Sternal Fractures & Dislocations - EMGuidewire Radiology Reading Room

Sternal Fractures & Dislocations
Carrie Bissell, MD1, Aaron Fox, MD1, Stephanie Jensen, MD2,
Kendrick Lim, DO1, Olivia Rice, MD3
Departments of Emergency Medicine1,
General Surgery2 and Orthopaedic Surgery3
Sean Dieffenbaugher, MD2 and Laurence Kempton, MD3 - Editors
Adult Orthopedic Imaging Mastery Project
Presentation #3

Disclosures
• This ongoing imaging interpretation series is proudly sponsored by the
Emergency Medicine, General Surgery, and Orthopedic Surgery
Residency Programs at Carolinas Medical Center.
• The goal is to promote diagnostic imaging interpretation mastery.
• There is no personal health information [PHI] within, and all ages have
been changed to protect patient confidentiality.

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Case 1:
45-year-old male
involved in a
motorcycle crash.

Case 1:
45-year-old male
involved in a
motorcycle crash.
Sternal Fracture

Sternal Fractures
• Mechanism of action: blunt chest trauma, deceleration injuries
• Exam: tenderness and/or crepitus of the mid-anterior chest wall.
Pain that is aggravated by deep inspiration
• Imaging: anterior-posterior and lateral chest X-Rays, CT chest
• Associated injuries:
• Thoracic injuries: pulmonary contusion, pneumothorax, hemothorax, rib
fractures, flail chest, thoracic spine compression fractures
• Cardiac injuries: cardiac contusion, cardiac tamponade

Anatomic Distribution Of Sternal Fractures In A
Retrospective Study of 72 Patients.
Injury 2016; 47:2465-2472.

Injury 2015; 46:1324-1327.
Objectives:
To assess: (1) diagnostic imaging results for sternal fracture (SF), (2) the frequency of required procedures
related to SF, (3) patient outcomes, (4) the frequency of myocardial contusion in patients with SF.
Methods:
Review of the NEXUS Chest CT database [n = 14,553 total patients; 292 (2%) with sternal fracture].
Results:
• 94% of sternal fractures were visible only on chest CT.
• Only one patient (0.4%) required a surgical procedure related to the sternal fracture.
• Cardiac contusion was diagnosed in 7 (2.4%) patients.
• Only two deaths (0.7%) were attributed to cardiac causes.
Conclusions:
Most sternal fractures are only seen on CT and the vast majority of cases have low associated morbidity and
mortality and no specific change in treatment.
Sternal Fracture In The Age Of Pan-Scan

61-Year-Old With Chest Pain After A Car Crash.
Point-Of-Care Ultrasound In Sternal Fracture
Western Journal of Emergency Medicine 2015; 16(7):1057-1058.

Sternal Fracture – An Analysis Of The National Trauma Data Bank
Journal of Surgical Research 2014; 186:39-43.
Objectives:
To assess the morbidity and mortality of sternal fractures (SF).
Methods:
Review of the National Trauma Data Bank (n = 32,746 patients with sternal fracture). The 1º outcome was
mortality, and the 2º outcomes were hospital length of stay and, ICU days, and ventilator days.
Results:
• Associated thoracic injury burden – fractures (rib, clavicle, scapula) and pulmonary contusions predicted
increased morbidity and mortality.
• For isolated SF mortality was 3.5% and this was more likely in patients with pre-existing comorbidities.
Conclusions:
In patient with sternal fractures, associated injuries and comorbidities are more highly predictive of poor
outcomes that sternal fractures themselves.

Journal of Trauma & Acute Care Surgery 2013; 75:448-452.
Sternal Fracture: Isolated Lesion Versus Polytrauma From Associated
Extrasternal Injuries – Analysis of 1,867 Cases
Objectives:
To characterize outcomes in patients with isolated of sternal fractures.
Methods:
Review of the Israeli National Trauma Registry (n = 1,867 hospitalized patients with sternal fracture) to
assess mechanism and severity of injury, diagnostic evaluation, and outcomes.
Results:
• Motor vehicle crashes in 84% and falls in 10%,
• Polytrauma sternal fractures (PSF) in 74% and isolated sternal fractures (ISF) in 26%,
• Endotracheal intubation, tube thoracostomy, thoracotomy in 17% of PSF and 0% of ISF.
Conclusions:
The morbidity associated with isolated sternal fracture is low and these injuries can be managed as
outpatients, provided adequate pain control can be achieved.

