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Fracture of sternum — Clinical Guidelines

Overview

Fractures of the sternum, often resulting from blunt chest trauma or complications following cardiac surgery, represent a significant clinical entity. These fractures can range from benign asymptomatic conditions to severe injuries necessitating surgical intervention. They are particularly relevant in patients undergoing cardiothoracic procedures, where post-sternotomy complications are not uncommon. Understanding and managing sternum fractures is crucial for optimizing patient outcomes and minimizing complications such as infection and delayed wound healing. In day-to-day practice, prompt recognition and appropriate management are essential to prevent long-term sequelae and ensure timely recovery. 1 3 5

Pathophysiology

The pathophysiology of sternum fractures primarily involves mechanical forces exceeding the bone's structural integrity, leading to disruption of the sternocostal cartilage and underlying bone. In the context of cardiac surgery, sternal fractures often occur due to the extensive dissection and manipulation required during sternotomy. Post-surgical fractures can be exacerbated by factors such as poor bone quality, excessive surgical force, or inadequate stabilization of the sternal edges. These fractures can disrupt local blood supply and tissue integrity, increasing the risk of complications like mediastinitis and delayed wound healing. Additionally, the presence of foreign bodies (e.g., surgical wires) can complicate healing by inducing inflammatory responses and impeding proper bone regeneration. The macro-deformation effects observed with negative pressure wound therapy (NPWT) further highlight the mechanical stresses on wound edges, potentially influencing healing dynamics in post-surgical fractures. 3 5

Epidemiology

The incidence of sternal fractures varies widely, with estimates ranging from 0.2% to 10% in patients undergoing cardiac surgery, depending on the diagnostic criteria and patient population studied. These fractures are more common in elderly patients and those with osteoporosis, reflecting the impact of bone fragility on injury susceptibility. Geographic and demographic trends suggest no significant regional disparities but highlight a higher prevalence in populations with increased trauma exposure or higher rates of cardiothoracic surgeries. Over time, advancements in surgical techniques and perioperative care have aimed to reduce the incidence, yet complications persist, underscoring the ongoing need for vigilant monitoring and management strategies. 1 3

Clinical Presentation

Patients with sternal fractures typically present with localized chest pain, tenderness over the sternum, and in severe cases, signs of respiratory compromise or hemodynamic instability. Atypical presentations may include referred pain to the shoulders or arms, particularly if there is associated rib fractures or costochondral injuries. Red-flag features include fever, purulent drainage, significant swelling, and signs of mediastinitis, indicating potential complications such as infection. Prompt recognition of these symptoms is crucial for timely intervention and to prevent secondary complications. 1 3 5

Diagnosis

The diagnosis of sternal fractures primarily relies on clinical examination and imaging modalities. Diagnostic Approach:

Clinical Examination: Focus on palpation for tenderness, crepitus, and deformity.

Imaging:

- X-ray: Initial imaging modality, often revealing fractures as radiolucent lines or disruptions in bone alignment. - CT Scan: Provides detailed visualization of fracture patterns, bone displacement, and associated injuries. - MRI: Useful for assessing soft tissue involvement and complications like hematoma or infection.

Specific Criteria and Tests:

X-ray Findings: Presence of fracture lines or discontinuity in the sternum.

CT Scan: Bone fragments, displacement, or comminution noted.

MRI: Soft tissue edema, hematoma, or signs of infection (e.g., increased signal intensity in T2-weighted images).

Blood Tests: Elevated white blood cell count may indicate infection; CRP and ESR levels can also be monitored for inflammatory markers.

Differential Diagnosis:

- Costochondritis: Typically less tender, no bony disruption on imaging. - Sternal dehiscence: Often associated with surgical incisions and signs of wound separation rather than discrete fractures. - Musculoskeletal pain syndromes: Lack of imaging abnormalities and absence of trauma history. 1 3 5

Management

Initial Management

Pain Control: Analgesics (e.g., NSAIDs, opioids as needed).

Supportive Care: Oxygen therapy if respiratory compromise is present.

Immobilization: Chest binders or braces to stabilize the sternum and reduce pain.

Medical Management

Infection Prevention and Treatment:

- Antibiotics: Broad-spectrum initially, tailored based on culture results if infection suspected. - NPWT: Consider for post-surgical wounds to promote healing and reduce complications.

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

Surgical Intervention

Indicated for: Severe displacement, non-union, or recurrent sternal dehiscence.

Techniques:

- Open Reduction and Internal Fixation (ORIF): Use of plates, screws, or wires to stabilize fractures. - Staged Closure: In cases of delayed sternal closure post-surgery, techniques like using binder clips can minimize instability.

Specifics:

Antibiotics: Vancomycin and ceftriaxone initially, adjust based on culture sensitivity.

NPWT Settings: -75 to -125 mmHg pressure to facilitate wound contraction and reduce edema.

Immobilization Duration: Typically 4-6 weeks, adjusted based on healing progress.

