Surgical Research

Open journal

ISSN 2377-1518

Surgical Treatment of Sternal Fracture: Case Report and Literature Review

Jorge PĂ©rez-Acosta, Orlando TĂ©llez-Almenares*, Justo Escalona-Cartaya, RaĂşl Calas-Balbuena and Olga M. Moreira-Barinaga

Corresponding Author

Orlando TĂ©llez-Almenares, MD, MSc
Saturnino Lora Provincial Hospital, Santiago de Cuba, Cuba; University of Medical Sciences of Santiago de Cuba, Santiago de Cuba, Cuba;
E-mail: orlandotellez.al@gmail.com

Introduction

Trauma remains a global health concern with meaningful repercussions on peoples’ lives and healthcare systems.1,2 The
development and mechanisation of industries and vehicles’ widespread use has been determining factors in increased traumas.3
The Swedish Trauma Registry informs that it is one of the leading
cause of death and disability in individuals under 45 worldwide,
surpassing cancer deaths among young adults.4
Road traffic crashes are a foremost cause of injury, posing
a critical matter in numerous nations.2
The World Health Organisation (WHO) conveyed that traffic accidents provoke approximately
1.3 million yearly casualties.5
As per National Trauma Data Bank’s
2016 annual report,6
223,866 motor vehicle accidents ensued in the
United States, resulting in 10,343 casualties. A recent Cuban report7
points out that between 2019 and 2020, there were 1,368 fatalities
from road traffic accidents, of which 80.8% were male.
Blunt trauma is a common occurrence in motor vehicle
collisions and is associated, in most cases, with severe organ damage.1,6,8 In Sweden, blunt injuries account for approximately 90%
of all injuries. Blunt thorax traumas (BTT) are the third leading
cause of trauma-related death, preceded only by traffic-related
head and abdominal injuries.8
The thorax is one of the most affected regions in motor
vehicle accidents. The 2016 National Trauma Data Bank statistics6
logged 1,29,338 thoracic traumas (TT) with AIS>3 with a fatality
rate of 9.53. Multiple authors have noted that TT mortality is approximately 25% of all traumatic deaths globally and contributes
25% to mortality from other types of traumas. South Korean research Byun et al1
shows that 33.6%-non-surviving caseload died
due to significant chest harm. In contrast, a Cuban study3
states
that TT accounts for 4-6% of trauma admissions in Cuba and has
a fatality rate of 15%.
The sternum is a peculiar, odd bone located in the anteromedial thorax region, it measures 15-20 cm in length, and as it
extends distally, its thickness gradually decreases.9
Fractures of this
bone are uncommon and can ensue in isolation or alongside other
organ damage, implying more significant morbidity and mortality.10,11 Studies Brookes et al,12 Hochhegger et al,13 Knobloch et al,14
and Bentley et al15 reveal traumatic sternal fractures (SFs) occur in
8-18% of BTT and polytrauma victims. In contrast, they are unusual in open trauma and refer that using seat belts is associated with
a higher frequency of these fractures.
These fractures arise from diverse aetiological mechanisms, some of which may provoke minor chest wall injuries,
while others can have deadly outcomes. The sternal fracture’s main
aetiological culprits are direct impact, the upper thoracic region’s
compression, and deceleration.16,17 In car crashes, the SFs are generally associate with seat belt use or the blow against the steering
wheels.17
This report aims to outline the case of a patient who suffered a traumatic SF after a traffic crash, the injury’s characteristics,
and its clinical and surgical management.

Affiliation

1 Saturnino Lora Provincial Hospital, Santiago de Cuba, Cuba
2 University of Medical Sciences of Santiago de Cuba, Santiago de Cuba, Cuba

Article History

Received: June 8th, 2023; Revised: July 10th, 2023; Accepted: July 14th, 2023; Published: July 21st, 2023

Cite this Article

PĂ©rez-Acosta J, TĂ©llez-Almenares O, Escalona-Cartaya J, Calas-Balbuena R, Moreira-Barinaga OM. Surgical treatment of sternal fracture: Case report and literature review. Surg Res Open J. 2023; 8(1): 1-6.

