Trauma 2009; 11: 77–92

Sternal fractures
Rangan Raghunathan and Keith Porter

Sternal fractures are relatively common and range from simple unicortical cracks to
displaced fractures associated with life threatening injuries. This paper describes the
relevant anatomy, biomechanics, mechanism of injury, clinical presentation,
investigation, treatment and complications and also includes associated and
concomitant injuries. A management flow chart including criteria for discharge from
the emergency department is presented.

Key words: sternal fractures; epidemiology; management; complications

Epidemiology mechanisms included, car versus pedestrian acci-

The incidence of sternal fractures is reported to be
between 0.64% and 3.7% of all injuries (Otremski
et al., 1990; Hills et al., 1993; Knobloch et al., 2006).
In relation to motor vehicle collisions the incidence
is higher at 3% to 6.8% due to the usage of seatbelts
(Brookes et al., 1993; Hills et al., 1993).
There is no specific preponderance in either sex,
some studies showing a greater incidence in males
and others females (Hills et al., 1993; Roy-shapira
et al., 1994; Athanassiadi et al., 2002; Von Garrel
et al., 2004). The higher proportion of female
patients sustaining sternal fractures in some cohort
studies may be due to the higher incidence of
osteoporosis and altered seatbelt mechanics in
females. The median age of patients sustaining
sternal fractures in motor vehicle collisions varied
between 40 and 50 years of age (Hills et al., 1993;
Roy-shapira et al., 1994; Athanassiadi et al., 2002;
Velissaris et al., 2002; Jin et al., 2006). One fifth of
patients suffered polytrauma involving deceleration
injury (Knobloch et al., 2006) either in a car
(frequently associated with non-functioning
air bag), motor bike or lorry, while other
Selly Oak Hospital, University Hospital Birmingham NHS
Trust, Selly Oak, Birmingham, West Midlands, B29 6JD, UK.
Address for correspondence: Mr Rangan Raghunathan,
Trauma Research Fellow Selly Oak Hospital, University
Hospital Birmingham NHS Trust, Selly Oak, Birmingham,
West Midlands, B29 6JD, UK. E-mail: drrraghu@hotmail.com
dents and falls (Hills et al., 1993; Knobloch et al.,
2006).
The majority of sternal fractures are either
undisplaced or minimally displaced at the corpus
sterni (Von Garrel et al., 2004; Jin et al., 2006). The
morphology is usually transverse, although vertical
fracture has been reported (Ayrik et al., 2005). The
hospital mortality following sternal fractures is
reported to be 0.6% to 2.6% (Brookes et al.,
1993; Knobloch et al., 2006) of all injuries with a
lower incidence in motor vehicle accident victims
(Hills et al., 1993).
Insufficiency fractures can occur as a result of
osteoporosis from various causes including in post--
menopausal women, long-term steroid therapy and
elderly patients (Horikawa et al., 2007). Pathological
fractures can occur spontaneously without a history
of trauma due to loss of bone strength (Kinsella
et al., 1947; Urovitz et al., 1977), which can be seen
on X-ray as osteolysis and soft-tissue swelling.
An athlete undertaking repetitive upper body
exercise can develop a stress fracture of the sternum
without a history of a single acute traumatic episode
(Robertsen et al., 1996). A high degree of clinical
suspicion is necessary to differentiate sternal frac-
tures from other causes of chest pain.
Sternal fractures are uncommon in children
though if present usually occur at the first or
second sternabra, either due to direct force or from
a hyperflexion injury to the thoracic spine
(Ferguson et al., 2003). Persistence of an unfused
growth centre can be a diagnostic challenge.

