Management and Treatment of Sternal Crepitus
Diagnostic Approach
- Initial radiographs are the first-line imaging study for suspected sternal crepitus to detect soft tissue gas and bony abnormalities 2, 3
- CT scan without contrast is recommended if radiographs show soft tissue gas, as it offers higher sensitivity for detecting the extent and compartmental location of gas 2, 3
- MRI with contrast is the preferred imaging modality for suspected osteomyelitis to determine the extent of bone and soft tissue involvement 2, 3
- Blood cultures and tissue/abscess cultures should be obtained to identify causative pathogens 4
Treatment Based on Etiology
For Sternal Osteomyelitis
- Surgical debridement of all necrotic tissue is strongly recommended 1
- For Candida sternal osteomyelitis, fluconazole 400 mg daily for at least 6 months OR an echinocandin for 2 weeks followed by fluconazole for at least 4 months 1
- For bacterial sternal osteomyelitis, empiric therapy should cover Staphylococcus aureus with vancomycin until culture results are available 4
For Soft Tissue Infection with Crepitus
- Prompt and aggressive surgical debridement of all necrotic tissue is essential 4, 6
- Broad-spectrum antibiotics covering gram-positive, gram-negative, and anaerobic organisms should be administered 4, 6
- Vancomycin plus an agent active against gram-negative bacilli is recommended for initial empirical therapy 4
Special Considerations
- Patients with diabetes or immunocompromised status may require more aggressive surgical debridement and longer courses of antimicrobial therapy 6
- Post-sternotomy infections require careful evaluation of sternal stability; rigid sternal fixation may be beneficial in some cases to improve healing and reduce complications 7
Follow-up and Monitoring
- Serial imaging (CT or MRI) may be necessary to evaluate treatment response in cases of osteomyelitis 2
- For patients with implanted hardware, long-term suppressive antibiotics may be required if complete removal is not possible 1, 5