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

Thoracic trauma: Clinical and paleopathological perspectives

OBJECTIVES

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.

MATERIALS AND METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

SIGNIFICANCE

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.

LIMITATIONS

Thoracic bones are often taphonomically altered and differentially preserved leading to difficulty in identifying and interpreting fractures.

SUGGESTIONS FOR FURTHER RESEARCH

Practical application of the data presented here to archaeological samples will help to advance paleopathological understandings of thoracic trauma.

Associated Injuries in Traumatic Sternal Fractures: A Review of the National Trauma Data Bank

Sternal fractures occur infrequently with blunt force trauma. The demographics and epidemiology of associated injuries have not been well characterized from a national trauma database. The National Trauma Data Bank was queried for patients with closed sternal fractures. The demographics were analyzed by age, gender, mechanism and indicators of anatomic and physiologic injuries. Types of commonly associated injuries were also determined. A total of 23,985 records were analyzed. Males accounted for 68.3 per cent and whites 70.9 per cent. Motor vehicle crash was the leading mechanism. More than 56 per cent had severe injuries based on Injury Severity Score (greater than 15) and 17 per cent with Glasgow Coma Score 8 or less. Crude mortality was 7.9 per cent. The majority (57.8%) and approximately one-third (33.7%) of the patients had rib fractures and lung contusions, respectively, 22.0 per cent with closed pneumothorax, 21.6 per cent had a closed thoracic vertebra fracture, 16.9 per cent with lumbar spine fracture, 3.9 per cent with concussion, and blunt cardiac injury in 3.6 per cent. Sternal fractures are usually associated with severe blunt trauma. Lung contusion remains the leading associated injury followed by vertebral spine fractures. Cardiac injuries are less frequent and vascular injuries less so. Mechanism of injury and presence of sternal fractures should alert providers to these potential associated injuries.

National risk factors for blunt cardiac injury: Hemopneumothorax is the strongest predictor

BACKGROUND

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.

METHODS

We queried the National Trauma Data Bank (NTDB) from 2007-2015 to identify adult blunt trauma patients.

RESULTS

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).

CONCLUSION

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.

SUMMARY

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.

Management Issues in Critically Ill Pediatric Patients with Trauma

The management of critically ill pediatric patients with trauma poses many challenges because of the infrequency and diversity of severe injuries and a paucity of high-level evidence to guide care for these uncommon events. This article discusses recent recommendations for early resuscitation and blood component therapy for hypovolemic pediatric patients with trauma. It also highlights the specific types of injuries that lead to severe injury in children and presents challenges related to their management.

Management of isolated sternal fractures using a practical algorithm

Background:

The implementation of seat belt legislation has led to an increase in the frequency of isolated sternal fractures (ISFs) in motor vehicle crash.

Aims:

We reviewed retrospectively the medical records of our tertiary center in order to find out the frequency of ISFs, review our experience in their management, and define the mean length of hospitalization.

Materials and Methods:

From January 2008 to April 2012, 64 patients were admitted to the accident and emergency department of the University Hospital of Larissa, Greece, suffering from sternal fractures (SFs). Of these 64 patients, 45 had sustained ISF, while the remaining 19 had SF and additional injuries (intrathoracic and extrathoracic). The files of these 45 patients were further investigating as concerning the mechanism of injury, hospitalization days, morbidity, and mortality.

Results:

All the patients had been involved in motor vehicle crashes and most of them were wearing seat belts during the accident (91%). The hospital length of stay (LOS) was 1.85 ± 1.67. All the patients had upon admission chest radiograms, serial electrocardiographs (ECGs), echocardiograms, and cardiac enzyme levels. Two patients had abnormal ECG and abnormal cardiac enzymes which contributed in prolonged hospitalization. However, there was no incidence of cardiac complications or deaths.

Conclusions:

ISFs, with normal electrocardiogram, cardiac enzymes, and chest X-ray in the absence of complications, require no further investigation.

The Association between Blunt Cardiac Injury and Isolated Sternal Fracture

The treatment of isolated sternal fractures (ISF) throughout the world is heterogeneous. This study aimed to identify the incidence, morbidity, and mortality associated with isolated fractures of the sternum and describe current practice for diagnosis and management of ISF and cardiac injury at a level I trauma center in the UK. A retrospective cohort study of adult patients (>16 years) with ISF presenting from 2006 to 2010 was conducted. Eighty-eight patients with ISF were identified. Most patients (88%, 77) were admitted to hospital with 66% (58) of them discharged within 48 hours. Two (2%) patients had an ER EKG with abnormality but both resolved to normal sinus rhythm within 6 hours of follow-up. Serum CEs were drawn from 55 (63%) patients with only 2 (2%) having a rise in serum troponin >0.04; however, in both of these patients troponin quickly normalized. Six (7%) patients underwent echocardiograms without significant findings. In all 88 patients with ISF, no cases of clinically significant cardiac injury were identified. Patients presenting with an isolated sternal fracture with no changes on EKG or chest X-ray do not warrant an admission to hospital and may be discharged from the ER.

