40 yo Male with no pmh presents as belted driver in head on MVC. Pt c/o midline chest pain, worse on movement and palpation, no sob, no abdominal pain. Pts VS are 109/50, 110, 18, 98% on 2L. Pt has a seatbelt sign on exam, normal breath sounds, and no crepitus. Rest of exam wnl, e-FAST negative. You have a high suspicion for a sternal fracture, besides CXR and sternal xray, what other testing should be done in this patient?
EKG and cardiac enzymes. There is a higher incidence of cardiac contusion and blunt cardiac injury with sternal fracture, about 12%. There is a possibility of initial EKG and cardiac enzymes being negative, but it is important to get for initial assessment, and baseline.
Facts from lifeinthefastlane.com:
- Sternal fractures result from severe mediastinal trauma, and occur in approximately 3% of blunt chest trauma.
- Sternal fractures are caused by blunt anterior chest trauma, with 60-90% of cases occurring in motor vehicle accidents by seat belts or by direct impact with the steering wheel. (Incidents are now decreasing with more cars fitted with airbags.)
- Other causes of sternal fracture are assaults, contact sports, and bone insufficiency
- Patients over 50 have a higher prevalence and risk of sustaining sternal fractures, with a higher incident in the elderly and women
- Fractures of the sternum are considering among the most painful thoracic wall injuries
- 6-12% of patients with sternal fractures will develop an associated myocardial contusion
Assess for associated injuries:
- Rib fractures
- Flail chest
- Pulmonary Contusion
- Blunt cardiac injuries
- Pericardial tamponade
- Sternoclavicular joint dislocation
- Vascular injury
- Spinal Injuires
- Trauma to head, neck, abdomen and extremities
Board Review question:
A 32-year-old man struck his chest on the dashboard during a rapid deceleration motor vehicle collision. He has a displaced sternal fracture. You know that:
A. The diagnosis of myocardial contusion is always made on initial EKG and serum cardiac biomarker levels.
B. Most displaced sternal fractures requires open fixation.
C. Traumatic pericardial tamponade may occur days after the initial injury.
D. He will require admission to a monitored bed.
E. Opioid pain relievers are contraindicated.
C. EKG and CPK-MB changes are initially absent in patients with myocardial contusion. Patients with persistent tachycardia following blunt chest trauma or a history consistent with significant blunt chest trauma are admitted for monitoring, serial EKG and isoenzyme determinations, and echocardiography. Echocardiography is a valuable diagnostic study for the evaluation of cardiac injury. Ventricular aneurysm is a late complication of myocardial contusion. Traumatic pericardial effusions may develop acutely or may develop days after injury. Constrictive pericarditis is a late complication of hemopericardium. Other complications following blunt cardiac injury include ventricular septal rupture, valvular injury, and aortic dissection.