Management of Sternal Fractures

Initial Assessment and Risk Stratification

The American College of Radiology recommends determining hemodynamic stability and excluding life-threatening cardiac injury in patients with sternal fractures, as myocardial contusion and malignant ventricular arrhythmias can occur 1
Obtaining ECG and cardiac troponin levels immediately is crucial in all patients with sternal fractures, as it can detect myocardial contusion and malignant ventricular arrhythmias, with a strength of evidence based on a multicenter study of 54 patients 1
CT chest without IV contrast accurately detects sternal fractures using sagittal and 3-D reconstructions, and can identify hemothorax or hemopericardium by measuring attenuation, according to the Journal of the American College of Radiology 1
Echocardiography is not recommended for isolated sternal fractures when ECG and cardiac troponins are normal, as stated by the American College of Radiology 1

The American College of Rheumatology suggests that appropriate pain management with regular analgesics should be provided as soon as possible before diagnostic investigations, with a moderate strength of evidence based on a study published in the Annals of the Rheumatic Diseases 2
Early mobilization should begin as the patient's pain allows, with a moderate strength of evidence based on studies published in the Annals of the Rheumatic Diseases 2, 3

Hemodynamically stable patients with abnormal ECG findings or rising cardiac troponin levels require cardiac monitoring, as recommended by the American College of Radiology 1
Patients with normal ECG and cardiac troponin levels are low probability for cardiac blunt trauma and can be safely discharged, according to the American College of Radiology 1

The right ventricle is most commonly affected due to its anterior location, followed by left ventricle and right atrium, with a high strength of evidence based on a study published in the Journal of the American College of Radiology 1
Hemopericardium and cardiac tamponade can occur when pericardium remains intact and hemorrhage accumulates, requiring immediate intervention, as stated by the American College of Radiology 1
CT chest with IV contrast identifies the source of bleeding and is complementary to chest radiography and transthoracic echocardiography, with a moderate strength of evidence based on a study published in the Journal of the American College of Radiology 1

The American College of Rheumatology recommends providing appropriate analgesics tailored to patient comorbidities as soon as possible, before diagnostic investigations, for patients with isolated sternal fractures 4
The American College of Rheumatology suggests assessing for underlying osteoporosis and considering calcium and vitamin D supplementation for elderly patients with sternal fractures, with a recommended dosage of 1000-1200 mg/day of calcium and 800 IU/day of vitamin D 5
Vitamin D supplementation with adequate calcium intake is associated with a 15-20% reduction in non-vertebral fractures and falls in elderly patients with sternal fractures 5
The American College of Rheumatology recommends ensuring appropriate pain management and fluid management for patients requiring hospitalization due to sternal fractures 4
A comprehensive admission assessment should include investigations for malnutrition, electrolyte disturbances, anemia, cardiac or pulmonary diseases for patients requiring hospitalization due to sternal fractures 4

The American Society of Anesthesiologists recommends starting with regular paracetamol (acetaminophen) unless contraindicated, and adding opioids as needed, with caution if renal function is unknown, as approximately 40% of trauma patients have moderate renal dysfunction 6, 7
The American Society of Anesthesiologists advises avoiding NSAIDs if renal function has not been assessed, as they are relatively contraindicated in patients with impaired kidney function 6, 7
Documenting pain scores at rest and with movement before and after analgesia administration is recommended by the American Society of Anesthesiologists 6, 7