Asian Cardiovasc Thorac Ann 2006;14:399-401
© 2006 Asia Publishing EXchange Ltd
Operative Treatment of Sternal Fractures
Abdullah Al-Qudah, MD
Section of Cardio-Thoracic and Vascular Surgery, Department of General Surgery, Jordan University Hospital and Faculty of Medicine, Amman, Jordan
For reprint information contact: Abdullah Al-Qudah, MD Tel: 962 6 515 0669 Fax: 962 6 515 0669 Email: al_qudah_as{at}hotmail.com, Section of Cardio-Thoracic and Vascular Surgery, Jordan University Hospital, PO Box 13255 Amman 11942, Jordan.
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ABSTRACT
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Four patients with displaced sternal fractures complained of intractable pain following road traffic accidents. They all had bone deformities, but only one had associated traumatic injuries. All patients underwent operative reduction and fixation of the fractured sternum using a T-shaped compression-tension stainless steel plate and screws. Pain relief was often dramatic and all patients progressed to sternal union. None required reoperation. No infections occurred. Two plates have subsequently been removed. On follow-up, all patients had excellent results. Sternal plating, which is based on the tension-band principle, is an effective treatment for displaced sternal fractures.
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INTRODUCTION
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Fractures of the sternum are relatively uncommon. They account for less than 0.5% of fractures and occur in 8% to 10% of patients with major blunt chest trauma.1–4 Sternal fractures are caused primarily by anterior blunt chest trauma, usually from automobile accidents when the chest strikes the steering wheel. Despite the diagnostic lateral sternal radiographic view, sternal fractures are frequently missed radiographically because a lateral plain chest radiograph is not usually obtained during the initial trauma evaluation. Chest computed tomography is also useful to establish the diagnosis, but horizontally oriented and minimally displaced fractures may be overlooked. However, it is often difficult to prove radiographically that a sternal fracture exists because superimposition of the underlying structures masks the sternum on most radiographic projections. Therefore, the initial radiographs are often reported to be normal. In addition, the rib cage and sternum may have been deformed at the level of the fracture at the time of the accident, but then returned to the normal anatomical position immediately, so that no deformity is obvious. Nevertheless, there will be localized pain and tenderness on clinical examination, and later serial radiographs will show new bone formation at the fracture site. The concern with a sternal fracture is not the fracture itself but the possibility of associated injuries such as myocardial contusion, cardiac rupture, tamponade, pulmonary injury, and spinal fracture. Also, sternal fractures are sometimes so unstable that flail chest, intractable pain, or a compound fracture may result. We report herein our experience with open reduction and fixation of displaced sternal fractures.
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PATIENTS AND METHODS
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From 1999 to 2005, 4 consecutive patients with displaced sternal fractures were treated at our thoracic surgical unit. All complained of severe pain. The patients were all men ranging in age from 24 to 45 years, with a mean age of 31.3 years. The presenting signs and symptoms as well as associated injuries are listed in Table 1
. Preoperative evaluation included a workup to rule out myocardial contusion and intrathoracic injuries. A plain radiograph and computed tomogram of the chest were obtained. Spiral computed tomography, which provides detailed information regarding sternal anatomy including the number and size of bone fragments, was carried out in two patients. The indications for surgery were severe deformity with dislocation and overlapping sternal edges (2 patients) and intractable pain that limited respiratory excursion with predictable difficulty of weaning from the ventilator (2 patients).
The procedure was performed under general anesthesia. Intravenous antibiotics were given at induction. The incision was transverse in two patients and longitudinal in two. Either incision can be used but the latter is more cosmetic. The sternal edges were reduced and brought close together. Any interposed soft tissue was excised. It is not necessary to expose the entire sternum or to enter the anterior mediastinum. After open reduction, T-shaped stainless steel plates (Mathys Medical Ltd, Bettlach, Switzerland) were used in all cases (Figure 1). This kind of plate has compression, tension, and anti-bending mechanisms that all contribute to interfragmental compression and faster bone healing due to primary bone formation. The final result is a controlled tension sternal osteosynthesis. The plate was selected according to the sternal width and depth as determined by 3-dimensional computed tomography and intraoperative measurements. A closed suction drain was placed and brought out through a separate incision. The incision was closed in three layers. As the low profile of the plates allows coverage with skin and subcutaneous tissue, a muscle flap is not necessary unless there is soft tissue loss. All patients were extubated in the operating room at the end of the procedure. A chest radiograph was obtained postoperatively to rule out hemothorax and/or pneumothorax. The patients were mobilized on the first postoperative day. Antibiotics were discontinued upon removal of the drain. Pre- and postoperative chest radiographs are shown in Figures 2 and 3.