Location of sternal fractures as a possible marker for associated injuries

Introduction. Sternal fractures often occur together with serious and life-threatening additional injuries. This retrospective study was designed to assess concomitant injuries and develop a correlation between fracture location and the severity of injury. Methods. All patients (n = 58) diagnosed with a fracture of the sternum by means of a CT scan were analysed with respect to accident circumstances, fracture morphology and topography, associated injuries, and outcome. Results. Isolated sternal fractures occurred in 9%. In all other admissions, concomitant injuries were diagnosed: mainly rip fractures (64%), injury to the head (48%), the thoracic spine (38%), lumbar spine (27%), and cervical spine (22%). Predominant fracture location was the manubrium sterni. In these locations, the observed mean ISS was the highest. They were strongly associated with thoracic spine and other chest injuries. Furthermore, the incidence of head injuries was significantly higher. ICU admission was significantly higher in patients with manubrium sterni fractures. Conclusion. Sternal fractures are frequently associated with other injuries. It appears that the fracture location can provide important information regarding concomitant injuries. In particular, in fractures of manubrium sterni, the need for further detailed clinical and radiologic workup is necessary to detect the frequently associated injuries and reduce the increased mortality.

Sternal fracture--an analysis of the National Trauma Data Bank

BACKGROUND

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.

MATERIALS AND METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Sternal fractures and their management

Sternal fractures are predominantly associated with deceleration injuries and blunt anterior chest trauma. Sternal trauma must be carefully evaluated by monitoring of vital parameters and it is of paramount importance that concomitant injuries are excluded. Nevertheless, routine admission of patients with isolated sternal fractures for observation is still common in today's practice, which is often unnecessary. This article aims to describe the prognosis, the recommended assessment and management of patients with sternal fractures, to help clinicians make an evidence-based judgment regarding the need for hospitalization.

Computed tomography-guided cement augmentation for pain relief of a symptomatic sternal fracture

The authors report a novel application of cement augmentation for treatment of a symptomatic sternal fracture. Sternal fractures often cause debilitating pain and can affect ventilation. Given the success of vertebroplasty in patients in treating back pain, the authors used a similar technique in a 56-year-old woman with chronic obstructive pulmonary disease and an acute comminuted sternal fracture refractory to conservative management. The authors used computed tomography guidance and cement augmentation for the fracture. The patient subsequently reported good pain relief and improved breathing. Sternoplasty may be a viable alternative for patients with sternal fractures and refractory pain.

M, Antonio Riera M J, A JDR, Merello T B, Thibaut L. C. Sternal and vertebral fractures, a well-known association, usually overlooked: review of six clinical cases

OBJECTIVE: the association of sternal and vertebral fractures has previously been described in the literature. These lesions are frequently overlooked at the initial evaluation. The purpose of this study was to review and discuss the diagnostic methods used to diagnose these lesions and to highlight the importance of early recognition of these fractures. METHODS: we performed a retrospective analysis of six patients who suffered sternal and concomitant vertebral fractures. Clinical charts and imaging studies were reviewed. RESULTS: all patients were diagnosed with sternal fractures at the initial evaluation, but only two were diagnosed with vertebral fractures. CONCLUSION: failure to recognize these fractures at initial evaluation may be associated with the fact that the upper thoracic region is difficult to explore. In the presence of sternal fractures, a vertebral fracture must be ruled out even though major injuries are not present. A computer tomography (CT) scan and magnetic resonance imaging (MRI) should be obtained despite negative X-rays if clinical suspicion is present.

Sternal fractures

Sternal fractures are relatively common and range from simple unicortical cracks to displaced fractures associated with life threatening injuries. This paper describes the relevant anatomy, biomechanics, mechanism of injury, clinical presentation, investigation, treatment and complications and also includes associated and concomitant injuries. A management flow chart including criteria for discharge from the emergency department is presented.

Chest Wall, Lung, and Pleural Space Trauma

Chest radiographs frequently underestimate the severity and extent of chest trauma and, in some cases, fail to detect the presence of injury. CT is more sensitive than chest radiography in the detection of pulmonary, pleural, and osseous abnormalities in the patient who has chest trauma. With the advent of multidetector CT (MDCT), high-quality multiplanar reformations are obtained easily and add to the diagnostic capabilities of MDCT. This article reviews the radiographic and CT findings of chest wall, pleural, and pulmonary injuries that are seen in the patient who has experienced blunt thoracic trauma.

Osteoporotic Manubrial Fracture Following a Fall

We describe a case in which an elderly woman sustained a manubrial fracture after a fall from standing. The patient did not sustain further complications from her injury and was managed medically. The radiographic appearance and clinical implications of this event are discussed.