Back to Our Patient
Our patient:
• Underwent a detailed trauma survey
with specific attention on associated
injuries with high morbidity and
mortality (cardiac contusion,
tamponade, pneumothorax)
• Was managed non-operatively and was
doing well at follow up appointments

Sternal Fracture Case From CMC
Seven Cases Managed Non-Operatively

32-Year-Old Car Crash
Pulmonary Contusion
#3

Manubrial Fracture
#4

Manubrial Fracture
#5

18-Year-Old Fall Off Ladder
1st Rib Fracture
#6

Sternal Fracture Case From CMC
A Case Managed With Sternal Fixation

Case #8
38-year-old male in a
high-speed car crash
presents with chest
pain and sternal
tenderness.

Patient In A High-Speed Car Crash Presents With Chest Pain And Sternal Tenderness.
Displaced Sternal Body Fracture (→)

Displaced Sternal Body Fracture (→)
Surgical Decision Making
Surgical stabilization of the sternum was
offered to the patient because of:
• Persistent pain despite multimodal
analgesia,
• Difficulty in reaching incentive
spirometry goals,
• His strong desire to return to a pre-
injury level of function.

Measurements Taken For Surgical Planning

Surgical Plates Seen On The Post-Operative Chest X-Ray (→)

European Journal of Trauma & Emergency Surgery 2022;48(1):219-224.
Comparison Of Surgical Fixation And Non-Operative Management In
Patients With Traumatic Sternum Facture
Objective:
To identify the national rate of surgical stabilization of sternal fractures (SSSF) in patients with a sternum
fracture hypothesizing patients undergoing SSSF will have a decreased rate of mortality and complications.
Methods:
TQIP (2015-2016) was queried for patients with sternum fracture. Propensity scores were calculated to match
patients undergoing SSSF to patients managed non-operatively in a 1:2 ratio using demographic data.
Results:
Of 9460 sternal fracture patients 114 (1.2%) underwent SSSF. After propensity-matching, 112 SSSF patients
were compared to 224 patients undergoing non-operative management (NOM). Baseline characteristics were
similar (all p >0.05).
See Next Slide For Study Results

European Journal of Trauma & Emergency Surgery 2022;48(1):219-224.
SSSF
(n=112)
NOM
(n=224)
Hospital Length Of Stay 16 Days 7 Days p<0.001
ICU Length Of Stay 9.5 Days 5.5 Days p=0.016
Ventilator Days 8 Days Days p=0.035
ARDS 2.7% 2.2% p=0.80
Pneumonia 1.8% 0.9% p=0.48
Unplanned Intubation 8.9% 5.8% p=0.29
Mortality 2.7% 11.2% p=0.080
Conclusions:
Just over 1% of patients with sternum fracture underwent SSSF in a national analysis. Patients undergoing
SSSF had an increased LOS and a similar rate of all measured pulmonary complications, however a lower
mortality rate when compared to patients managed non-operatively.

Journal of Trauma & Acute Care Surgery 2023;94:573-577.
Impact Of Sternal Fixation On Patient Outcomes: A Case Matched Review
Objective:
To further examine the benefits of sternal fixation (SF) versus non-operative management (NOM).
Methods:
A retrospective review was performed between patients with sternal fractures who underwent NOM versus
operative SF. Outcomes of interest included mean pain score, total opioid requirements (in morphine
milliequivalents [MMA]) within 24 hours of discharge, intensive care unit and hospital length of stay (LOS), and
incentive spirometry percent predicted value at discharge.
Results:
Although pain scores were similar for both cohorts, the SF group required significantly less opioids at discharge
(62.1 vs. 92.2 MMA; p = 0.007). In addition, the SF cohort demonstrated significantly improved respiratory
function per incentive spirometry percent predicted value at discharge (75.5% vs. 59.9%; p < 0.001). Intensive
care unit LOS and hospital LOS were similar between cohorts.

Sternal Fractures -Emergency Medicine Essentials
Mechanism of
Injury
• Blunt chest trauma, deceleration injury
Physical
Examination
• Consistent mechanism with tenderness or crepitus to the mid-anterior chest
wall. Pain that is aggravated by deep inspiration
ED Imaging • Anterior-posterior and lateral chest X-ray, CT chest, ultrasound
Associated
Injuries
• Thoracic injuries: pulmonary contusion, rib fractures, flail chest, thoracic
spine compression fractures, pneumothorax, hemothorax
Consultation
And Follow-Up
• Usually managed non-operatively with orthopedic follow-up
• Surgical stabilization considered for cases with significant displacement
and/or bony instability, persistent pain, impaired respiratory effort

Manubriosternal Dislocation
A Case From Carolinas Medical Center

Case 9:
56-year-old female
involved in a motor
vehicle collision
complains of severe
anterior chest pain.