 SAGE Publications 2009

Los Angeles, London, New Delhi and Singapore 10.1177/1460408608102007
78 R Raghunathan and K Porter
Anatomy and biomechanics
To understand the mechanism of injury, fracture
patterns and sternal biomechanics, an understand-
ing of the basic anatomy and biomechanics is
essential. The sternum consists of three parts:
Manubrium (most dense portion)
The body
Xiphisternum.
The sternum is dagger shaped and triangular
in outline and has many attachments including
bone, cartilage, muscle. As a subcutaneous bone it is
prone to injury in anterior chest trauma. Being
connected to the thoracic spine through the ribs,
it is also known as the ‘fourth column’ of spinal
stability (the first three being components of the
spine itself) as postulated by Berg et al. (1993).
The clavicle and first rib are attached in a rigid
way to the manubrium, while the second rib is
attached at the manubrio-sternal junction – the
‘angle of Louis’. The 3rd to 7th ribs are attached to
the body of sternum. The xiphisternum is connected
by a flexible fibro cartilaginous joint to the inferior
aspect of the sternum.
The ‘Membrana sternum’ covers the sternum
anteriorly and posteriorly, and is basically the
chondro-sternal ligaments from the ends of the
costal cartilages. The pectoralis major muscle and
the sternal head of the sternocleidomastoid are
attached anteriorly, posteriorly the sternohyoid and
sternothyroid muscles attach to the manubrium.
The diaphragmatic muscles & transverse thoracis
attach to the body of the sternum, whilst the rectus
abdominis is attached to the distal part of sternum
(Figure 1).
The thorax is an osteo-cartilagenous cage, conical
in shape, being narrowest above, flattened antero-
posteriorly and longer behind than in front. Its
posterior surface is formed by the 12 dorsal vertebrae
and the posterior part of the ribs. The anterior
surface is slightly convex and inclined forwards and
downward and comprises the sternum and costal
cartilages. Watkins et al. (2005) reported a cadaveric
biomechanical study showing that the rib cage and
sternum provide 40% of the stability of the thoracic
spine in flexion-extension, 35% of stability in lateral
bending and 31% of stability in axial rotation – all
important features in understanding the flexion
Trauma 2009; 11: 77–92
compression and flexion-rotation injuries, which
cause sternal and spinal fractures.
Union of the manubrium with the body rarely
takes place except in old age. The four segments
of the body of the sternum commence uniting from
bottom upwards, the caudal segment fusing at
puberty, middle segments fusing in adolescence
and the cranial part in early adult life. By the age
of 25 years this portion of bone consists of one
piece. Manubriosternal synostosis, xyphisternal
synostosis and sternal segment synostosis occurs in
6–11%, 90 and 6.7% of individuals, respectively.
Classification
Sternal fractures can be classified based on the
mechanism of injury into direct and indirect injuries
(De Tarnowsky, 1905). The original classification
included a separate category for muscular action
which essentially fits the ‘indirect category’.
Cooper (1988) divided stress fractures into fatigue
or insufficiency fractures. Insufficiency fractures
can be defined as stress fractures occurring in bones
with decreased elastic resistance that are weakened
and unable to withstand the stresses of daily living,
especially during spinal flexion and extension
(Figure 2). Chen et al. (1990) classified sternal
fractures into buckling and non buckling, where
buckling was defined as a sternal deformity in which
the upper portion of the sternum is supero-posterior
to the lower portion and in which there was no
‘cortical disruption, focal bone resorption or callus
formation’.
However, one of the simplest ways to classify
sternal fractures is to consider them as either
displaced or undisplaced (Figure 3).
Direct violence
The commonest cause of sternal fracture is direct
violence, often due to seat belt usage or steering
wheel impaction from motor vehicle collisions.
Other direct impacts include pedestrians struck by
vehicles, falls striking the front of the chest, contact
sports, assaults and cardiorespiratory resuscitation.
Apart from sternal fractures, seat belt usage also
causes rib fractures, clavicle fractures, myocardial
and pulmonary contusions. Following the intro-
duction of compulsory seat belt wearing in the
 Sternal fractures 79

Stemothyroid muscle (posterior)

Stemohyroid muscle (posterior)
Manubrium.
The most dense
part of the sternum
Clavicle Stemoceidomastoid muscle

First rib
Pectorialis major muscle
(cut)
Second rib attached to sternal
angle acting as a lever for
flexion-compression injuries

Body of sternum.
The most common part
of sternal injuries

Transverse thoracis muscles

(posterior)

3 to 7 ribs

Diaphramatic muscles
(posterior)

Rectus abdominis muscle

Biomechanics Xiphoid
Sternum and rib complex process
provides 40%, 35% and 31%
stability of thoraic spine
during flexion/extension,
lateral bending and axial
rotation, respectively.

