Sternal fracture

Infobox_Disease
Name = Sternal fracture

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Caption = CT scan showing a comminuted sternal fracture.cite journal |author=Monkhouse SJ, Kelly MD |title=Airbag-related chest wall burn as a marker of underlying injury: a case report |journal=Journal of medical case reports |volume=2 |issue= |pages=91 |year=2008 |pmid=18361799 |pmc=2330057 |doi=10.1186/1752-1947-2-91 |url=http://www.jmedicalcasereports.com/content/2/1/91 ]
DiseasesDB =
ICD10 = ICD10|S|22|2|s|20
ICD9 = ICD9|807.2, ICD9|807.3
ICDO =
OMIM =
MedlinePlus =
eMedicineSubj = emerg
eMedicineTopic = 206
eMedicine_mult = eMedicine2|radio|654
MeshID = A sternal fracture is a fracture of the sternum (the breastbone), located in the center of the chest. The injury, which occurs in 5–8% of people who experience significant blunt chest trauma, may occur in vehicle accidents, when the still-moving chest strikes a steering wheel or dashboard or is injured by a seatbelt.cite book |author=Smith M, Ball V |Chapter=Thoracic trauma |title=Cardiovascular/respiratory physiotherapy |publisher=Mosby |location=St. Louis |year=1998 |pages=217 |isbn=0-7234-2595-7 |oclc= |doi= |accessdate=2008-06-12 |url = http://books.google.com/books?id=vzFR-ylAeSMC&pg=PA217&dq=sternal+fracture&client=firefox-a&sig=VYdwi-hYKvmMSqN1lSICKCwM10E#PPA217,M1] Sternal fracture can interfere with breathing by making it more painful; however, its primary significance is that it can indicate the presence of serious associated internal injuries, especially to the heart and lungs.

Causes

Vehicle collisions are the usual cause of sternal fracture;cite book |author=Marini JJ, Wheeler AP |title=Critical Care Medicine: The Essentials |publisher=Lippincott Williams & Wilkins |location=Hagerstown, MD |year=2006 |pages=580 |isbn=0-7817-3916-0 |oclc= |doi= |accessdate= 2008-06-12 |url = http://books.google.com/books?id=0BbCQoiVCssC&pg=PA580&dq=sternal+fracture&client=firefox-a&sig=ZYXr3v301wwYs-frXQuqIoJkeAc] the injury is estimated to occur in about 3% of auto accidents.cite book |author=Myers JW, Tannehill-Jones R, Neighbors M|title=Principles of Pathophysiology and Emergency Medical Care |publisher=Delmar Thomson Learning |location=Albany, N.Y |year=2002 |pages= |isbn=0-7668-2548-5 |oclc= |doi= |accessdate= 2008-06-14 |url= http://books.google.com/books?id=GgDdMkAZNPkC&pg=PA121&dq=sternal+fracture&lr=&client=firefox-a&sig=C7epwySocqqYZ5GNIG2en4knPrE] The chest of a driver who is not wearing a seat belt may strike the steering wheel, and the shoulder component of a seatbelt may injure the chest if it is worn without the lap component. It was common enough for the sternum to be injured by the seatbelt that it was included in the 'safety belt syndrome', a pattern of injuries caused by seat belts in vehicle accidents.cite journal |author=Lechaux JP, Poinsard JP, Ravaud Y, Asseraf J, Boulakia C |title=Abdominal traumas due to the safety belt|language=French |journal=Nouv Presse Med |volume=10 |issue=41 |pages=3385–8 |year=1981 |month=November |pmid=7301568 |doi= |url=]

The injury can also occur when the chest suddenly flexes, in the absence of an impact.

Associated injuries

Because of the high frequency of associated injuries, clinicians are taught to suspect that a patient has multiple severe injuries if a sternal fracture is present.cite book |author= Livingston DH, Hauser CJ| editor = Moore EJ, Feliciano DV, Mattox KL |chapter= Trauma to the chest wall and lung| title=Trauma |publisher=McGraw-Hill, Medical Pub. Division |location=New York |year=2004 |pages=517 |isbn=0-07-137069-2 |oclc= |doi= |accessdate=2008-06-11 |url = http://books.google.com/books?id=VgizxQg-8QQC&pg=PA517&dq=sternal+fracture&client=firefox-a&sig=QHedjSkQ44fbrb3Zm9ZmzYX908g#PPA517,M1] Sternal fracture is commonly associated with injuries to the heart and lungs; if a person is injured with enough force to fracture the sternum, injuries such as myocardial and pulmonary contusions are likely.cite book |chapter = Thoracic trauma | author=Beck RJ, Pollak AN, Rahm SJ |title=Intermediate Emergency Care and Transportation of the Sick and Injured |publisher=Jones and Bartlett |location=Boston |year=2005 |pages= |isbn=0-7637-2244-8 |oclc= |doi= |accessdate= 2008-06-11 |url= http://books.google.com/books?id=PY8TO5EIBRAC&pg=PT763&dq=%22sternal+fracture%22+intermediate&client=firefox-a&sig=8gW2quc0ewMStC3kAd3dzoyYrQw ] Other associated injuries that may occur include damage to blood vessels in the chest, myocardial rupture, head and abdominal injuries, flail chest, and vertebral fracture. Sternal fractures may also accompany rib fractures and are high-energy enough injuries to cause bronchial tears (ruptures of the bronchioles).cite journal |author= Hwang JCF, Hanowell LH, Grande CM |title=Peri-operative concerns in thoracic trauma |journal= Baillière's Clinical Anaesthesiology |volume = 10 |issue = 1 |page=123–153 |doi= doi:10.1016/S0950-3501(96)80009-2 | date=1996] They may hinder breathing. Due to the associated injuries, the mortality rate for people with sternal fracture is high, at an estimated 25–45%. However, when sternal fractures occur in isolation, their outcome is very good.cite journal |author=Wright SW |title=Myth of the dangerous sternal fracture |journal=Ann Emerg Med |volume=22 |issue=10 |pages=1589–92 |year=1993 |month=October |pmid=8214842 |doi= ]