56-Year-Old Female Involved In A Motor Vehicle Crash
Type II Manubriosternal Dislocation

• Mechanism of action: high energy direct blow to the anterior chest
• Exam: mid-sternal tenderness +/- a palpable bony step-off,
respiratory distress may be seen
• Imaging: anterior-posterior and lateral chest X-ray, CT chest
• Associated injuries:
• Thoracic injuries: pulmonary contusion, pneumothorax, hemothorax, rib
fractures, flail chest, thoracic spine compression fractures

Type I Manubriosternal Dislocation
Posterior Dislocation Of The Sternal Body
Relative To The Manubrium
Posterior Dislocation Of The Manubrium
Over The Sternal Body

Trauma Case Reports 2022;40:1-4.
Extensive Traumatic Anterior Chest Wall Injury Including
40-year-old unrestrained drive in a high-speed car
crash. On arrival she was awake and alert
complaining of severe anterior chest pain.
Examination showed increased work of breathing,
mid-sternal subcutaneous emphysema, and a step
deformity at the manubriosternal junction. She
subsequently developed respiratory failure
requiring intubation and mechanical ventilation.

A. Displaced manubriosternal dislocation, B. Sternal reduction, C. 3.5 mm compression plates.

• When suspected on physical exam,
manubriosternal dislocation is confirmed on
lateral chest X-ray or chest CT,
• Because manubriosternal dislocation is a rare
injury, there is not a clear consensus on best
management strategies,
• Surgical stabilization is generally recommended
if there is presence of associated surgical
injuries, intractable pain, mechanical instability,
or respiratory impairment.
Post-Operative Chest X-Ray

Measurements Taken For Surgical Planning
Back To Our Patient

Courtesy Of Drs. Stephanie Jensen And Sean Dieffenbaugher
The Bony Edges Are Aligned And Secured With Two Vertically Oriented Steel Plates

Case #10

Manubriosternal Dislocation -Emergency Medicine Essentials
Mechanism of
Injury
• High-energy direct blow to the anterior chest
• Classified as Type I and Type II (see Slide 36)
Physical
Examination
• Mid-sternal tenderness +/- a palpable bony step-off
• Respiratory distress is common in severe cases
ED Imaging • Anterior-posterior and lateral chest X-ray, CT chest, ultrasound
Associated
Injuries
• Thoracic injuries: pulmonary contusion, rib fractures, flail chest, thoracic
spine compression fractures, pneumothorax, hemothorax
Consultation
And Follow-Up
• Immediate Orthopedic Surgery or Trauma Surgery consultation
• Surgical stabilization is indicated in patients with associated surgical thoracic
injuries, intractable pain, bony instability, or respiratory failure.

Sternoclavicular Dislocation
A Case From Carolinas Medical Center

A 12-Year-Old Boy Presents With Left Shoulder Pain 2 Days After Falling On His Left Side.
It Is Difficult For Him To Abduct His Arm. His Neurovascular Exam Is Normal.
X-Rays Of The Shoulder And Clavicle Are Read As Normal

A Chest X-Ray Is Also
Read As Normal.

A Chest X-Ray Is Also
Read As Normal.
Because The Patient
Had Persistent Pain
And Inability To Raise
His Left Arm A Chest
CT Was Obtained.

Chest CT Reveals A Left Posterior Sternoclavicular Dislocation With The Left
Clavicular Head (←) Behind The Manubrium (➤) Abutting The Aortic Arch (A)
A
←
Right Right

• Mechanism of action: most involve contact sports (e.g., football or
rugby tackles) and motor vehicle crashes
• Exam: tenderness over the sternoclavicular joint, marked limitation
of arm movement, particularly abduction at the shoulder
• Imaging: difficult to identify on plain films. CT imaging is essential if
the injury is suspected
• Classification: anterior (70% - 90%) and posterior (10% - 30%)
• Associated injuries: in patients with posterior sternoclavicular
dislocation, mediastinal injuries are seen in up to 30% of patients