Figure 1 Anatomy and biomechanics

United Kingdom on 1 February 1983 there has been
a 3-fold increase in the number of patients sustain-
ing sternal fractures, coupled with an increase in the
number of survivors from high-speed road traffic
collisions. We could derive possible reasons and
some mechanisms as in (Figure 4).
Newman and Jones (1984) found that analysis of
all injured occupants showed seatbelt use to be
associated with a significant downward shift in
injury severity. Newman also reported that
restrained front occupants were twice as likely to
sustain sternal fractures and fractures of the 1st–3rd
ribs than non-restrained occupants. Knobloch et al.
(2006) in a series of 262 patients with sternal
fractures reported that 92.1% of fractures in car
occupants occurred in front seat occupants particu-
larly in vehicles without an airbag or with airbag
malfunction. The relationships between seat belt
and airbag and associated injures are detailed in
Table 1.
Fractures to the body are more common than
fractures to the denser manubrium. Manubrial
injuries are associated with a greater incidence of
internal thoracic injuries, for example injuries to the
great vessels (Gibson, 1962). The sternum classically
fractures at the site of impact, where direct violence
to the lower sternum displaces the lower fragment
posteriorly when the impact is to the lower sternum
(Figure 3). Similarly, direct injuries to the upper
sternum displace the upper sternum posteriorly
(Figure 3). Occasionally the sternum fractures at
multiple sites (Von Garrel et al., 2004) and
rarely it may be comminuted. Common fracture
patterns are transverse or oblique, although

Trauma 2009; 11: 77–92

80 R Raghunathan and K Porter

Sternal fractures based on Stress fractures

mechanism of injuries

Direct violence Indirect violence Normal bone Abnormal bone

• seat belt, steering wheel
• run over
• direct hit against hard
object
• CPR
Compression injuries
• Flexion-rotation
• Flexion-compression
• Falls on the head
• Falls on the shoulder
Acute
Retraction injuries
• Sudden muscle pull
tetanus, epilepsy women in
labour, severe coughing
Insufficiency fractures Pathological fractures
Chronic
• Osteoporosis steroid • Malignancy metastasis
induced old age menopause myeloma infections TB
cystic fibrosis
Fatigue fractures
• non-contact sports
Buckling Non-buckling

Figure 2 Classification of sternal fractures (CPR ¼ Cardio Pulmonary Resuscitation)

(a) Posterior Anterior (b) Posterior Anterior

Mandubrium Mandubrium

Force displaces the

upper segment
posteriorly
Force displaces the
lower segment
posteriorly
Xiphisternum Xiphisternum

(c) Posterior Anterior

Force such as
flexion compression
injury displacing the
manubrium posteriorly

Xiphisternum

Figure 3 (a) Displacement of lower sternal body posteriorly; (b) Displacement of upper sternal body posteriorly;
(c) Displacement/dislocation of Manubrio-sternal joint

Aryrik et al. (2005), has reported a vertical fracture seat belt bruising or contusions from other direct
pattern. points of contact, sternal tenderness with or
The usual presentation is a patient post road without a step deformity and crepitus (Gouldman
traffic collision complaining of anterior chest pain, and Miller, 1997) (Table 2). De Tarnowsky (1905)
aggravated by deep breathing and attempts to described the classical picture of patients
cough (cough test). Some patients experience with sternal fractures – the patient is standing
dyspnoea. On examination, inspection reveals or sitting with their head flexed forwards and

Trauma 2009; 11: 77–92

 Sternal fractures 81

(b)

(a) Manubrium sterni

Sterni corpi
External force External force
Fracture line
(Seat belt) (Seat belt)

No intrathoracic injuries Force breaks the sternum

or minimal injuries and has spread up, down
(Except in completely and along the ribs.
Xiphisternum displaced fractures) (Brunt of the attack is
taken by sternum)

(c)

No fracture
External force
(Seat belt)
Intrathoracic
injuries noted

Force transferred
through sternum

Figure 4 (a) External force 1; (b) External force 2; (c) External force 3

Table 1 Association of air bag, seat belt and sternal fractures (Blacksin, 1993): In motor vehicle accidents, the
common patterns of injuries
Air bag present þ seat belt present
Air bag absent þ seatbelt present
Air bag present þ seat belt absent
Air bag absent þ seat belt absent
Extension injury to upper cervical spine occurs.
Rare incidence of sternal fracture
Sternal fractures occur with greater incidence, associated
with rib and pulmonary injuries
Flexion injury to cervical and thoracic spine, facial injuries,
sternal fracture, associated other injuries
Steering wheel impaction injuries, life threatening injuries
happen with increased frequency

to one side. Breaths are short and shallow and
movements of the head and thorax slow and
cautious. Holderman (1928) quoting added the
fact that the shoulder may be drooped with part
of the weight of the patient’s arms being supported
on the bed.
Indirect violence
Indirect forces can cause sternal fractures either as a
consequence of hyperflexion of the spine due to
severe muscular action where the transmission of
forces results in compression or retraction of the
sternum.

