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AUTHOR AND EDITOR INFORMATION

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Author: David A Fisher, MD, Consulting Staff, Zwanger-Pesiri Radiology Group

David A Fisher is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, and Radiological Society of North America

Coauthor(s): David Gazzaniga, MD, Department of Orthopaedics and Sports Medicine, North Shore University Hospital; Stephen Lastig MD

Editors: Leon Lenchik, MD, Director, Densitometry Minifellowship, Assistant Professor, Department of Radiology, Wake Forest University Medical Center; Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand; Theodore E Keats, MD, Professor, Departments of Radiology and Orthopedics, University of Virginia School of Medicine; Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute; Felix S Chew, MD, EdM, MBA, Professor, Department of Radiology, Section Head of Musculoskeletal Radiology, Vice Chairman for Radiology Informatics, University of Washington

Author and Editor Disclosure

Synonyms and related keywords: breastbone, chest trauma, chest injury, sternal fractures

INTRODUCTION

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Background

Sternal fractures are often seen in association with deceleration injuries and/or direct blows to the chest, and they occur in approximately 3% of patients suffering blunt chest trauma.1 The introduction of seat-belt legislation has resulted in an increased frequency of these types of injuries.2

Most sternal fractures occur in the midbody, and they are typically transverse. Manubrial fractures are the next most common. Stress fractures are occasionally seen in athletes such as wrestlers, but they can also occur in women with osteoporosis and kyphotic thoracic spines.

Pathophysiology

Most sternal fractures are caused by blunt anterior chest trauma and have a risk of associated thoracic, mediastinal, or cardiac injury. Sternal fractures have also been reported in association with sports activities such as golf and weight lifting but are less frequently seen in association with cardiopulmonary resuscitation.3 

Frequency

United States

Motor vehicle accidents account for the vast majority of sternal fractures.

Mortality/Morbidity

An increased mortality rate has been reported with sternal fractures as a result of associated chest injuries, such as cardiac contusion, aortic rupture, pulmonary contusion, and thoracic spine compression fractures. However, more recent literature suggests an associated mortality rate of less than 1%.4, 5

Race

No racial predilection exists.

Sex

No definite sexual predilection exists.

Age

A large study from Greece showed that patients with sternum fractures have a mean age of 50.3 years (range, 15-93 y).5

Anatomy

The sternum has 3 parts: the manubrium, the body (corpus), and the xiphoid process (tip).

The manubrium lies at the level of the third (T3) and fourth thoracic (T4) vertebrae. Along the superior margin of the manubrium is the suprasternal or jugular notch. Both the clavicle and the first rib articulate with the manubrium, and the sternal head of the sternocleidomastoid muscle inserts onto this portion of the sternum.

The joint between the manubrium and the body, the manubriosternal joint, forms the sternal angle, which is at the level of the second rib. In older people, this joint tends to be fused.

The xiphoid process is cartilaginous in younger people and ossified in older people.

Clinical Details

Trauma patients presenting to a hospital with sternal fractures are usually admitted for monitoring for possible associated blunt cardiac injury. The monitoring usually entails serial determination of cardiac enzyme levels (creatine phosphokinase–MB [CPK-MB]) and electrocardiography (ECG).

Preferred Examination

The routine radiologic study of the sternum consists of a lateral projection and frontal views, which are obtained with the patient prone and rotated slightly off the midline in each direction. Normal anatomic variants, such as nonunited ossification centers, may sometimes cause a diagnostic dilemma.

Limitations of Techniques

Initially computed tomography (CT) scan studies were less sensitive than plain radiographs. However, the newer generation of multidetector-row CT (MDCT) scanning units now allow for multiplanar and 3-dimensional (3-D) reconstruction, which greatly improve accuracy.

CT scanning provides superior sensitivity and specificity but at greater cost and with increased radiation exposure.

Ultrasonography has been proven to be as accurate as radiography in diagnosing sternal fractures. However, lateral radiographs remain the standard means of demonstrating the grade of sternal displacement.


DIFFERENTIALS

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Aorta, Trauma

Other Problems to be Considered

Cardiac contusion
Pulmonary contusion


RADIOGRAPH

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Findings

The lateral radiograph is usually the most valuable view for detecting sternal fractures and for determining the degree of displacement.

Degree of Confidence

Almost all patients with sternal fractures complain of localized sternal pain. Therefore, correlation with the clinical presentation is important.

False Positives/Negatives

Nonunited ossification centers and failure of bony fusion of the sternomanubrial and sternoxiphoid articulations can simulate fractures; the angulation is variable at both of these sites.