←
R L
To Ensure That We Are All Properly Oriented
Our Illustration “Looks Down” At The
Relevant Anatomy From The Top
CT Images ”Look Up” At The Same
Anatomy From The Bottom
Left Posterior Dislocation
Left Right

The Medial Clavicular Head Is Exposed And Elevated
Courtesy Of Drs. Olivia Rice And Michael Paloski
Our Patient Was Taken To The Operating Room For Open Reduction And Internal Fixation

A Figure-Of-Eight Suture Secures The Sternoclavicular Articulation
Courtesy Of Drs. Olivia Rice And Michael Paloski

With The Diagnosis
Revealed Let’s Go Back
And Re-Examine The
Initial Chest X-Ray.

With The Diagnosis
Revealed Let’s Go Back
And Re-Examine The
Initial Chest X-Ray.
Notice The Very Subtle
Positional Asymmetry Of
The Right And Left
Medial Clavicles
Easier To Pick Up In
Retrospect Yet Tough To
Identify In Prospect
Before The Diagnosis Is
Known!

The Journal of Emergency Medicine 2021;61(5):499-506.
Evaluation and Management of Sternoclavicular Dislocation (SCD)
in the Emergency Department
Demographics
• Sternoclavicular dislocations (SCDs) are rare injuries, representing <1% of dislocations,
• Most involve contact sports (e.g.: football or rugby tackles) and motor vehicle crashes,
• These are classified as anterior SCDs (70% - 90%) and posterior SCDs based on the
direction of displacement of the medial end of the clavicle,
• There are several important mediastinal structures in close proximity to the
sternoclavicular joint and posterior SCD may injure these structures. Significant
complications of posterior SCDs include pneumothorax, subclavian artery or vein injury,
esophageal injury, tracheal injury, and brachial plexus injuries.

Physical Examination
• Most patients report shoulder or clavicular pain with decreased active range of motion,
particularly with abduction of the ipsilateral extremity at the shoulder joint .
• Patients with an anteriorly displaced SCD might report a painfully protruding lump at the
sternoclavicular joint, and patients with posterior SCD might describe a depression in their
upper chest.
• One key to early identification of SCD is the presence of gross deformity at the
sternoclavicular joint, with protrusion or depression.
• Depending on the mechanism and surrounding trauma, localized edema can conceal
evidence of the gross deformity, and palpation might not reveal protrusion or depression.

Physical Examination (continued)
• The distal extremity should be examined for signs of neurovascular compromise, which
can resemble thoracic outlet syndrome. This should include assessment of distal pulses,
skin color, and sensation. Distal radiculopathy due to brachial plexus compression can
manifest with paresthesias alone or with decreased sensation on physical examination.

Evaluation
• Initial evaluation often includes radiographs of the chest and shoulder, although both have
limited utility in identifying SCD due to overlapping structures, with numerous cases of
false-negative imaging when these radiographs are used in isolation.
• Significant shoulder pain, especially with palpable swelling or deformity at the
sternoclavicular joint, should prompt CT imaging of the chest as it provides an enhanced
view of the sternoclavicular joint while also evaluating for concomitant fracture and
compression of nearby structures.
• Intravenous contrast should be utilized in suspected posterior SCD to evaluate for vascular
compromise. Mediastinal injuries occur in up to 30% of patients with posterior SCD.

When plain films are inconclusive, another imaging option is to obtain a
Serendipity View in which the projections is angled 40° caudally.
• With anterior sternoclavicular dislocation – elevation of the clavicle
• With posterior sternoclavicular dislocation – depression of the clavicle

Emergency Medicine Journal 2011;28:542.
The Use Of Bedside Ultrasound To Diagnose Posterior Sternoclavicular
Dislocation
Images Obtained With A High-Frequency (10-15 mHz) Linear Probe

Point-Of-Care Ultrasound Ultrasound Diagnosis Of Posterior
Sternoclavicular Joint Dislocation (SCD)
Images Obtained With A High-Frequency (10-15 mHz) Linear Probe
SCD with the clavicle (→) angulated posteriorly
relative to the sternum (★).
Normal contralateral sternoclavicular joint
in the same patient.

