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ORIGINAL CONTRIBUTIONS |
| Department of Thoracic Surgery District General Hospital of Attica "KAT" Kifissia, Greece |
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| Konstantinos Potaris, MD Tel: 30 10 628 0731 Fax: 30 10 326 5162 email: konstantinospotaris{at}yahoo.com Department of Thoracic Surgery, District General Hospital of Attica "KAT", 2 Nikis Street, Kifissia 14561, Greece. |
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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On the contrary, more recent studies not only question the necessity of such management, but also differentiate between the mechanisms of this injury. Moreover, an increased incidence of SF has been linked to the implementation of seat belt legislation in Europe. The introduction of new guidelines in the management of SF has resulted in a drastic change in the treatment of patients who sustain this injury.5–7
We reviewed the experience of the busiest trauma center in our country in the management of SF as regards the incidence, mechanism of injury, significance, and associated morbidity and mortality.
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PATIENTS AND METHODS |
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TOPABSTRACTINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Acute ischemic changes, arrhythmias, and atrioventricular conduction defects are considered specific for myocardial contusion ECG changes. Also considered specific for myocardial contusion is the elevation of the CPK-MB fraction to 5% of total creatine phosphokinase level. Elevation to < 5% of total creatine phosphokinase level is considered nonspecific.
Continuous variables were compared by the use of unpaired Student':s t test, while categorical variables were assessed using the chi-squared test. Differences are considered significant if p < 0.05.
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RESULTS |
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TOPABSTRACTINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Prevalent signs and symptoms included chest pain and tenderness in 196 patients (82%), shortness of breath in 36 (15%), hypovolemic shock in 5 (2%), and arrhythmias in 2 (1%). Sternal and any associated fractures were confirmed by means of specific radiography (e.g., lateral radiographs of the sternum, chest radiograph) and computed tomography according to clinical indications, such as hemothorax, lung contusion, and mediastinal enlargement.
The location of the fracture on the sternum is documented in Table 1
. The degree of displacement of SF was classified into three categories in relation to the anteroposterior thickness of the sternum and is shown in Table 2.
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shows that 90% of the patients sustained SF from road accidents, 95% of whom in motorcars and all were front seat occupants. Of the 116 male motorcar occupants, 98 (84%) were drivers compared to 28 of the 88 female occupants (32%). Only 31% of the motorcar occupants reported that they were restrained, despite the introduction of seat belt legislation in our country in 1985. The percentages of men and women who were restrained were 24% and 41%, respectively. The difference, analyzed by the chi-squared test, was significant (p = 0.01).
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The mean hospital stay of the remaining 225 patients was 6.7 days (range, 1 to 62 days). Excluding 13 patients who were admitted to the intensive care unit (ICU), the mean hospital stay of the 212 patients remaining in the ward was 6.4 days (range, 1 to 32 days). Extended hospitali-zation was needed in some patients to treat concomitant injuries. The mean injury severity score of these 212 patients was 5.8 (range, 4 to 25). The score of the 13 ICU patients ranged from 4 to 42 with a mean of 14.5. Their mean hospital stay was 13.7 days (range, 1 to 62 days). Using the t test to compare the ward and ICU groups, the severity scores were significantly different (p = 0.02), while the lengths of hospital stay were not.
In 18 of the 212 patients (8.5%) who remained in the ward, nonspecific ECG changes (slight ST elevation, occasional T wave inversion, premature atrial beats, and right bundle branch block) were observed. ECG and CE measurements were taken in these patients every 6 hours in the first 24 hours. In 12 of these 18 patients, there was also nonspecific elevation of CE, while in the rest CE levels were normal. Cardiological evaluation and echocardiography of these 12 patients were unrevealing. In all of them, ECG and CE abnormalities resolved without further incident. ECG and CE measurements were taken in the remaining 194 patients upon admission and in the ensuing 6 hours. As the results were normal, cardiological evaluation was not undertaken.
