Sternal Fractures: Anterior Plating Rationale

Abstract

L arge studies have shown some safety in treating isolated sternal fractures with nonoperative management outside of an intensive care setting. Sternal fractures in highvelocity injuries may indicate more severe underlying abnormalities such as cardiac arrhythmias and aortic contusions. [1][2][3] This type of fracture occurs usually as a result of motor vehicle collisions and involves the upper and middle thirds of the sternal body. If nondisplaced, they are treated with analgesics and rest. 2 When displaced, sternal fractures may require operative intervention. 4 The indications for operative treatment have been severe pain limiting respiratory efforts, displaced fractures that cannot be corrected by closed reduction, or fractures leading to mechanical instability of the thorax. If sternal fractures are not stabilized, pseudoarthrosis of the sternum can result in ongoing pain and instability. 5 Several reports have demonstrated that the sternum can be rigidly fixed with either custom plates or posterior dissection and circumferential wiring. 6 Circumferential wiring has been the standard of fixation after cardiac surgery but has been associated with complications including cutout of wires, osteomyelitis, and nonunion. 7 We wish to report on three cases treated with internal fixation with standard plates and screws from a minimally intrusive anterior approach. This approach decreases soft tissue dissection, which ensures maintenance of anatomic blood supply and could decrease pulmonary complications from retrosternal dissection. CASE REPORTS Case 1A 55-year-old man complained of sharp chest pain and dyspnea after an motor vehicle crash in which he was the front passenger. Anteroposterior and lateral radiographs of his thorax showed no evidence of a fracture. A thoracic computed tomographic scan revealed no internal trauma. At 4-month follow-up, the patient reported sternal pain that worsened on movement. Physical examination revealed a protuberance over the middle third of the sternal body that reproduced the patient's symptoms when palpated. A new thoracic computed tomographic scan showed a nondisplaced transverse fracture across the middle third of the sternum. At surgery, open reduction and internal fixation (ORIF) with a six-hole plate stabilized the sternum. Autogenous bone graft was accomplished with asymmetric sternal osteotomy with no complications. The patient had marked decrease in pain immediately postoperatively and was free of all pain related to the fracture at 1 month. Twelve months postoperatively, the patient had normal range of neck and shoulder motion and reported a decrease in pain. The patient was able to feel the plate under his skin even though it was causing him no discomfort, and he requested hardware removal. Case 2A young karate practitioner felt a sharp pain in his chest when struck by a kick while sparring. Radiographs showed a 50%, posterior, displaced, transverse fracture across the middle third of the sternal body. The fracture was treated by ORIF on postinjury day 3 using an anter...

Surveyed Opinion of American Trauma, Orthopedic, and Thoracic Surgeons On Rib and Sternal Fracture Repair

“…14,34,35 Most occur at the manubrial-sternal junction or between the upper and mid-body and are also most commonly seen after a motor vehicle crash or fall from height. 34,36 Current acute management recommendations focus mainly on pain control and associated injury management, e.g., blunt cardiac injury. 34,37,38 The first case report of a sternal fracture repair appeared in 1943, 39 but subsequent case series of fixation of acutely displaced sternal fractures and sternal nonunions are few and there are no cohort comparisons or randomized trials.…”

Orthopaedic anatomy of the sternum: A micro-CT study to guide the fixation of sternal fractures

“…A larger scale CT study of living patients with a normal age and equal gender distribution is warranted before areas of greatest screw purchase can be determined with certainty. In addition, the success of preliminary trials of rigid plate fixation for displaced MSJ and other sternal fractures show promise for development of an orthopedic standard for sternal fracture fixation [2,7,10,11,13,14,19].…”

“…Rigid plate fixation has been shown to be an effective method of fixation of MSJ and other sternal fractures [2,7,10,11,13,14,19]. Ostensibly, the close proximity of vital organs directly abutting the dorsal surface of the sternum makes substantive bicortical constructs unfeasible.…”

“…In these studies, plating has been proven to provide lower rates of nonunion and mediastinitis, reduced pain, increased safety, closer sternal approximation, and required minimal soft tissue dissection as compared to cerclage wiring [2,11,12]. Additionally, preliminary studies of plate fixation of MSJ fracture-dislocations have shown low rates of complications and infection, excellent healing, and minimal damage to surrounding structures and vascular supply [10,13,14]. These studies along with the overwhelming success of rigid plate fixation in other orthopedic applications, place this method in the forefront for fixation of displaced MSJ fractures.…”

Surgical Fixation of Sternal Fractures: Preoperative Planning and a Safe Surgical Technique Using Locked Titanium Plates and Depth Limited Drilling

“…This procedure may injure mediastinal organs, surrounding vessels and the sternal blood supply 7,18 . Performing strictly subperiosteal dissection around the sternum as shown in step 2.1.7 will minimize the risk of complications.…”