Trauma 2009; 11: 77–92

82 R Raghunathan and K Porter

Displaced sternal fracture

Multiple lelvel sternal fractures

Figure 6 Multiple fractures

Figure 5 Displaced sternal fracture

Table 2 Clinical presentation of sternal fractures
Hyperflexion of the spine History
Compression forces to the sternum with bowing can Restrained motor vehicle occupant
explain the posterior displacement of the proximal Direct injury to sternum by fall or direct hit
fragment and the association with wedge compres- Fallen onto head or shoulder
sion fractures to the thoracic spine. Herbert and Sudden severe muscle pull
De Tarnowsky (1905), analysed the mechanism of Anterior chest pain
Increased pain on coughing or deep inspiration
indirect violence due to compression (contrecoup
fractures) and summarised the opinion of various Examination
authors into four points. Inspection
Bruise noted over sternum
Seatbelt contusion
(1) Falls onto the head or shoulder press the ribs
Haematoma
forwards and upward and the range of motion Deformity
increases from the first to the seventh pair of ribs. Dyspnoea
(2) The clavicle may sometimes act as a lever
Palpation
to help to wrench the manubrium from the Ventral chest compression tenderness
body of the sternum. This is especially relevant Sternal step
in fall onto extended arms. Crepitance
(3) At the time of injury an acute increase in intra
thoracic pressure impacts on the thoracic wall
(4) The second costal cartilage acts as a wedge,
tending to separate the manubrium from the
body of the sternum. that injury from indirect violence was usually
due to flexion compression or flexion-rotation of
Dislocations of the manubriosternal joints can be the thorax, resulting in a combined injury to the
related to cervico-thoracic injuries. Fowler (1957) vertebral column and sternum. Berg (1993). has
postulated that the ribs were instrumental in postulated a ‘fourth column’ to the spine repre-
transmitting force from the spine to the sternum sented by the sternum and ribs providing an
while the clavicle and chin played only a smaller important adjunctive stabilisation function in the
part. Gopalakrishman and el Masri (1986) reported thoracic region and axial skeleton.

Trauma 2009; 11: 77–92


Watkins et al. (2005), in a cadaveric biomecha-
nical flexion-compression study showed that in
indirect flexion-compression injuries the stability
of the thoracic spine is decreased by 42% in flexion/
extension, 22% in lateral bending and 15% in axial
rotation. These theories explain why an indirect
force resulting in compression produces forward
buckling of the sternum and the resulting displace-
ment of the upper fragment is behind the lower.
(Figure 3), opposite to what is seen following a
direct injury to the lower part of the sternum.
Muscular action
Herbert and De Tarnowsky (1905) reported frac-
tures secondary to severe muscular action or
retraction of the sternum in non contact sports
such as gymnastics, following strenuous exercises
and lifting heavy weights. Other causes include
forcible extension of the vertebral column during
labour, tetanus (Robertson, 1955) and epilepsy
(Dastgeer and Mikolich, 1987).
The xiphisternum can be fractured as a result of
the powerful action of the anterior abdominal
muscles producing a large hollow at the end of the
sternum due to its forward projection.
The clinical presentation of indirect violence is
essentially similar to that described above.
However, compression type sternal fractures may
be associated with spinal fracture at any level
possibly resulting in incomplete or complete neuro-
logical deficit. Gopalarkrishnan and el Masri (1986)
reported complete paraplegia in 10 out of 12 of
patients with combined sternal and spinal fractures.
This is a similar picture to that reported by
Vioreano et al. (2005), who found positive neurol-
ogy in 8 out of 10 patients (complete 4, incomplete 3,
central cord syndrome 1).
Fatigue sternal fractures
Fatigue sternal fractures have been reported in
wrestlers (Gregory et al., 2002), golfers (Barbaix,
1996), body building exercises (Robertsen, 1996)
and athletes (Hill et al., 1997) in whom normal bony
architecture is exposed to repeated abnormal
stresses. Due to continuous or repeated trauma to
the same site, osteoclastic activity exceeds osteo-
blastic activity resulting in trabecular micro-
fractures, eventually leading to small cortical
fractures, termed stress fractures. If trauma persists,
Sternal fractures 83
a complete fracture can result. With fatigue
fractures the patient presents with sudden severe
sharp anterior chest pain whilst exercising or
playing sport. This pain may mimic myocardial
infarction or pulmonary embolism (Schapira et al.,
1995). A careful history, thoracic clinical examina-
tion and appropriate investigations will give the
correct diagnosis.
Insufficiency fractures
Insufficiency fractures occur in weakened bones
unable to withstand the stresses of normal daily
activities or occur after minimal trauma, for
example in osteoporotic patients, post menopausal
women, patients taking steroids and other condi-
tions predisposing to osteoporosis. In the presence
of a thoracic kyphosis normal flexion and extension
of the spine can produce insufficiency fractures of
the sternum (Fowler, 1937; Horikawa et al., 2007;
Latzin et al., 2005, Robertson, 1955). The majority
of insufficiency fractures occur in the body of the
sternum, very few in the manubrium. Clinically
these fractures can be silent or cause spontaneous
and sometimes severe anterior chest pain.
Pathological fractures of the sternum
Pathological fractures are fractures occurring in
a bone weakened by pre-existing disease,
commonly metastatic disease. A necropsy study
by Urovitz et al. (1977) reviewing 415 cases of
malignant neoplasm recorded 63 patients with
sternal metastasis and 19 with fractures, an inci-
dence of sternal metastasis in malignancy of 15.1%
and of sternal fractures in the presence of sternal
malignancy of 30.2%. Pathological fractures fre-
quently display no healing, slow healing and
deformity. Ninty-five percent of metastasis were in
the body of the sternum with the commonest being
breast, lymphoma and myeloma in decreasing order
of frequency. Interestingly a previous survey pub-
lished by Kinsella et al. (1947) reported metastatic
thyroid, kidney and breast malignancy being the
most common, affecting the manubrium.
Spinal fractures and sternal fractures
Proper assessment of patients sustaining sternal
fractures requires awareness of associated injuries
Trauma 2009; 11: 77–92
84 R Raghunathan and K Porter

