Chest Case 15

43 YOM with a pmhx notable for hypertension presents following a motor vehicle collision. He was the unrestrained driver of a vehicle traveling approx. 35mph on a local street – he explains that he was distracted and collided with the rear end of a car stopped at an intersection and was thrown into the steering wheel of his car. He denies LOC; he is complaining of mid chest pain worse with deep inspiration; he denies dyspnea. He feels otherwise well denying other pain or associated injury. He is awake/alert, conversational in NAD.

History and Physical T 98.7 P 95 BP 164/90 O2

98% Gen: WDWN CV: RRR, no m/r/g, cr<3

sec globally. Pulses 2/4 in 4 extremities.

Pulm: Lungs CTA bilat, BBSE, pt shows obvious contusion overlying the sternum; he is tender to palpation over the associated soft tissue. There is no other injury appreciable – he has good rise and fall of his chest with insp./exp.

Abd: no signs of trauma, soft/nt/nd.

Chest X-Ray

Diagnosis: Sternal Fracture

Lateral radiograph demonstrates complete dislocation at the sternal angle

Upright frontal radiograph shows mild widening of the superior mediastinum after blunt trauma to the chest

Oxygen IV Fluids Diagnostics

Initial work-up should include complete screening for associated traumatic injuries included but not limited to cardiac tamponade, flail chest, cardiac contusion pulmonary contusion, thoracic spine injury, etc.

CT Chest is typically indicated to evaluate for mediastinal injuries

Medical management ER medical management of an isolated sternal fracture in a

stable patient is similar to that for uncomplicated rib fracture including adequate pain management and incentive spirometry.

In the setting of isolated sternal fracture it is recommended an ecg be obtained initially and again at 6 hours prior to discharge.

ED Management

Outcome Sternal fractures were once thought to be high-morbidity

injuries, with a mortality rate of 25-45% from associated injuries. Recent literature reveals that the morbidity rate may be lower, yet caution is warranted when evaluating and treating patients with this injury

The mortality rate from isolated sternal fracture is extremely low. Death and morbidity are related almost entirely to associated injuries such as aortic disruption, cardiac contusion, and pulmonary contusion, or unrelated injuries to the abdomen or head sustained in the accident.

Mechanism Most sternal fractures are caused by blunt anterior chest

truama. Motor vehicle collisions account for 60-90% of sternal fractures

.

Pearls