A 36 year old male is brought into the trauma bay after involvement in a MVC. This patient was the unrestrained driver when he rear ended a truck at a speed of approximately 55mph. Per EMS, the air bag did not deploy and the patient did not lose consciousness. GCS 15 at the scene. He has remained hemodynamically stable with vitals on arrival:
172/90 123 16 100% RA
His sole complaint is chest pain exacerbated with movement and deep inspiration.
Patient is placed on a monitor, 2 large bore IV’s are placed, and the FAST examined is reported as normal.
As you begin your secondary survey, you notice ecchymosis, tenderness, and soft tissue swelling involving the sternum.
– occur secondary to a high energy blow to the anterior chest, typically from a MVC when patient’s chest
strikes the steering wheel or in rapid deceleration when the seatbelt strikes the chest
– comprise approximately 3% of blunt chest trauma.
– 6-12% of patients with sternal fractures will develop an associated myocardial contusion
-ecchymosis and soft tissue swelling of the anterior chest wall is common
-patients will generally complain of localized pain to the sternum that is positional and exacerbated with increased intrathoracic pressure
-sterna instability is generally not elicited on exam unless the fracture involves significant displacement. Rarely is crepitance elicited on exam.
Sternal fractures are associated with an increased risk of internal injuries. Rib fractures, flail chest, pneumothorax, hemothorax, pulmonary contusion, blunt cardiac injuries, pericardial tamponade, sternoclavicular joint dislocation, and vascular injury have been associated with sternal fractures
Obtain a 12 lead ECG to evaluate for ST-segment changes consistent with myocardial injury
To assess for dysrhythmia or conduction disturbances as a consequence of cardiac contusion
Cardiac markers to assess for blunt cardiac injury
Management and Disposition
-supportive care with supplemental oxygen, cardiac monitoring, and pain control in the immediate
-hemodynamically stable patient with an isolated, nondisplaced sternal fracture and no ekg
abnormalities may be discharged
-those with associated intrathoracic injuries, severe pain, poor pulmonary reserve, or the elderly should
be admitted for observation
– ekg changes and positive cardiac markers require admission for further monitoring
Peek GJ, Firmin RK. Isolated sterna fracture: an audit of 10 years’ experience. Injury 1995; 26:385.
Stephens NG. Morgan AS. Sternal facures- the natural history. Ann Emerg Med 1988: 17:912