There is controversy over the question of whether the presence of sternal fracture is an indication of cardiac injuries. Though over half of people with sternal fractures have been found to have electrocardiogram and radionucleotide abnormalities (abnormal test results indicating cardiac dysfunction), blunt injury to the heart may not occur at a higher rate with sternal fractures than they do in other patients with multisystem trauma.

igns and symptoms

Signs and symptoms include crepitus (a crunching sound made when broken bone ends rub together), pain, tenderness, bruising, and swelling over the fracture site. The fracture may visibly move when the person breathes, and it may be bent or deformed, potentially forming a "step" at the junction of the broken bone ends that is detectable by palpation. Associated injuries such as those to the heart may cause symptoms such as abnormalities seen on electrocardiograms.

The upper and middle parts of the sternum are those most likely to fracture, but most sternal fractures occur below the sternal angle.

Assessment and treatment

X-rays of the chest are taken in people with chest trauma and symptoms of sternal fractures, and these may be followed by CT scanning. Since X-rays taken from the front may miss the injury, they are taken from the side as well.cite book |chapter= Trauma| author=Stead L, Thomas SH |title=Emergency Medicine: Board Review Series |publisher=Lippincott Williams & Wilkins |location=Hagerstown, MD |year=2000 |pages= 469 |isbn=0-683-30617-0 |oclc= |doi= |accessdate=2008-06-16 |url = http://books.google.com/books?id=vqehwRewe3AC&pg=PA469&dq=%22sternal+fracture%22&lr=&client=firefox-a&sig=zzU-0Fdu93-NmnOhuxZkEfJatCI]

Management involves treating associated injuries; people with sternal fractures but no other injuries do not need to be hospitalized. However, because it is common for cardiac injuries to accompany sternal fracture, heart function is monitored with electrocardiogram.cite journal |author=Buckman R, Trooskin SZ, Flancbaum L, Chandler J |title=The significance of stable patients with sternal fractures |journal=Surg Gynecol Obstet |volume=164 |issue=3 |pages=261–5 |year=1987 |month=March |pmid=3824115 |doi= |url=] Fractures that are very painful or extremely out of place can be operated on to fix the bone fragments into place, but in most cases treatment consists mainly of reducing pain and limiting movement. The fracture may interfere with breathing, requiring intubation and mechanical ventilation.cite book |author= Jenkins JL, Braen GR |chapter = Chest trauma| title=Manual of emergency medicine |publisher=Lippincott Williams & Wilkins |location=Hagerstown, MD |year=2005 |pages=74 |isbn=0-7817-5035-0 |oclc= |doi= |accessdate=2008-06-16 |url = http://books.google.com/books?id=_D6V9kp0VzsC&pg=PA74&dq=%22sternal+fracture%22&lr=&client=firefox-a&sig=U9PrjqU3jwpfRTNCYqIegcWTkPM]

History

In 1864, E. Guilt published a handbook recording sternal fractures as a rare injury found in severe trauma.cite journal |author=Johnson I, Branfoot T |title=Sternal fracture: A modern review |journal=Arch Emerg Med |volume=10 |issue=1 |pages=24–8 |year=1993 |month=March |pmid=8452609 |pmc=1285920 |doi= |url=] The injury became more common with the introduction and wide use of vehicles and the subsequent rise in traffic accidents. A rise in sternal fractures has also been seen with an increase in the frequency of laws requiring that seat belts be worn.cite book |author= Owens MW, Milligan SA, Eggerstet JM |chapter = Thoracic trauma, surgery, and perioperative management |editor= George RB, Light RJ, Matthay MA |title=Chest Medicine: Essentials of Pulmonary and Critical Care Medicine |publisher=Lippincott Williams & Wilkins |location=Hagerstown, MD |year=2005 |pages=574–5 |isbn=0-7817-5273-6 |oclc= |doi= |accessdate=2008-06-16 |url= http://books.google.com/books?id=ZzlX2zJMbdgC&pg=RA1-PA575&dq=%22sternal+fracture%22&client=firefox-a&sig=b4CTcxVlMwghMY1KnGR3P0WwbTY#PRA1-PA574,M1]

ee also

*Pulmonary toilet

References