and a high index of suspicion (Jones et al., 1989;
Scher, 1983). Vioreanu et al. (2005) reported an
incidence of spinal fractures associated with sternal
fractures of 9.2%, the majority being upper thoracic
fractures, rib fractures and sternal fractures.
There is a clear association of neurological
trauma with combined injury patterns including
paraplegia (Jones, 1998; Athanassiadi et al., 2002;
Vioreanu et al., 2005). The majority of sternal
fractures with associated spinal injuries involve the
manubrosternum junction. There is a high level of
association between manubriosternum dissociation
and spinal injuries. The spinal injury may be silent
(Park et al., 1980)
Sternal fractures in children
Sternal fractures in children are uncommon because
the increased pliability and elasticity of the child’s
chest wall reduces susceptibility to fractures.
Childhood sternal fractures are generally thought
to be the hallmark of severe trauma. Surprisingly a
review of the literature (Table 3) reveals a similar
pattern to that of adult trauma with both direct and
indirect mechanisms of injury. Common causes
include falls from bicycles, trampolining accidents
and simple falls.
The absence of road traffic collision victims may
suggest bias resulting from the fact that some
childhood non-survivors may have had sternal
fractures. Combined thoracic spinal fractures and
sternal fractures have been reported in children
(De friend and Franklin, 2001). In addition the
diagnosis may be difficult to make on conventional
X-rays, particularly in undisplaced trans syn-
chondral fractures (Larson and Fischer, 2003).
In children with a good history and local tenderness
the likely diagnosis is a sternal fracture.
Associated and concomitant injuries
A key criterion in deciding to admit a patient with
a sternal fracture is the management of associated
and concomitant injuries. Concomitant injuries,
as part of a polytrauma scenario frequently include
head injuries and limb injuries. Associated injuries
include chest wall bruising and fractures, spinal
injuries and lung injuries (Hills et al., 1993;
Vioreanu et al., 2005; Knobloch et al., 2006). Roy
Shapira et al. (1994) and Juan et al. (2002) have
reported a small number of cases where sternal
fractures are associated with cardiac tamponade.

Table 3 Paediatric fracture

Number of
paediatric Mechanism
Year Author fractures of injury Outcome
2003 Kusaba et al. 1 Direct injury Open reduction, plate and screw fixation
performed due to instability
2003 Ferguson et al. 12 Direct and indirect No rib fractures. No spinal fractures.
One patient with displacement needed
operation due to instability
2002 Hechter et al. 12 Not highly specific for abusive injuries
2001 DeFriend and Franklin. 2 Fall from swing One patient had associated flexion-compression
thoracic spine injury
1996 Pérez-Martinez 1 Plying in jumping-bed Flexion-compression injury. Uneventful outcome
1994 Korovessis et al. 1 Spontaneous fracture Kyphoscoliosis and sternal fracture managed with
modification of brace. Uneventful healing
1983 Pérez Jr et al. 1 Conservative treatment.
1981 Jaschke 1 Insignificant trauma Conservative treatment resulted in quick recovery
1979 Chi 3 Chinese article
1979 Klaber 1 German article
1970 Schulte 1 German article
1970 Rajić et al. 1 Serbian article
Total 37

