European Journal of Cardiovascular Medicine

The incidence of sternal fractures (SF) is estimated to be present in 8% of all chest trauma cases and up to 7% of all road traffic accidents [1]. SF is found in association with surrounding mediastinal structures damage especially the heart is found to be damaged in up to 60% of cases [2]. A serious complication of SF is sternal dislocation which is rarely found in traumatic cases [3]. The etiological factors of SF include blunt chest trauma (anterior) caused by numerous reasons, the most common being road traffic accidents [4,5]. We present here three cases of sternal fracture that were presented to our centre.

Case Presentation:

Patient 1:

A 24-year-old gentleman reported to the trauma centre with an alleged history of a road traffic accident, in which he was riding a bike and was hit by a bullock cart, in a head-on collision. Due to the blunt trauma to the chest, he had a fracture in the mid-half of the sternum, displaced sterno-manubrial joint, along with a bilateral 4th and 5th ribs fracture, with flail segments (Figure 1). He was managed as per the standard ATLS protocols, following which he was stable and was planned for surgery in the Department of Trauma Surgery.

A midline incision was given along the sternum and the fracture of the sternum was approximated using pliers and stabilised by using two Titanium plates (k/a plates- matrix rib universal PL 8 HO Tan, screw 10-12 mm) De puysynthes; another plate was used to stabilise the sterno-manubrial joint. The bilateral 4th rib flail segment was stabilised using titanium plates. The plate prevents the movement of the sternal ends, as it provides strong support for the fractured sternum, with the screws anchored both above and below the fracture at the required distance. These locking screws provide rigid fixation that can resist multidirectional tension.No separate incision was given to fix the rib. The bilateral intercostal drain was placed. Hemostasis was achieved and the wound was closed in layers. The postoperative stay was uneventful. The patient was extubated 48 hours later.

Patient 2:

A 23-year-old gentleman presented to the trauma centre with an alleged history of road traffic accidents. He had a Sternal fracture which was displaced with a right 6^th & 7th rib fracture with a flail segment of the 6th rib (Figure 2). In the anterior portion of the thorax, paradoxical movements were present. The patient was brought to the trauma centre where he was managed by following the ATLS guidelines following which he was stable and planned for surgery.

A midline incision was given along the sternum and approximated and fixed using a De Buy synthesis system titanium plate (k/a plates- matrix rib universal PL 8 ho Tan, screw 10-12 mm). As the flail segment of the right 6th rib was stable, no fixation of that segment was required (Figure 3). The midline wound was closed in layers and right-sided intercostal drainage was placed. The postoperative stay was uneventful (Figure 4).

Patient 3:

A 25-year-old gentleman presented to the Thoracic Surgery emergency ward with an alleged history of fall from height, in which he fractured and dislocated the manubrium-sternal joint. He developed traumatic paraparesis with sensory deficit. Fracture of the manubrium-sternal joint was accompanied by fractures of the L3 vertebrae and bilateral calcaneum. Physical examination revealed crepitus and tenderness.

The patient was taken up for surgery. A midline incision was given along the sternum and the fractured segment was approximated and fixed with two titanium plates (k/a plates- matrix rib universal PL 8 ho Tan, screw 10-12 mm). The wound was closed in layers. The postoperative stay was uneventful.

Patient 4:

A 34-year-old gentleman reported to the trauma centre with an alleged history of a road traffic accident, in a head-on collision. Due to the blunt trauma to the chest, he had a fracture in the upper half of the sternum, along with a bilateral 4th and 5th rib fracture, with flail segments. He was managed as per the standard ATLS protocols, following which he was stable and was planned for surgery in the Department of Trauma Surgery.

A midline incision was given along the sternum and fracture of the sternum was approximated using pliers and stabilised by using two Titanium plates (k/a plates- matrix rib universal PL 8 HO Tan, screw 10-12 mm) De puysynthes; another plate was used to stabilise fractured displaced  4th and 5th ribs using titanium plates. No separate incision was given to fix the rib (Figure 5). The bilateral intercostal drain was placed. Hemostasis was achieved and the wound was closed in layers. The postoperative stay was uneventful. The patient was extubated 72  hours later.

Patient 5:

A 27-year-old gentleman presented to the trauma centre with an alleged history of road traffic accidents. He had mid mid-mid-half Sternal fracture which was displaced with the right 5^th & 6th rib fracture with paroxysmal movement of the anterior chest wall. The patient was brought to the trauma centre, where he was managed by following the ATLS guidelines, following which he was stable and planned for surgery.

A midline incision was given along the sternum and approximated and fixed using a De Buy synthesis system titanium plate (k/a plates- matrix rib universal PL 8 ho Tan, screw 10-12 mm). As the fractured rib segment was stable, no fixation of that segment was required. The midline wound was closed in layers and right-sided intercostal drainage was placed. The postoperative stay was uneventful (Figure 6). The patient was extubated 48 hours later.

 For pain relief, Epidural analgesia was administered to all the patients. A chest corset was applied in all the patients to give support to the sternal fracture site.

The overall prognosis and mortality of such patients are closely dependent on the associated injuries of the surrounding structures and range from 4 to 45% [6,7]. Associated injuries include fractures of the vertebrae, ribs, and scapula; lesions in the heart, lung, and major blood vessels leading to numerous complications. Less commonly, the abdomen and brain can also be associated [8]. These complications can lead to multiple organ failure, respiratory distress and finally death [6]. A study comparing the various treatment modalities employed in the management of SF revealed that most of them are managed conservatively [9]. Conservative management includes rest, analgesia fixation and reduction of displacement as its mainstays [10]. Klei et al. conducted a study to study the various forms of surgeries performed for the management of SF, they found that a major proportion underwent sternal fixation with plates (about 80%), followed by a combination of plates and bone graft in about 16 % of the cases [11]. Sternal plating provides the advantages of maintaining stability and function of the chest wall along with improving the chances of union of SF as compared to surgeries involving wires as the fixative [12].

The management of SF produces a dilemma as it may represent a major injury beneath itself [13]. The diagnosis of SF is made with the help of radiographs taken in the sagittal and oblique planes [14]. However, once SF is diagnosed, a thorough workup of the other surrounding structures must be done to reveal any associated injuries. Isolated SF is a benign entity and heals upon itself without leading to distortions. Hence, patients with SF are treated as a case of blunt chest trauma patients, thus necessitating the standard protocol of investigations [15]. A study conducted by Athanassiadi et al. showed that the duration of hospital stay and outcomes are closely dependent on the associated injuries [16]. Non-union of the sternum post-sternotomy is a highly rare phenomenon (less than 1%) [17]. Due to SF being a rare phenomenon a dearth of experience among surgeons and a lack of literature on this topic have led to no defined algorithm or standard for the correction of SF [18]. This can be corrected by conducting future research studying the incidence and outcomes of operated SF using different techniques [19]. Titanium plate internal fixation is a fast and minimally invasive procedure with the advantages of the exposure of the sternal fracture being minimal, without the need to expose the ribs and costal cartilage; thus, the risk of iatrogenic complications (intercostal and internal mammary artery injuries) is maximally reduced. Besides this, if the sternal face is not completely smooth, the titanium plate can easily be modelled according to the contour of the fracture.

The presented case series highlights the complexity and potential severity of sternal fractures, often associated with significant trauma and diverse complications involving adjacent structures. While conservative management remains common, surgical intervention, particularly sternal plating, proves effective in stabilizing the chest wall and promoting healing, thus improving outcomes. However, the absence of standardized protocols highlights the need for further research to establish optimal management strategies and enhance clinical understanding of this relatively rare condition.

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