The 13 ICU patients underwent continuous ECG monitoring and serial CE measurements. Blunt cardiac injury was diagnosed in 6 of them, who had specific ECG and CPK-MB changes. Two-dimensional echocardi-ography and Swan-Ganz measurements produced results that were consistent with myocardial injury. Besides blunt cardiac injury, pump failure was also found in 2 patients and arrhythmia (ventricular tachycardia) in 1, while the remaining 3 patients showed no evident clinical signs or symptoms. Echocardiography revealed myocardial wall dyskinesia in both patients with pump failure and a mild pericardial effusion without myocardial wall dyskinesia in 1 of the 3 patients with no clinical signs or symptoms.
Isolated SF were sustained by 112 patients (47%), of whom 61 were men and 51 women. Their mean age was 48.6 years (range, 17 to 83 years). Their hospital stay ranged from 2 to 15 days with a mean of 4.7 days. The lengths of hospitalization of patients with isolated SF and those with SF and associated injuries admitted to the ward (mean, 8.4 days; range, 1 to 32 days) were not significantly different. Admissions were justified for pain control and for social reasons (e.g., elderly patients living alone whose compliance with medication regimens was doubtful).
It is interesting to note that 3 patients with isolated SF developed complications and 1 of them died. Two of them sustained blunt cardiac injury and had abnormal CE and ECG results. Patient 1 developed premature ventricular beats and episodes of ventricular tachycardia. Patient 2 initially developed supraventricular tachycardia and later acute ST elevations in the anterior leads. They were both monitored in the ICU and were treated conservatively. Their ECG and CE levels returned to normal before discharge. Patient 3 was an 88-year-old man with chronic obstructive pulmonary disease. He progressively became confused, short of breath, and hypoxemic. He was intubated but never regained strength to be weaned off. He died of adult respiratory distress syndrome 2 months later in the ICU.
Concomitant injuries were sustained by 127 patients (53%). They are summarized in Table 4. Head and abdominal injuries were minor. Multiple rib fractures caused flail chest in 4 patients, 2 of whom developed respiratory distress and required management in the ICU. Rib fractures also contributed to longer hospitalization of patients with concomitant injuries compared to those with isolated SF, so did pulmonary contusion associated with multiple rib fractures. Only 1 patient with pneumothorax and hemothorax needed emergency surgery, while the others required chest tubes only. The right subclavian artery was lacerated in a patient who sustained SF and a 2nd right rib fracture.
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Complications developed in 13 patients, who had to be admitted to the ICU. They accounted for a morbidity rate of 5.4% and included flail chest in 4 patients, respiratory failure in 3, and blunt cardiac injury in 6 as noted earlier. Ten of these patients sustained multiple injuries, while 3 had isolated SF.
There were 2 deaths, one of cardiogenic shock and another of respiratory failure, accounting for a mortality rate of 0.8%. The former was a severely injured patient with multiple rib fractures and head and abdominal injuries. He was resuscitated with blood and fluids and transferred to the ICU. He had ST elevations in the anterior leads and abnormal CE levels and was hypotensive. A traumatic aortic rupture was also suspected, but he was unstable for aortography. The latter was the elderly patient with chronic obstructive pulmonary disease noted earlier.
Four patients (1.7%) underwent surgery. There were urgent surgical indications for all of them. No patients needed operation for cosmetic reasons. Indications included retrosternal hematoma and tamponade, left hemothorax and right pneumothorax, laceration of the subclavian artery, and complicated SF. Surgical procedures included ligation of the bleeding internal mammary artery and drainage of hematoma and blood from the pericardial sac; ligation of the bleeding intercostal artery and drainage of hemothorax; repair of the lacerated subclavian artery with an innominate axillary polytetrafluoroethylene graft; and debridement of devitalized tissues and reapproximation of the fractured sternum. In all these patients, the fractured sternum was reapproximated with stainless steel wires. The patient with retrosternal hematoma was put on heart failure medications and postoperatively developed ECG and CE abnormalities consistent with myocardial injury (included in the 5.4% morbidity). There were no other intraoperative or postoperative complications.
