Ultrasound-Guided Parasternal Block Allows Optimal Pain Relief and Ventilation Improvement After a Sternal Fracture

Abstract

IntroductionSternal fractures are a painful condition which can result in pulmonary morbidity if not treated promptly. The management of isolated fractures has changed from hospital to home-based treatment, provided other major injuries have been excluded. Pain management is the mainstay of treatment. In this case report, we describe how a parasternal block under ultrasound guidance for sternal fracture provided better analgesia thereby improving ventilation.Case reportA 26-year-old man was admitted to the emergency department following a road traffic accident. His initial evaluation revealed a radio-cubital displaced fracture at the elbow level with severe tenderness over the sternum. Chest X-ray on admission did not reveal any abnormality. On preoperative checkup he was found to have altered chest mechanics with severe pain and tenderness over the sternum. Arterial blood gas (ABG) analysis showed respiratory acidosis. Pulmonary electrical impedance tomography showed hypoventilation of anterior portions of both lungs. An ultrasound examination of the sternum showed a fractured sternum with complete disjunction. An ultrasound-guided bilateral parasternal block was performed which resulted in efficient analgesia and thereby improved his ventilation as indicated by the improvement in ABG.ConclusionTimely and proper analgesia can reduce the pulmonary morbidity in sternal fractures. Of the various analgesic techniques, parasternal block under ultrasound guidance is a relatively simple, safe, and target-specific procedure that can provide efficient pain relief.Electronic supplementary materialThe online version of this article (doi:10.1007/s40122-016-0050-5) contains supplementary material, which is available to authorized users.

Transversus Thoracis Muscle Plane Block

“…The available literature demonstrates the use of TTP blocks in breast resection surgery, subcutaneous internal cardiac defibrillator placement [10], and pericardial effusion drainage [21]. Other applications include acute pain management associated with sternal fractures [22] and chronic pain treatment for postthoracotomy internal mammary pain syndrome [12].…”

Current treatment and outcomes of traumatic sternal fractures—a systematic review

“…The majority of sternal fractures (> 95%) is treated conservatively [ 1 , 3 , 10 , 14 ]. Conservative treatment options consist of analgesia, corset fixation, rest, and passive reduction of displacement if necessary [ 1 , 15 ]. Adequate analgesia is of vital importance to prevent pulmonary complications caused by respiratory insufficiency as a consequence of painful respiration [ 15 , 16 ].…”

“…Conservative treatment options consist of analgesia, corset fixation, rest, and passive reduction of displacement if necessary [ 1 , 15 ]. Adequate analgesia is of vital importance to prevent pulmonary complications caused by respiratory insufficiency as a consequence of painful respiration [ 15 , 16 ]. However, in case of unstable fractures, thoracic wall instability, fracture displacement or persistent dislocation, sternal deformity, respiratory insufficiency, severe pain, and fracture non-union, surgical fixation could be performed [ 1 , 2 , 4 , 5 , 7 , 10 , 17 ].…”

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“…Landmark‐guided peripheral nerve blocks have long been utilized for laceration repairs, joint reductions, and pain control; however, one study noted that more than 30% of nerve blocks fail if performed by anatomic landmarks alone. The addition of ultrasound guidance has made regional anesthesia procedures faster, more accurate, and more successful as a pain management modality . Despite a growing demand for training, effective teaching strategies for ultrasound‐guided regional anesthesia (UGRA) procedures have yet to be established in the ED setting.…”