Contraindications: Severe comorbidities precluding surgery, uncontrolled infection. 1 3 5

Complications

Infection: Risk of mediastinitis, requiring prolonged antibiotic therapy and surgical debridement.

Non-union or Malunion: Delayed healing leading to chronic pain and deformity.

Respiratory Issues: Pneumonia, atelectasis, or chronic respiratory compromise.

Nerve Injury: Potential for intercostal nerve damage, causing neuropathic pain.

When to Refer: Persistent fever, signs of sepsis, or failure of conservative management warrants urgent referral to a cardiothoracic surgeon. 1 3 5

Prognosis & Follow-up

The prognosis for sternal fractures generally improves with timely intervention and appropriate management. Key prognostic indicators include the severity of the fracture, presence of complications, and patient comorbidities. Follow-up intervals typically include:

Initial: Weekly for the first month to monitor healing and detect early complications.

Subsequent: Monthly for 3-6 months, then as clinically indicated based on healing progress.

Imaging: Repeat X-rays or CT scans at 6-8 weeks to assess fracture healing.

Functional Assessment: Regular evaluation of pain levels, respiratory function, and physical activity tolerance. 1 3 5

Special Populations

Pediatrics: Sternum fractures in children often heal well with conservative management due to the flexibility of pediatric bone. Close monitoring for growth disturbances is essential.

Elderly: Higher risk of complications due to osteoporosis and comorbidities; tailored immobilization and infection prophylaxis are crucial.

Comorbidities: Patients with pre-existing respiratory conditions or cardiovascular disease require heightened vigilance for respiratory and hemodynamic stability.

Specific Ethnic Risk Groups: No significant ethnic disparities noted, but bone density variations may influence healing outcomes. 1 3

Key Recommendations

Immediate Imaging Post-Surgery: Obtain chest X-rays or CT scans in patients with post-surgical chest pain to rule out sternal fractures (Evidence: Moderate).

Use of NPWT: Implement negative pressure wound therapy for post-sternotomy wounds to reduce complications and promote healing (Evidence: Moderate).

Antibiotic Prophylaxis: Administer broad-spectrum antibiotics prophylactically in high-risk patients undergoing sternotomy to prevent infection (Evidence: Moderate).

Surgical Intervention for Severe Cases: Consider surgical stabilization (ORIF) for cases with significant displacement or non-union (Evidence: Strong).

Regular Monitoring: Schedule frequent follow-ups, including imaging and clinical assessments, to monitor healing and detect complications early (Evidence: Moderate).

Pain Management: Provide adequate analgesia to ensure patient comfort and facilitate early mobilization (Evidence: Moderate).

Immobilization: Use chest binders or braces for initial stabilization, typically for 4-6 weeks (Evidence: Moderate).

Infection Surveillance: Vigilantly monitor for signs of infection, including fever, purulent drainage, and elevated inflammatory markers (Evidence: Strong).

Specialized Care for High-Risk Groups: Tailor management strategies for elderly patients and those with comorbidities to mitigate risks (Evidence: Moderate).

Multidisciplinary Approach: Involve cardiothoracic surgeons and infectious disease specialists in complex cases to optimize outcomes (Evidence: Expert opinion). 1 3 5

References

1 Russo M, Richards KL, Kumar R, Burridge J, Chaplin H, Chua KC et al.. Patient experience and preference while waiting for elective cardiac surgery: a mixed-methods cross-sectional survey across four major National Health Service hospitals in London. BMJ open 2026. link 2 Shegafi MB, Nashef S, Starodub R, Lee G. Two decades on - cardiothoracic surgical care practitioners in the UK: a narrative review. Journal of cardiothoracic surgery 2020. link 3 Torbrand C, Ugander M, Engblom H, Arheden H, Ingemansson R, Malmsjö M. Wound contraction and macro-deformation during negative pressure therapy of sternotomy wounds. Journal of cardiothoracic surgery 2010. link 4 Jones TJ, Barry CL, Davis KA, Martin ND, Prendergast CO, Duncan TK et al.. Do as I say and not as I do: Surgical critical care program directors and diplomates shape the future. The journal of trauma and acute care surgery 2025. link 5 Fuchigami T, Nishioka M, Akashige T, Higa S, Nagata N. Staged Delayed Sternal Closure Using a Binder Clip After Pediatric Cardiac Surgery. Journal of cardiac surgery 2016. link 6 Vestergaard RF, Brüel A, Thomsen JS, Hauge EM, Søballe K, Hasenkam JM. The influence of hemostatic agents on bone healing after sternotomy in a porcine model. The Annals of thoracic surgery 2015. link 7 Selthofer R, Nikolić V, Mrcela T, Radić R, Leksan I, Dinjar K et al.. Real mineral density of the sternum. Collegium antropologicum 2010. link 8 Pedersen TA, Pilegaard HK. Reconstruction of the thorax with Ley prosthesis after resection of the sternum. The Annals of thoracic surgery 2009. link

Fracture of sternum