Open reduction and internal fixation of a non-united transverse sternal fracture

Abstract

A 60-year-old male crane-driver slipped at work and fell onto his anterior chest against a concrete bar. This caused a transverse fracture of the body of his sternum. The pain in his anterior chest wall and sternum caused him such severe pain that, 4 months after the injury he was still taking daily morphine derivatives and was unable to work. On examination, he had a very painful and tender area at the site of the fracture, with mobility and crepitus. Sternal radiographs showed a transverse, posteriorly displaced fracture of the body of the sternum with fibrous non-union of the fracture plane ( Fig. 1). He was therefore referred to a thoracic surgeon for advice regarding surgical management of his sternum.The fracture was exposed through a paramedian skin incision, so that the wound would not be directly over the plate. The chest wall muscles were elevated from their insertion onto the sternum. The transverse sternal fracture, which was located towards the upper half of the body of the sternum, was exposed and the fibrous non-union carefully taken down by a combination of sharp dissection with a No. 15 blade and a Volkmann's spoon. Despite this it was not possible to safely mobilise the bone ends enough to allow end-to-end apposition without damage to the soft bone. Approximately 3-4 mm of the distal fragment was therefore excised. This allowed for satisfactory reduction of the fracture with a bone clamp (Fig. 2).Using an aluminium template, a seven-hole reconstruction plate was chosen and contoured. This allowed for three holes above and three holes below the fracture line. The three proximal holes for 4 mm cancellous screws were pre-drilled, measured and partially tapped using the definitive plate as a guide. A bone lever was placed posteriorly to the bone to protect the deep structures during this procedure. The plate was then fixed to the proximal fragment and then the fracture reduced and held with a bone clamp. The distal screws were then inserted. Iliac crest cancellous bone autograft chips were laid alongside the plate. A lateral sternal radiograph confirmed the correct position of the plate, appropriate length of the screws, and a complete reduction of the fracture. The soft tissues were closed over a redivac drain and the skin closed with a subcuticular undyed 3-0 Vicryl 1 . The skin was closed with clips. The patient was not Injury Extra (2005) 36, 214-216

A Novel Approach to Sternal Fracture Repair With the Implementation of a Compression/Distraction Device

“…Little has been published on for sternal fracture reduction to reapproximate the fractured segments and provide compression across the fracture line. The articles cited in this report either briefly state that the fracture was reduced using bone clamps or reduction forceps [1][2][3]6] or make no mention of the technique used for fracture reduction [4,5].…”

“…Surgical repair of sternal fractures is not well studied in the literature, which primarily consists of case reports and case series, but there are specific scenarios where surgical repair is warranted. In particular, surgical fixation should be considered in cases of severe pain, respiratory failure or dependency on mechanical ventilation, cosmetic deformity, malunion, disunion, and compression of the heart [1][2][3][4][5][6]. A variety of surgical approaches to sternal fracture fixation have been documented (steel wire, suture materials, a seven-hole aluminum plate, an eight-holed Sternolock X plate, a sternum-osteosynthesis plate, t-shaped plate).…”

“…A variety of surgical approaches to sternal fracture fixation have been documented (steel wire, suture materials, a seven-hole aluminum plate, an eight-holed Sternolock X plate, a sternum-osteosynthesis plate, t-shaped plate). However, only a few techniques have been discussed for the initial reduction of the sternal fracture prior to fixation [1][2][3][4][5][6]. In the following report, we describe a novel surgical technique for sternal fracture reduction using a compression/distraction device.…”

Postoperative transverse sternal nonunion with a chest wall defect managed by a tibial locking plate and a Gore-Tex dual mesh membrane: a case report

“…The sternal defect was also bone grafted with a tricortical iliac crest autograft. Bone grafting was advocated for and performed in some other published cases of transverse sternal nonunion with a bone defect [ 1 , 2 , 19 , 20 ]. Common late complications of the sternal plating are local pain and irritation caused by the prominent material, requiring removal of the plate in 15.4% and 27% of the patients, respectively [ 5 , 11 ].…”

Postoperative transverse sternal nonunion with a chest wall defect managed by a tibial locking plate and a Gore-Tex dual mesh membrane: a case report.

“…The sternal defect was also bone grafted with a tricortical iliac crest autograft. Bone grafting was also advocated for and performed in some other published cases of transverse sternal nonunion with a bone defect [1,5,16,17]. Important late complications of the sternal plating are pain and irritation, caused by the prominent material, requiring removal of the plate in 15.4% and in 27% of the patients, respectively [2,9].…”