CT SCAN

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Findings

CT scan studies were initially less sensitive than plain radiography. The newer generation of MDCT scanning units now allow for multiplanar and 3-D reconstruction, which greatly improve accuracy. CT scanning provides superior sensitivity and specificity but at a greater cost and with more radiation exposure.

CT scanning is particularly useful to assess patients with sternal fractures for associated injuries such as pulmonary contusion, pneumothorax, or retrosternal hematoma.


ULTRASOUND

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Findings

Ultrasonography is a useful way to demonstrate fractures of the sternum.

Degree of Confidence

The sensitivity of ultrasonography is comparable to that of plain radiography, but conventional radiography remains the standard means of documenting a sternal fracture.


NUCLEAR MEDICINE

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Findings

Nuclear bone scanning may be needed if the initial radiographic findings are not definitive.

Degree of Confidence

Total-body bone scans are sensitive for acute sternal trauma. However, the anatomic detail is limited, and correlation with the results of radiography or CT scanning is often necessary.


MULTIMEDIA

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Media file 1:  Lateral radiograph of the normal sternum.
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Media type:  X-RAY

Media file 2:  Frontal radiograph of the normal sternum.
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Media type:  X-RAY

Media file 3:  Posterior surface of the sternum.
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Media type:  Image

Media file 4:  Lateral border of the sternum.
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Media type:  Image

Media file 5:  Nuclear bone scan of fractures of the sternum (arrow) and of the ribs on the right side (arrowheads).
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Media type:  Image

Media file 6:  Lateral radiograph demonstrates complete dislocation at the sternal angle. (See Image 7.)
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Media type:  X-RAY

Media file 7:  Upright frontal radiograph in the same patient as in Image 6 shows mild widening of the superior mediastinum after blunt trauma to the chest (same patient as in Image 6).
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Media type:  X-RAY

Media file 8:  Supine frontal radiograph after significant blunt trauma to the anterior chest wall shows marked mediastinal widening. (See Image 9.)
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Media type:  X-RAY

Media file 9:  Lateral radiograph shows a complete displaced fracture of the sternum (arrow) (same patient as in Image 8).
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Media type:  X-RAY


REFERENCES

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  1. Brookes JG, Dunn RJ, Rogers IR. Sternal fractures: a retrospective analysis of 272 cases. J Trauma. Jul 1993;35(1):46-54. [Medline].
  2. Budd JS. Effect of seat belt legislation on the incidence of sternal fractures seen in the accident department. Br Med J (Clin Res Ed). Sep 21 1985;291(6498):785. [Medline]. [Full Text].
  3. Hashimoto Y, Moriya F, Furumiya J. Forensic aspects of complications resulting from cardiopulmonary resuscitation. Leg Med (Tokyo). Mar 2007;9(2):94-9. [Medline]. [Full Text].
  4. Bar I, Friedman T, Rudis E, Shargal Y, Friedman M, Elami A. Isolated sternal fracture--a benign condition?. Isr Med Assoc J. Feb 2003;5(2):105-6. [Medline].
  5. Potaris K, Gakidis J, Mihos P, Voutsinas V, Deligeorgis A, Petsinis V. Management of sternal fractures: 239 cases. Asian Cardiovasc Thorac Ann. Jun 2002;10(2):145-9. [Medline].
  6. Breederveld RS, Patka P, van Mourik JC. Fractures of the sternum. Neth J Surg. Oct 1988;40(5):133-5. [Medline].
  7. Carey S, Pezzella AT, Gilliam H. Traumatic sternal fractures: current concepts in diagnosis and management. Mil Med. Sep 1988;153(9):451-3. [Medline].
  8. Gray H. Anatomy of the human body. Available at http://www.bartleby.com/107/. Accessed February 21, 2007.
  9. Harris JH, Harris WH, eds. Radiology of Emergency Medicine. 2nd ed. Philadelphia, Pa; Lippincott Williams & Wilkins:1981: 313-6.
  10. Huggett JM, Roszler MH. CT findings of sternal fracture. Injury. Oct 1998;29(8):623-6. [Medline].
  11. Jin W, Yang DM, Kim HC, Ryu KN. Diagnostic values of sonography for assessment of sternal fractures compared with conventional radiography and bone scans. J Ultrasound Med. Oct 2006;25(10):1263-8; quiz 1269-70.
  12. Ohry A. Sternal fractures. J Trauma. Mar 1995;38(3):463-4. [Medline].
  13. Roy-Shapira A, Levi I, Khoda J. Sternal fractures: a red flag or a red herring?. J Trauma. Jul 1994;37(1):59-61. [Medline].
  14. Wojcik JB, Morgan AS. Sternal fractures--the natural history. Ann Emerg Med. Sep 1988;17(9):912-4. [Medline].

Sternum, Fractures excerpt

Article Last Updated: Mar 21, 2007