Doi

10.17140/SROJ-8-129

Sternal fractures are uncommon thoracic trauma that can ensue in isolation or conjunction with other organ injuries, implying
more significant morbidity and mortality. These fractures result from diverse aetiological mechanisms, some of which may provoke minor chest wall issues, while others can have deadly outcomes. The sternal fracture’s primary aetiological culprits are direct
impact and the upper thoracic region’s compression. Studies reveal that traumatic sternum fractures occur in 8-18% of blunt
thoracic and polytrauma victims, whereas they are unusual in open trauma. This report aims to outline the case of a 54-year-old
Caucasian male with hypertension and an alcohol consumption history who sustained a direct impact on the anterior thorax after
a traffic accident. He experienced severe pain that worsened with movement and coughing, and breathing difficulty. We noticed a
painful haematoma and depression with bony crepitus at the sternal body level. Abdominal-pelvic echography indicated no intraabdominal lesions and showed pleural effusion in the left lung base, while thoracic X-rays (lateral and anteroposterior view) and
chest computerized tomography (CT) scan exhibited mid-sternum segment displaced fracture and haemothorax. We diagnosed a
mid-sternum completely displaced overlapping fracture and a traumatic left haemothorax. Therefore, urgent surgical intervention
was required. We performed a minimal-lower pleurotomy and internal fixation to address the fracture. His post-operative recovery
was satisfactory. Although various authors advocate X-rays as an effective diagnostic means for sternal fractures, CT uncovers
overlooked radiography abnormalities; therefore, CT must be considered in patients’ initial assessment. While most sternal fractures can be treated conservatively, surgery is feasible in displaced fractures.

Case Presentation

Clinical Assessment

A 54-year-old Caucasian male with hypertension and an alcohol
consumption history was transferred by the Integrated Medical
Emergency Service (SIUM for its Spanish acronym) to the Accident and Emergency Department (A&E) following a traffic incident. He sustained a direct impact on the anterior thorax, causing
severe pain that worsened with movement and coughing, making it
difficult for him to breathe.
In the medical interview, the patient shared accident details
describing how he collided with a parked lorry while riding his motorbike. He confirmed the impact was only in his chest and denied
experiencing discomfort in his abdomen, neck or other regions.
We adhered to the advanced trauma life support (ATLS)
guidelines, and a complete physical examination was conducted. Two
peripheral veins were cannulated, and a Fowley catheter was placed.
The noteworthy findings on the physical assessment included a weight of 65 kg, a height of 172 cm, and a body mass
index (BMI) of 22.4 kg/m2
; the skin and mucous membranes appeared slightly pale and dry, predominantly affecting the conjunctival and oral mucosa. We noticed a haematoma and depression at
the sternal body level. It was painful on palpation and had bony
crepitus. No abnormalities were detected upon abdominal examination through palpation, percussion, and auscultation. Additionally, the abdominal puncture was negative.
Upon respiratory system asses, it was found that there
was reduced thoracic expansion, a respiratory rate of 28 breaths
per minute, decreased vocal resonance, and vesicular breath sounds
towards the left lung base without crackles or pleural friction rub.
As for the cardiovascular system, was found audible heart sounds,
good tone with tachycardic, and a heart rate (HR) of 114 beats per
min (b.p.m). Peripheral pulses were present, accelerated and synchronous, and blood pressure was measured at 140/110 mmHg.
Neurological sphere assessment showed that consciousness and orientation were preserved, and a Glasgow Scale score of
15 points was logged.
During the patient’s initial evaluation at A&E, we diagnosed mild dehydration. We were administered crystalloid fluids
(isotonic sodium chloride) at a 1,500 ml/m2
sc/24 h rate, passing
750 ml of fluid in the first hour. We conducted paraclinical examinations after ensuring the patient’s clinical and haemodynamic
stability.

Laboratory Tests

The detailed values of all the laboratory tests are given in the below
box.

Electrocardiogram

Electrocardiogram showed sinus tachycardia without changes in
the Q wave, R wave and S wave (QRS complex) or ST-segment
and HR of 112 b.p.m.

Imaging Studies

Abdominal-pelvic echography showed no organ damage, no fluid in the abdominal cavity, no urinary tract injury, and an empty
bladder due to the Fowley catheter inside. Nevertheless, there was
evidence of pleural effusion in the left lung base.
Chest X-ray in a standing position (posteroanterior view)
showed sternum body displaced fracture and a radiopacity that obscured the left costophrenic angle. (Figures 1 and 2).

Surgical Management and Post-surgery

Based on clinical and imaging studies, it was determined that the
patient had suffered a mid-sternum complete displaced overlapping fracture and a traumatic left haemothorax. As a result, emergency surgical treatment was required.
The haemothorax was evacuated through a minimal lower pleurotomy under local anaesthesia; it removed approximately
480 ml of haematic contents. The sternum was fixed under general
endotracheal anaesthesia using an internal fixation system of galvanised stainless-steel plates and screws (Figure 3).
The fracture was accessed through a longitudinal incision
approximately 12-15 cm above the sternum. Fortunately, there
were no intraoperative complications.
Following a 1 hour and 20-minute surgery, he was transferred to the intermediate care unit (ICU), where he stayed for
12-days. During his stay, he experienced cardiac arrhythmia, which
subsided after removing his chest tube. After 18-days, he was discharged with regular outpatient follow-up and pain management.
The patient complained of mild pain three months later,
but the sternum was stable. There were no reported complications
at six months, and the radiological images showed favourable healing with intact bony fixation (Figure 4).

Funding

FINANCIAL SUPPORT AND SPONSORSHIP

The authors stated that no grants were involved in supporting this
work.

We thank the radiologists and intensivists, the nurses and the operating theatre technical staff involved in the patient’s care.

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