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Figure 3. Postoperative chest radiograph in lateral view showing good alignment of the fractured sternal edges with the stainless steel T-shaped plate.
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RESULTS
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Following surgery, the sternum was stable in all cases after plating. All patients improved after the operation; pain relief was often dramatic. No patient required reoperation, and all progressed to sternal union. No infections occurred. The operations were uneventful and the postoperative courses were unremarkable. The associated chest injuries found included rib fractures, hemothorax, and pneumothorax. No patient was found to have midline thoracic trauma, such as cardiac, aortic, or thoracic spinal injury. The mean length of hospital stay was 8 days. Two plates have subsequently been removed. On follow-up, all patients had excellent results and have resumed normal activities.
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DISCUSSION
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Surgical fixation of the sternum has received very little attention in the past. If unrecognized in the early post-trauma period, displaced sternal fractures may result in pseudoarthrosis, ventilatory difficulties, or anterior chest wall deformity.5 Pseudoarthrosis is frequently associated with substantial pain, which can be limiting for the patient. In addition, late correction of an anterior chest wall deformity may also be regarded as a challenging problem from the surgical point of view. Among the techniques suggested for closure of displaced sternal fractures are hyperextension of the thoracic spine, figure-of-eight periosteal wiring or suturing, and internal fixation using plates.1,5–8
Hyperextension as a conservative type of treatment for displaced sternal fractures might be achieved by hyperextension of the dorsal spine. Adequate hyperextension may be accomplished by having the patient lie supine with a pillow under the thoracic vertebrae. Occasionally, however, closed reduction is not obtained, and open reduction and fixation may be indicated. Furthermore, the figure-of-eight techniques using stainless steel wires or sutures are blind methods and do not produce a rigid fixation such as can be achieved with open reduction and internal fixation. In 1972, Kurzweg and colleagues9 used Steinmann pins to fix a multifragmented sternum. The ends were buried under the skin. A modification of this technique was also used by Molina10 in 2005. In 1993 and 2004, Kitchens11 and Bonney12 respectively used a T-shaped compression plate in the treatment of displaced sternal fracture in their patients.
None of the previously reported therapeutic modalities apply the tension and compression mechanism. The sternal bone has one cortex that is subjected to tension on the convex side, while the concave side is under compression. Fixation of the fractures in such bones requires resistance to both bending and compression stresses. Tension plates are placed on the convex surface of the fractured bone, away from the load axis. As the load increases, the plate comes under tension, and the far cortex is dynamically compressed. Thus the plate itself resists the bending stresses, and the bone resists the compressive forces. Sternal plating provides a stable, well-approximated closure that allows healing to occur. An additional advantage to sternal plating is that minimal dissection of the soft tissues of the mediastinum is necessary, thereby lowering the risk of injury to vital structures or compromising the collateral blood supply of the sternum.
Sternal fractures generally have a benign nature and require no specific treatment. In addition, such patients do not usually have severe associated thoracic injuries. Therefore, the management of patients with sternal fracture should be directed to the treatment of associated injuries. Surgery is generally not indicated except for cosmetic reasons, difficultly in extubation due to an unstable flail chest, intractable pain, or compound sternal fracture. Once surgery is indicated, a T-shaped plate with a compression-tension mechanism constitutes the treatment of choice for displaced sternal fractures. It produces satisfactory results with stable alignment of the fracture, and does not need extensive dissection of mediastinal soft tissue, which aims to preserve the blood supply to the already damaged sternum.
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REFERENCES
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