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Displaced sternal fractures may be associated
with pulmonary injuries, pericardial effusions,
spinal fractures and rib fractures (Von Garrel
et al., 2004).
Complications
Complications following sternal fractures are not
uncommon, but can range from non-serious to life-
threatening, and also be chronic and debilitating.
The duration of chest pain post-injury ranged
from 2 to 28 weeks with a mean duration of 8 to
12 weeks for all age groups. The pain range is more
pronounced in older patients (De Oliveria et al.,
1998). Malunion with visible deformity will not
need surgery unless painful and cosmetically
unsightly (Holderman, 1928). Brookes et al. (1993)
in a study of 272 patients with sternal fractures,
reported the incidence of cardiac complication,
mainly arrhythmias, to be 5.2%. Roy Shapira
et al. (1994) reported a 21% incidence of myocardial
contusion based on the admission ECG in 28
patients following which two patients died.
Knobloch et al. (2006) reported the incidence of
cardiac contusion to be between 2.5% and 6.2%.
Clearly, detection depends on appropriate investi-
gations. Respiratory complications occur secondary
to associated injuries including rib fractures, pneu-
mothoraces, flail chest, lung contusion and dorsal
vertebral fractures (Holderman, 1928; Carey et al.,
1988; Knobloch et al., 2006) where chest infection is
the most common problem.
Rarer complications include non-union where
persistent features of pain, tenderness and clicking
raise awareness (Holderman, 1928; Mayba, 1986;
Wu et al., 2004; Gallo et al., 2006; Grosse et al.,
2007). Surgery if indicated should include bone
grafting and internal fixation (Mayba, 1986;
Hendrickson et al., 1996; Bertin et al., 2002; Wu
et al., 2004; Gallo et al., 2006). Sternal dislocation
can follow both direct and indirect injuries. Brookes
et al. (1993) reported an incidence of 11.8% in 272
sternal fractures, similar to that of 8.5% in 200
fractures reported by Von Garrel et al. (2004).
There is a significant association between complete
displacement of sternal fractures and pulmonary
injuries, multiple rib fractures, pericardial effusion
and spinal fractures. Treatment of dislocation is
symptomatic but may require surgery. Rare
Sternal fractures 85
complications include osteomyelitis (Robinson
et al., 1993), sternal abscess and mediastinitis
(Rehring et al., 1999; Cuschieri et al., 1999;
Velissaris et al., 2002; Randell and Somers, 2006).
Sternal osteomyelitis complicating CPR has been
recorded (Enat et al., 1979; Mensah et al., 1988;
Mallinson et al., 1999). Cuschieri et al. (1999)
identified the risk factors associated with post-
traumatic mediastinal abscess to be a triad of the
presence of haematoma, intravenous drug use and
a source of staphylococcal infection. Randell
and Somers (2006) extended the list of risk factors
to include immunocompromised patients such as
those who are HIV positive. Early diagnosis,
surgical debridement and antibiotic therapy are
vital to achieve a successful outcome (Mallinson
et al., 1999; Randell and Someys, 2006). Loss of
thoracic stability in sternal fractures was reported
particularly in association with rib fractures (Karev,
1997; Vodicka et al., 2007) and or spinal fractures
(Vioreanu et al., 2005). Aortic injury was not found
to be associated with sternal fractures ( Sturm et al.,
1989).
Investigations
The gold standard investigation in a suspected case
of sternal fracture is a lateral chest X-ray, as the
fracture and any displacement or dislocation
commonly occurs in the sagittal plane (Purkiss
and Graham, 1993; Hendrich et al., 1995; Huggett
and Rozzles, 1998; Sarquis et al., 2003; Von Garrel,
2004) (Table 4). The presence of a widened
mediastinum (Table 5) on a chest X-ray anteropos-
terior view in a patient with a fractured sternum
may be due to many reasons and warrants further
investigation usually by multislice spiral CT (Saab
et al., 1997; Geusens et al., 2005).
An ECG at the time of fracture diagnosis is
essential in order to diagnose cardiac arrhythmias
(Brookes et al., 1993; Roy Shapira et al., 1994) and
also for monitoring purposes. An ECG by itself is
not diagnostic and may not predict cardiac
arrhythmias that require treatment (Brookes et al.,
1993). Despite it’s limitation ECG is recommended
at the time of clinical presentation (Johnson and
Branfoot, 1993; Hills et al., 1993; Heyes and
Vincent, 1993; illig et al., 1991) in conjunction
with a lateral chest X-ray and vital signs.
Trauma 2009; 11: 77–92
86 R Raghunathan and K Porter
Table 4 Investigations in sternal injuries
Chest lateral X-ray
Chest X-ray AP view
12 lead ECG
ECHO
CT-scan of chest
US sternum
Blood tests such as cardiac enzyme measurements
(AST, CK, LDH)
Bone scan
Table 5 Causes of widened mediastinum (Saab et al.)
 Sternal fracture
 Thoracic spine fracture
 Mediastinal haematoma of any cause
 Aortic rupture
 Cardiac injuries such as pericardial effusion
 Tracheo-bronchial injuries
 other vessel injuries of the chest
 X-ray taken in the supine position
Ultrasonography is ideal for the emergency
department and intensive care unit. Mahlfeld et al.
(2001) reports sonography to be as good as radio-
graphy in diagnosing sternal fractures, though Jin
(2006) reported that sonography performed better
than radiography. In addition bone scintigraphy is
superior diagnostically and will recognise fractures
missed in the plain radiographs. (Erhan et al., 2001).
Moreover, sonography is better than radiography
in detecting rib fractures and pleural effusions
(Bitschnau et al., 1997; Wüstner et al., 2005).
The downside to sonography is that it cannot
identify the degree of displacement information,
which is required for management (Hendrich et al.,
1995; Engin et al., 2000).
Interestingly, Huggett and Rozzles (1998) report
axial CT to be inferior to radiography for sternal
fracture diagnosis, possibly because CT cuts
may miss transverse sternal fractures. An ECHO
of the heart has been recommended by Wiener et al.
Trauma 2009; 11: 77–92
Gold standard test for sternal fractures, also shows thoracic spine
Look for widened mediastinum, haemothorax, pneumothorax,
rib fractures, clavicle fracture, raised hemidiaphragm, air under
the diaphragm
Can detect arrhythmias
May be indicated when sternal injuries are associated with other
injuries (Wiener et al., 2001)
Mainly to rule out associated injuries
Can detect sternal fractures more frequently than X-ray. But,
it will not show the displacement. (Engin et al., 2000)
May be unnecessary, as it will not predict the clinical outcome of the
patient and may unnecessarily prolong the admission period.
(Wedde et al., 2007)
Can be useful in contact and noncontact sports related injuries
(Jin et al., Sarquis et al.)
(2001) for patients with sternal fractures and other
associated injuries.
Treatment
The treatment of isolated sternal fractures is mainly
non-operative (Carey et al., 1988; Jones, 1998;
Metaxas et al., 2006; Popovici and Goia, 2007;
Jackson and Walker, 1992) with good outcomes
associated with low morbidity and mortality
(Brookes et al., 1993; Potaris et al., 2002). Many
patients can be discharged home provided they are
not dyspnoeic (Roy Shapira et al., 1994) their ECG
is normal (Wright, 1993; Hills et al., 1993; Roy
Shapira et al., 1994; Höcker and Renner, 1994, Peek
and Firmin, 1995) they are haemodynamically
stable (Roy Shapira et al., 1994, Chiu et al., 1997)
have no associated injuries (Hills et al., 1993; Roy
Shapira et al., 1994) and no underlying pre-existing
chest pathology or chest injury (Johnson and
Branfoot, 1993). All patients require adequate
analgesia and good home support (Table 6).
Patients with suspected sternal injuries should be
assessed and managed by following 5C4ABCDE
guidelines. The clinician should obtain a careful
history of the mechanism of injury and any
comorbidity and must look for vital signs, asso-
ciated and concomitant injuries and treat them
accordingly (Figure 7).
Sternal fracture pain may be difficult to control,
particularly in the elderly and patients with

