Sternal fracture: isolated lesion versus polytrauma from associated extrasternal injuries--analysis of 1,867 cases

Abstract

Background: Sternal fractures fall into two distinct categories as follows: (1) isolated sternal fracture (ISF) without associated injury and (2) polytrauma sternal fracture (PSF) with associated extrasternal injury. PSF can be sufficiently severe to require hospitalization, while ISF is usually a mild insult manageable in an ambulatory setting. Nonetheless, most patients with ISF are hospitalized. The disconnect between treatment based on existing evidence and actual clinical practice may be caused in large part by the small patient cohorts in published studies conducive to inaccurate conclusions. This article addresses the issue by analyzing prospectively collected data on a far larger population than hitherto available.

Methods: The Israeli National Trauma Registry (INTR) collects data prospectively on patients admitted to trauma centers in Israel. We analyzed the INTR database on sternal fractures for demographics, mechanisms and severity of injury, diagnostic evaluation, treatment, and outcomes.

Results: Between 1997 and 2008, the INTR received data on 1,867 consecutive patients hospitalized with sternal fractures. The injury was sustained most often during motor vehicle accidents (84.1%), followed by falls (10.3%) and other blunt or penetrating mechanisms (5.6%). ISF was sustained in 26.4%, and PSF was sustained in 73.6%. Associated injuries involved most parts of the body. Cardiac contusions or lacerations were diagnosed in 1.8% of the 1,867 patients. ISF was associated with a lower incidence of cardiorespiratory compromise, more favorable trauma scores (Glasgow Coma Scale [GCS] score > 14, Revised Trauma Score > 11), and use of fewer intensive care facilities or operations compared with PSF. Endotracheal intubation, chest tube insertion, or thoracotomy was not performed in any ISF patient but was performed in 16.9% of the PSF cohort. The differences between ISF and PSF were statistically significant in all analyzed indices of injury severity.

Conclusion: This study produced compelling evidence that ISF is an identifiable and mild injury. Consequently, pain, the major clinical manifestation of ISF, can usually be treated in outpatient settings. To avoid the inconvenience, risk of complications, and cost associated with hospitalization, discharge from the emergency department merits serious consideration.

Level of evidence: Prognostic and epidemiologic study, level II.