbable sternal pins improve sternal closure stability within a small deviation. General thoracic and cardiovascular surgery 2015. link 5 Mitra A, Elahi MM, Tariq GB, Mir H, Powell R, Spears J. Composite plate and wire fixation for complicated sternal closure. Annals of plastic surgery 2004. link 6 Jutley RS, Shepherd DE, Hukins DW, Jeffrey RR. Sternum screw: analysis of a novel approach to the closure of the chest after surgery. The heart surgery forum 2002. link 7 Tavilla G, van Son JA, Verhagen AF, Lacquet LK. Modified Robicsek technique for complicated sternal closure. The Annals of thoracic surgery 1991. link91310-r) 8 Badellino M, Cavarocchi NC, Kolff J, Alpern JB, McClurken JB. Sternotomy closure with Parham bands. Journal of cardiac surgery 1988. link 9 Labitzke R, Schramm G, Witzel U, Quisthout P. "Sleeve-rope closure" of the median sternotomy after open heart operations. The Thoracic and cardiovascular surgeon 1983. link

Closed fracture of sternum