Should We Admit All Patients with Sternal Fractures?

Should We Admit All Patients with Sternal Fractures?

2016-11-11T19:18:08+00:00

Sternum-FractureThe detection rate of sternal fractures following motor vehicle collisions and blunt trauma to the chest and abdomen has increased over the past decade.  The reason for this increase is most likely from the use of seat belts and better imaging modalities such as computed tomography (CT) in trauma patients. I can recall as a resident being told that any patient with a sternal fracture should be admitted to trauma because of the high likelihood of blunt cardiac injury and high mortality rate associated with this injury, but is this always true?

In isolated sternal fractures, what is the rate of cardiac complications and mortality?

Study Year Published Number of Patients with Isolated Sternal Fracture Cardiac Complications Deaths
Athanassiadi K et al 2002 67 3 (pericarditis 1; hemo-pneumothorax 1; hemomediastinum 1) None
Wiener et al 2001 50 (22 with isolated sternal fracture) 11 (benign pericardial effusion 7; arrhythmia 3; ST-T abnormality 1) None
Sadaba JR et al 2000 37 1 (atrial fibrillation) None
Peek GJ et al 1995 117 None None
Heyes FLP et al 1993 55 total patients (Unknown how many isolated sternal fractures) None None
Brookes JG et al 1993 123 None None
Wright SW et al 1993 31 None None
Johnson I et al 1992 103 total patients (Unknown how many isolated sternal fractures None None
Jackson M et al 1992 104 None None
Breederveld RS et al 1988 52 None None

Does the location of the sternal fracture make a difference? 1

  • 58 patients with sternal fracture
  • Isolated sternal fracture in 9% of these patients
  • Predominant fracture location was the manubrium (36.2%)
  • 76.2% of patients with manubrium fractures ended up in ICU
  • 23.8% of patients with manubrium fractures died (largest mortality rate)
  • Most commonly associated injuries: rib fractures (63%) and spinal fractures (57%)
  • Most common causes of sternal fractures were frontal car collision and fall from greater than 5 meters
  • Conclusion: Fractures of the manubrium are associated with other injuries and have a higher mortality rates

Are there guidelines for screening of blunt cardiac injury (BCI)? 2

  • Eastern Association for the Surgery of Trauma practice management guideline
  • 35 studies reviewed
  • Great blunt cardiac injury algorithm from The Trauma Professional’s Blog 
  • Another blunt cardiac injury algorithm from EM Clinics of North America paper (2012) summarized as PV card 3
  • Note that in both algorithms above, a troponin level is only warranted if there is an abnormal ECG.

Level 1 Recommendations

  • ECG should be performed on all patients in whom BCI is suspected

Level 2 Recommendations

  • If ECG reveals a new abnormality (arrhythmia, ST changes, ischemia, heart block, and unexplained ST changes), patient should be admitted for telemetry
  • If normal ECG and normal troponin, blunt cardiac injury is ruled out
  • Hemodynamically unstable patients, or persistent new arrhythmia, echocardiogram should be obtained
  • Presence of sternal fracture alone does not predict presence of blunt cardiac injury in setting of normal ECG and cardiac enzymes
  • CPK and CK-MB should not be performed in predicting blunt cardiac injury

Level 3 Recommendations

  • Elderly patients with known CAD, hemodynamically unstable patients, and patients with abnormal screening ECG can safely undergo emergent surgery with appropriate monitoring
  • Cardiac computed tomography or magnetic resonance imaging can be used to differentiate acute myocardial infarction form blunt cardiac injury in trauma patients with abnormal ECG, cardiac enzymes, and/or abnormal echocardiogram

What is the role of troponin in BCI?

Per the EAST guidelines:

“ECG remains the most commonly recommended tool for initial diagnosis of BCI. Less clear is the role that troponin should play in addition to ECG in the diagnostic workup, although it seems that this may allow for safe discharge or admission to a regular ward. A normal ECG result has an excellent NPV, in most studies being greater than 95%. Some studies, however, indicate that the addition of troponin I will increase the NPV to 100%, which could potentially decrease overall costs should that allow for more discharges and avoidance of intensive care unit stay.”

 Take Home Messages

  • Diagnosis of sternal fracture does require a high index of suspicion for associated injuries (especially fracture of the manubrium).
  • When isolated, sternal fracture can be surprisingly benign, but screening ECG should be obtained.
  • Abnormal ECG or cardiac enzymes with an isolated sternal fracture requires observation for possible blunt cardiac injury.
  • Bottom Line: Isolated sternal fractures, not involving the manubrium with normal ECG and cardiac enzymes (if ordered) can be safely discharged home.
1.
Scheyerer M, Zimmermann S, Bouaicha S, Simmen H, Wanner G, Werner C. Location of sternal fractures as a possible marker for associated injuries. Emerg Med Int. 2013;2013:407589. [PubMed]
2.
Clancy K, Velopulos C, Bilaniuk J, et al. Screening for blunt cardiac injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S301-6. [PubMed]
3.
Bernardin B, Troquet J. Initial management and resuscitation of severe chest trauma. Emerg Med Clin North Am. 2012;30(2):377-400, viii-ix. [PubMed]

Salim Rezaie, MD

Salim Rezaie, MD

ALiEM Associate Editor
Clinical Assistant Professor of EM and IM
University of Texas Health Science Center at San Antonio
Founder, Editor, Author of R.E.B.E.L. EM and REBEL Reviews
  • Andrew Bowman

    Cannot find the PV card

  • Paul Jones

    Great review of a relevant topic. I certainly see many blunt force injuries due to winter driving conditions.

    • Salim R. Rezaie

      TY Paul,
      Hopefully this helped clarify, how to work up BCI and to be suspicious of other injuries, but no need to admit all pts with sternal fxs.

      Salim

  • Katielousmith

    How soon after the incident should cardiac enzymes be measured to be reassuring if they turn out negative – is the lag time similar to that in MI?

    • Salim R. Rezaie

      Hello Katie,
      To my knowledge, I do not know that timing of the cardiac enzymes has truly been studied, but I would surmise that it depends on the type of troponin you have (i.e. POC, sensitive, or highly sensitive). That being said use of cardiac enzymes is a bit controversial. A simple way to look at these patients is the following:

      1. Normal ECG + Normal Echo (E-FAST) –> no BCI
      2. Abnormal ECG + Hemodynamically stable –> Monitor on telemetry +/- cardiac enzymes
      3. Abnormal ECG + Hemodynamically unstable –> Monitor in ICU + cardiac enzymes for prognostication

      I hope this helps. TY for reading and your comment.

      Salim

  • Christine Robin

    Thanks for the review. In our center, we observe the patient for 8-24hrs with serial ECG. Is only one negative ECG at the arrival enough to exclude bci in an isolated sternal fracture patient?