The Sternal Fracture: Radiographic Analysis of 200 Fractures with Special Reference to Concomitant Injuries

BACKGROUND

The assessment of the sternal fracture and concomitant injuries is discussed.

METHODS

Two hundred sternal fractures were analyzed with respect to accident circumstances, fracture morphology and topography, and associated injuries.

RESULTS

Traffic accidents were frequent; 89.2% of them were motor vehicle crashes of restrained passengers, 76.5% of fractures were localized in the corpus sterni, and 8.5% of the injuries resulted in fractures or complete disruptions of the synchondrosis manubriosternalis. Nondisplaced or slightly displaced fractures (75.5%) occurred more frequently compared with moderately and severely displaced fractures (24.5%). In 29.5% of the patients, concomitant thoracic injuries were diagnosed. Spinal fractures were evaluated in 13%. In displaced fractures of the corpus, thoracic and cardiac injuries were observed frequently. In fractures or disruptions of the synchondrosis manubriosternalis, concurrence of spinal fractures clearly increased.

CONCLUSION

The observation of fracture morphology and topography, with reference to displacement, gives important information about the existence of serious concomitant injuries and can determine further diagnostic and therapeutic options in sternal fractures.

Blunt cardiac injury

In summary, the incidence of BCI following blunt thoracic trauma patients has been reported between 20% and 76%, and no gold standard exists to diagnose BCI. Diagnostic tests should be limited to identify those patients who are at risk of developing cardiac complications as a result of BCI. Therapeutic interventions should be directed to treat the complications of BCI. Finally, the prognosis and outcome of BCI patients is encouraging

Diagnosing cardiac contusion: old wisdom and new insights

Cardiac contusion is usually caused by blunt chest trauma and therefore is frequently suspected in patients involved in car or motorcycle accidents. The diagnosis of a myocardial contusion is difficult because of non-specific symptoms and the lack of an ideal test to detect myocardial damage. Cardiac contusion can cause life threatening arrhythmias and cardiac failure. Many diagnostic methods, such as ECG, biochemical cardiac markers, transthoracic and transoesophageal echocardiography, and radionuclide imaging studies, have been investigated to determine their use in predicting such complications. Recently, cardiac troponin I and T were found to be highly sensitive for myocardial injury. Troponin I and T have also proved to be useful in the stratification of patients at risk for complications. Nevertheless, diagnosis of a cardiac contusion and identification of patients at risk remain a challenge. In this review the current diagnostic tests will be discussed. Also, based on these diagnostic tests, a screening strategy containing data from the latest studies is presented, with the intention of detecting patients at risk.

Chest pain in athletes

The symptom of chest pain in the athlete can represent anything from a nonspecific musculoskeletal strain to a life-threatening condition such as tension pneumothorax. For the physician charged with evaluating this patient population, a thorough knowledge of the possible etiologies, their usual diagnostic algorithms, available imaging modalities, and potential therapeutic options is essential. Although the vast majority of patients with traumatic chest pain will not harbor significant pathology, the clinician must be prepared for those few who do have such conditions, and be prepared to intervene in an appropriate, time-sensitive fashion.

Echocardiogram in sternal fracture

We reviewed the records of 50 consecutive patients presenting with sternal fracture after blunt chest trauma. The relationships between electrocardiogram, creatine kinase MB isoenzyme and echocardiogram (ECHO) were assessed in reference to myocardial contusion. Eleven patients (22%) had 1 or more abnormal cardiac tests but only 3 (6%) had clinically symptomatic myocardial contusion. Seven (22.5%) out of 31 ECHO studies revealed pericardial effusion which was not associated with the severity of all other associated injuries. The incidence of an abnormal ECHO study in patients with isolated sternal fracture was similar to that of patients who suffered multiple injuries. In 5 patients with pericardial effusion, this finding was not associated with any other abnormal tests and was regarded as of no clinical cardiac significance. On the other hand, a myocardial contusion was shown by ECHO examination only while echocardiogram and creatine kinase MB tests remained normal in that patient. We suggest that the ECHO should be used as a diagnostic and triage tool in every patient with sternal fracture associated with other injuries. However, patients with "benign" pericardial effusion can be discharged as soon as their medical condition improves regardless of other associated injuries.

[Evaluation and treatment of cardiac injuries]

Cardiac injuries caused by a heart traumatism are not frequent but, of great importance given their high morbidity. Two different groups in terms of etiology, clinical picture, application of diagnostic techniques, treatment and prognosis can be considered. On one hand, there are cardiac injuries caused by a thoracal contusion, which provokes a contused lesion can affect the free wall, the interventricular septum, the valves, the subvalvular apparatus, the conduction system and the coronary vessels and, on the other hand, cardiac injuries caused by penetrating objects. Cardiac injury can lead to a life-threatening hemodynamic instability which mandates prompt and clear diagnostic and therapeutic approaches.