SplintER Series: Don’t Go Breaking My Heart

Oct 11, 21

A 45-year-old man presents to the emergency department with chest pain after a high-speed motor vehicle accident where his sternum hit the steering wheel. You notice an area of ecchymosis noted over his sternum, so you decide to get a CT scan (Figure 1).

Figure 1. Case courtesy of Dr Henry Knipe, Radiopaedia.org, rID: 26332

What is your diagnosis?

The patient is diagnosed with a sternal fracture. These fractures are associated with deceleration injuries and trauma to the anterior chest [1]. Patients will most commonly present with shortness of breath and chest pain that worsens with respirations [2].

Pearl: An AP and lateral chest x-ray is typically the initial imaging modality of choice (Figure 2). However, a CT scan can be performed to better characterize the fracture and its sequelae [2].

Figure 2: Case courtesy of Dr Jayanth Keshavamurthy, Radiopaedia.org, rID: 38447

What is your management in the ED?

Management in the ED follows ATLS guidelines and resuscitation. These injuries are frequently associated with other injuries, such as hemothorax, pneumothorax, and flail chest. The mainstay of treatment in isolated, nondisplaced fractures is primarily supportive with appropriate analgesia. Displaced fractures may require operative management. Similar to the management of rib fractures, deep breathing and incentive spirometry are recommended to avoid pulmonary complications [1,2].

Pearl: Look for blunt cardiac injury in these patients. Cardiac biomarkers, an ECG, and telemonitoring should be performed in patients presenting with this injury [1].

What is your disposition?

Isolated, nondisplaced sternal fractures in patients without evidence of cardiac injury can be safely discharged with close follow-up. Those with signs of blunt cardiac injury should be admitted for further monitoring [1].

Check out ALiEM’s Paucis Verbis cards to brush up on other can’t miss orthopedic injuries, and SplintER Series for more thoracic cases.

References

Khoriati A, Rajakulasingam R, Shah R. Sternal fractures and their management. J Emerg Trauma Shock. 2013;6(2):113-116. PMID: 23723620
Bentley TP, Ponnarasu S, Journey JD. Sternal Fracture. In: StatPearls. StatPearls Publishing; 2021. Accessed July 8, 2021. PMID: 29939567