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Three women in a car
  1. S Satchithananda
  1. Emergency Department, Queen Elizabeth Hospital, Gayton Road, Kings Lynn, Norfolk PE30 4ET, UK
  1. Correspondence to:
 Dr S Satchithananda; 
 sue.satchi{at}doctors.org.uk

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Isolated sternal fractures have been increasing in number since the advent of seat belt legislation in 1983.1 The management of these patients has been a matter of debate for some time. These cases demonstrate that other coexistent pathology may be difficult to identify at the time of presentation and that a high level of suspicion for other injuries is necessary. Three women presented to the emergency department after a collision between their car travelling at 45 miles per hour and a stationary van.

CASE 1

The 71 year old restrained driver of the car presented complaining of chest pain and tenderness. Previous medical history included osteoporosis and long term corticosteroid use for asthma. Initial observations, examination, chest radiograph, and electrocardiogram were normal. A sternal radiograph demonstrated a fracture of the sternum. A brief episode of hypotension was noted (systolic blood pressure of 90) but thought to be vagal and the patient was later discharged home with oral analgesia.

CASE 2

The 77 year old restrained front seat passenger also presented with chest pain and tenderness. Initial observations, chest radiograph and electrocardiogram were also normal. A fractured sternum was confirmed on radiography. The patient required intravenous opioids as analgesia and as she lived alone she was admitted to the emergency department observation ward overnight.

Over the next 16 hours she developed an ileus. After a normal CT scan of her abdomen she was managed conservatively and discharged home after three days. Her CT scan demonstrated a small right sided pleural effusion not evident on initial chest radiograph or clinical examination.

Box 1 ECG abnormalities of myocardial contusion10 Possible ECG findings

  • Unexplained sinus tachycardia

  • Arrhythmias and conduction abnormalities

  • ST segment changes

    • – non-specific in myocardial injury

    • – concave ST segment classical of pericarditis (may be associated with low voltage complexes)

Box 2 Chest radiograph abnormalities associated with sternal fracture

Possible chest radiograph findings

  • Chest trauma

    • – Haemothorax

    • – Pneumothorax

    • – Clavicle/rib fractures

    • – Surgical emphysema

    • – Pulmonary contusion

    • – Increased cardiothoracic ratio suggestive of haemopericardium

    • – Widened mediastinum (may indicate retrosternal haematoma or mediastinal great vessel injury)

    • – Pneumomediastinum/pneumopericardium

  • Associated injuries

    • – Fractures of thoracic spine

    • – Pneumoperitoneum

CASE 3

This 77 year old restrained rear seat passenger of the car was also complaining of chest pain and tenderness. The initial observations, examination, and chest radiograph were normal and her electrocardiogram showed a left bundle branch block morphology (although the patient reported no known cardiac history). A radiograph of her sternum demonstrated a fracture. During the administration of intravenous morphine for analgesia a hypotensive episode was observed. This patient was therefore referred to the surgical team and despite repeated examination no abnormality was found. The following morning a repeated haemoglobin estimation showed a fall from 9.3 g/dl on admission to 6.9g/dl. An ultrasound of the abdomen demonstrated free fluid and at exploratory laparotomy later that day a splenectomy was performed for a capsular tear of her spleen.

DISCUSSION

Advanced Trauma Life Support2 advocates awareness of the risk of blunt cardiac injury and pulmonary contusions associated with sternal fractures during the assessment for multisystem injury.

Many authors have written regarding the incidence of complications in isolated sternal fractures and whether admission of these patients is warranted. Most studies have been retrospective in design and therefore do not address the difficulty in initial assessment to rule out other injuries. Sadaba et al3 published a review article in May 2000 identifying the problem of wide regional variations in the management of isolated sternal fractures in the United Kingdom. The authors suggested guidelines for the management of isolated sternal fractures implying that if a chest radiograph and electrocardiogram were normal on admission (in a patient without underlying cardiorespiratory disease) and adequate analgesia was achieved then that patient may be appropriate for discharge to a home environment. Evidence of complications of sternal injury may be evident on ECG or chest radiograph (boxes 1 and 2) but normal investigations do not necessarily imply that the fracture is an isolated injury. Most articles advocating discharge from accident and emergency focus on the low incidence of cardiac complications associated with sternal fractures.4–8 Unintentionally these papers may have led to a perception that patients with presumed isolated sternal fractures may be safe to discharge from the emergency department. Considering the high incidence of associated injuries demonstrated by Brookes et al9 (table 1) (a prospective study of a series of 272 patients in which 54.7% with sternal fractures had other skeletal or visceral injuries) we should continue to be vigilant in our assessment of this group of patients.

Table 1

Incidence of injuries associated with sternal fracture (adapted from Brookes et al9)

The cases reported here show that early identification of “isolated” sternal fractures may be difficult and that in fact two of these three cases had significant complications warranting further investigation despite minimal symptoms and signs at the time of presentation. A sternal fracture is an indicator of significant blunt injury to the patient and should therefore be treated with a high degree of suspicion and a careful search for other injuries made. The “isolated sternal fracture” may be a diagnosis only safely made retrospectively after a period of observation.

Acknowledgments

Contributors

Dr S Satchithananda researched and wrote the case report. Mr B Roy, emergency medicine consultant at Peterborough District Hospital, kindly reviewed the manuscript.

REFERENCES

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