After a thorough clinical and laboratory evaluation and following treatment of any associated injuries, patients with SF were managed with pain relief medications, rest and progressive ambulation, and physical therapy. A combination of oral analgesics (acetaminophen and codeine) together with nonsteroidal antiinflammatory drugs was instituted as soon as possible to allow earlier discharge from the hospital. Patients were also instructed on how to get out of bed and to avoid heavy lifting and driving for one month.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Myocardial and great vessel injuries are classically associated with SF. The term myocardial contusion or concussion used to refer to myocardial injury has been replaced by the more accurate term of blunt cardiac injury, which can take specific descriptions to fit clinical and laboratory findings.9 The traditional procedure for patients with SF was admission for monitoring and serial measurements of CPK-MB as well as other more expensive tests regardless of the mechanism of injury and other associated injuries. However, recent studies have shown that SF sustained by car occupants in the absence of other injuries are benign. In such patients, who have no signs and symptoms of cardiac dysfunction and have normal ECG, CE levels, and chest radiographs, no further tests are justified.1,2,5,7 We believe clinical signs and symptoms should be the major determinants of whether to proceed with cardiological evaluation and further tests.
The literature contains equivocal evidence of the usefulness of ECG, CPK-MB measurements, echocardi-ography, and other tests in the detection of blunt cardiac injury. Heyes and Vincent noted two general trends for patients with SF: first, ECG, though not very specific, is sensitive in identifying potential problems; and second, CPK-MB measurements are noncontributory.1 Fabian and colleagues4 concluded that the CPK-MB level is the most reliable indicator of myocardial injury. Hills and co-workers3 argued that myocardial contusion should be routinely investigated by serial ECG, while CPK-MB measurements and echocardiography may contribute little. Peek and Firmin7 concluded that only ECG abnormalities or frank cardiogenic shock can accurately predict myocardial contusion, even after extensive thoracic injury; other investigations including cardiac isoenzymes and echocardiography are therefore valueless. We agree that serial measurements of CPK-MB and echocardiography are not justified in patients with isolated SF without signs and symptoms of heart dysfunction and who have a normal ECG and chest radiograph at admission. Hence, our protocol for isolated SF has changed lately; and we also allow these patients, if they feel comfortable on oral analgesics and are otherwise fit and well, to be discharged early or not to be admitted at all.
We assume that the low mortality rate (0.8%) in our survey was due to the minor head or abdominal injury sustained in our study population. We did not observe a high incidence of associated spine and great vessel injuries either, in contrast to other reports.2,3 On the contrary, blunt cardiac injury and multiple rib fractures were the most important factors of morbidity and mortality in our patients. The mortality rate of our patients was very close to those reported by Brookes and colleagues6 (0.7%) in 1993 and Gouldman and Miller2 (1.4%) in 1997. As these authors noted, the reported mortality in series before 1990 ranged from 4% to 24%. A lower mortality rate in recent series probably reflects a different mechanism and pattern of injury and different population groups being involved. Associated head or abdominal injury contributed to the high mortality rates in other reports. Although seat belt compliance of our patients was lower than those reported by the above studies, the incidence of isolated SF in our series (47%) was very close to those they reported (46% and 48.5%, respectively).
In conclusion, SF is a common injury in traffic accidents. Restrained front seat occupants, particularly older people and females, are most at risk. In the absence of significant associated injuries and symptoms of cardiac dysfunction, morbidity and mortality are low. In such circumstances, the injury can be considered benign, and continuous ECG monitoring, serial CPK-MB measurements, and further cardiological evaluation are not justified. However, associated injuries, particularly multiple rib fractures and blunt cardiac injury, can cause lifethreatening complications. Patients who sustain isolated SF with a normal ECG and chest radiograph and who otherwise look fit and well can be discharged early on oral analgesics.
Presented at the 32nd World Congress of the International College of Surgeons, Singapore, October 8–12, 2000.
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REFERENCES |
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TOPABSTRACTINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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This article has been cited by other articles:
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  R. Raghunathan and K. Porter Sternal fractures Trauma, April 1, 2009; 11(2): 77 - 92. [Abstract] [PDF]
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 A. Al-Qudah Operative Treatment of Sternal Fractures Asian Cardiovasc Thorac Ann, October 1, 2006; 14(5): 399 - 401. [Abstract] [Full Text] [PDF]
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