Acute Dislocations Of The Sternoclavicular Joint: A Review Article
Journal Of The American Academy Of Orthopedic Surgery 2022;30(4):148-154.
Sternoclavicular joint dislocations are uncommon, accounting for 1% to 3% of
injuries to the upper extremity. These are described by:
• The direction of the displacement of the medial clavicle (anterior or posterior),
• The chronicity of the injury (acute, subacute, chronic),
• The degree of displacement (capsular strain, subluxation, or dislocation).
No Level I evidence exists for the management of these injuries. For acute
injuries, if closed reduction is unsuccessful, an open approach is generally
recommended. In some cases with mild symptoms, the injury can be managed
expectantly with physician-patient shared decision making.

Our Patient Had A Figure-Of-Eight Reconstruction

Sternoclavicular Dislocation -Emergency Medicine Essentials
Mechanism of
Injury
• Most involve contact sports (e.g., football or rugby tackles) and MVCs
• Classified and Anterior or Posterior (see Slide 57)
Physical
Examination
• Tenderness over the sternoclavicular joint
• Marked limitation of shoulder movement, especially abduction
ED Imaging • Easily missed on plain films and CT imaging is essential to make the diagnosis
when the injury is suspected
Associated
Injuries
• Associated mediastinal injuries are are seen in up to 30% of patients with
posterior sternoclavicular dislocation
Consultation
And Follow-Up
• Depending on the primary and secondary injuries, immediate consultation
with Orthopedic Surgery, Trauma Surgery, and/or Vascular Surgery for
reduction and definitive management of mediastinal injuries

Sternal Fractures And Dislocation
Essentials For The Acute Care Clinician

Sternal Fracture And Dislocation Essentials
Sternal Fractures
• Most sternal fractures are not well seen on chest X-Ray and CT imaging is
required to make an accurate diagnosis,
• Point-of-care ultrasound is a useful adjunct in the bedside diagnosis of sternal
fracture,
• Mortality in patients with sternal fracture is most often the result of associated
injuries,
• Mortality in patients with isolated sternal fractures is low, at 3.5%,
• Effective management of isolated sternal fractures is dependent of adequate
pain control,
• Surgical stabilization of sternal fractures can be considered for cases with
significant displacement and/or bony instability, persistent pain, impaired
respiratory effort.

Sternal Fracture And Dislocation Essentials
• Manubriosternal dislocations are classified as Type I and Type II (Slide 36),
• These injuries are best seen on lateral chest X-Ray and chest CT,
• Reduction and surgical fixation is usually required.
• Sternoclavicular dislocations are classified as Anterior or Posterior (Slide 56 ),
• Injury of important intrathoracic structures occur in up to 30% of patients with
posterior sternoclavicular dislocations,
• When the diagnosis is suspected, chest CT imaging is recommended to identify
the dislocation along with any associated injuries,
• Point-of-care ultrasound is a useful adjunct in the bedside diagnosis of
posterior sternoclavicular dislocations.

References:
Sternal Fracture In The Age Of Pan-Scan. Injury 2015; 46:1324-1327.
Point-Of-Care Ultrasound In Sternal Fracture. Western Journal of Emergency Medicine 2015;
16(7):1057-1058.
Sternal Fracture – An Analysis Of The National Trauma Data Bank. Journal of Surgical Research 2014;
186:39-43.
Sternal Fracture: Isolated Lesion Versus Polytrauma From Associated Extrasternal Injuries – Analysis of
1,867 Cases. Journal of Trauma & Acute Care Surgery 2013; 75:448-452.
Comparison Of Surgical Fixation And Non-Operative Management In Patients With Traumatic Sternum
Facture. European Journal of Trauma & Emergency Surgery 2022;48(1):219-224.
Impact Of Sternal Fixation On Patient Outcomes: A Case Matched Review. Journal of Trauma & Acute
Care Surgery 2023;94:573-577.

References:
Extensive Traumatic Anterior Chest Wall Injury Including Type I Manubriosternal Dislocation. Trauma
Case Reports 2022;40:1-4.
Evaluation and Management of Sternoclavicular Dislocation in the Emergency Department. The Journal
of Emergency Medicine 2021;61(5):499-506.
The Use Of Bedside Ultrasound To Diagnose Posterior Sternoclavicular Dislocation. Emergency Medicine
Journal 2011;28:542.
Point-Of-Care Ultrasound Ultrasound Diagnosis Of Posterior Sternoclavicular Joint Dislocation (SCD). The
Journal of Emergency Medicine 2016;52(4):513-515.
Acute Dislocations Of The Sternoclavicular Joint: A Review Article. Journal Of The American Academy Of
Orthopedic Surgery 2022;30(4):148-154.

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