Table 6 Check list before discharging the patient to home
with sternal fracture
(1) Patient fully conscious and oriented
(2) No dyspnoea
(3) No serious underlying comorbidity
(4) No associated injuries
(5) Vital signs are stable
(6) ECG normal
(7) Chest X-ray is normal without rib injury, pulmonary injury,
widened mediastinum
(8) Fracture is not completely displaced or severely deformed
(9) Somebody to look after the patient at home
(10) Pain controlled and take home advice slip given
regarding chest injuries or told about breathing exercised
and outpatient appointment given
comorbidity in whom anti-inflammatories (bleeding
peptic ulcer) or opiates (increased sedation) may
produce harmful effects. An alternative and novel
technique involving direct local infiltration of local
anaesthesia into the fracture site may have a role
(Inweregbu and Blackburn, 2000; Duncan et al.,
2002; Appelboam et al., 2006) Using a standard
epidural catheter set and under aseptic precautions
the catheter is inserted into the fracture site. 10 to
20 mls of 0.5% levobupivacaine is injected followed
by 10 mls every 4–6 h. Duration of catheter use
between 2 and 14 days has been recorded without
complications. However beyond 14 days, infections
are recorded (Duncan et al., 2002). Effective pain
control and satisfactory results were recorded.
Historically the approach of closed reduction of
dislocation was a challenging one. De Tarnowsky in
1905, described a technique in which the patient was
placed in a supine position with the angle of the
scapula resting over the end of the operating table.
With an assistant fixing the legs to produce counter
traction. The spine was strongly extended by
traction downwards applied to the chin and occiput.
Simultaneously the arms are brought up and
outwards and the patient was directed to cough
which was usually sufficient for the reduction to
take place. The reduction was maintained with a
pad over the lower fragment with a figure of eight
bandage applied to keep the shoulders pulled
backwards.
Nowadays in the acute setting, operative fixation
is recommended if the fracture is displaced,
Sternal fractures 87
unstable, causing severe pain or associated with
flail chest jeopardising pulmonary or cardiac
function. In chronic cases operation may be
recommended for persistent pain, non-union and
cosmetically unacceptable appearance for the
patient (Carey et al., 1988). Richardson (1975 and
2007) reported excellent reduction in pain and
improved pulmonary function post-fixation. Many
authors however do not advocate operative fixation
unless there are clear indications to do so. (Kitchens
and Richardson, 1993; Hendrickson et al., 1996,
Karev, 1997; Wu et al., 2005; Gallo et al., 2006;
Popovici and Goia, 2007; Vodicka et al., 2007).
Sternal fixation can be effectively undertaken using
sternal wires (Gibson et al., 1962) or formal
osteosynthesis using plate and screws (Kitchens
and Richardson, 1993; Hendrickson et al., 1996;
Sommer, 2005, Wu et al., 2005).
Conclusion
Sternal fractures are not uncommon injuries. The
mechanism of injury includes direct force, for
example motor vehicle collisions, and indirect
force, for example muscular pull injuries and
flexion – compression injuries (Spine and sternum)
as well as insufficiency and pathological fractures.
The commonest site is the body of the sternum and
most are transverse. Common presenting features
include chest pain, aggravated by inspiration and
coughing, dyspnoea, bruising to the anterior chest
wall, sternal tenderness with or without deformity
and a characteristic sitting attitude. Unusual pre-
sentations often mimic myocardial infarction and
pulmonary embolism. Assessment should follow
standard 5C4 ABCDE protocols which will also
identify associated and concomitant injuries such
as rib fractures, spinal fractures, pulmonary and
cardiac injuries, head injuries, chest injury, abdom-
inal injury and limb trauma. Completely displaced
fractures may have associated rib or pulmonary or
cardiac injuries or spine injuries. Vital signs, chest
x-ray for mediastinal widening, lateral radiograph
of the chest to include sternum and the thoracic
spine and an ECG are recommended as the
minimum investigations for suspected isolated
sternal fracture. Complications include persistent
pain, non-union, malunion, loss of thoracic stability
and rarely osteomyelitis. Unstable or completely
Trauma 2009; 11: 77–92
88 R Raghunathan and K Porter

Patients suspected to have sternal injuries from

history and / or examination

ATLS protocol should be followed

Lateral radiograph of the chest is the gold

standard test for sternal injuries

Associated injuries / concomiant injuries

Unstable vital signs
Widened mediastinum; ECG abnormal

Yes No

Admitand stabilise
• Admit and thestabilise
patient the patient • Completely displaced
• CT scan of chest to evaluate the • Sternal fracture
associated injuries in detail
• Identify and treat the associated
injuries
No

Yes

Intolerable pain even after giving analgesia

Yes No

Admit for pain control • Discharge to home

• Chest injury / rib injury advise sheet
• Sufficient oral analgesics
(anti-inflammatories, opiate
groups - make sure there are no
contrindications) review in fracture
clinic

Figure 7 Management

Trauma 2009; 11: 77–92


displaced sternal fractures are associated with a risk
of life threatening chest injuries, spinal injuries and
internal mammary vessel ruptures. The treatment
for isolated sternal fracture is rest and pain control.
Acute operative indications include unstable inju-
ries, displaced fractures, uncontrollable pain and
associated injuries complicating pulmonary or
cardiac function. Chronic indications for operative
fixation include persistent pain, non-union and
cosmesis (malunion and deformity). Surgical
options include wiring and plate and screws.
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