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Case Report
The Rule of Sternal Fractures
in Life-Threatening Blunt-
Chest-Trauma: Treatment
and Indications for Operative
Stabilization
K Reese*, M Breul, SJ Kamminga, and O Pieske
Department of Trauma, Medical Campus University of Oldenburg, Germany
Abstract
Road traffic accidents frequently result in blunt-force thoracic and concomitant
injuries including flail-chest and pulmonary fail. The severity and type of injury
determines the treatment modalities and prognosis. We report the case of a 56-year-
old car driver, who suffered a complex thoracic trauma following a frontal collision. His
life-threatening injuries included a dislocated sternum fracture, multiple rib fractures
and thoracic-spinal fracture as well as cardio-pulmonary contusion with bilateral
haemopneumothorax (Injury Severity Score 35). We discuss the operative chest-wall
strategies in context with pulmonary considerations and the literature.
INTRODUCTION
Sternal fractures are observed in high-impact-accidents
[1,2]. The injury mechanism is usually either (a) a direct force
to the anterior chest wall most commonly seen in frontal car
collisions with steering-wheel/belt/airbag contact or (b) a
flexion-compression movement of the trunk associate most
often combined with rib and/or spine fractures leading to an
unstable thorax [1-4]. The incidence of sternal fracture described
in literature is rare and significantly different, ranging from
1.5% ~18.5% but the concomitant injuries of thoracic organs in
severe chest trauma lead to a high mortality of up to 45% [1,5-
7]. Unstable thorax may result in shallow tidal volumes, collapse
of alveoli, arteriovenous shunting and hypoxemia, leading to
pulmonary insufficiency [8]. Accompanying thoracic or lumbar
spine injury was reported in up to 39.1% of patients [7,9-11].
Therapeutic strategies are still under scientific discussion
concerning conservative or operative treatment including choice
of implant-type and best time between trauma and surgery not
only to treat the thoracic-wall but also pulmonary instability
[12-16]. This paper describe a severely injured car-driver
after frontal collision with pulmonary insufficiency as well as
grossly displaced sternal fracture, ribs fractures and an unstable
vertebral fracture.
CASE PRESENTATION
A 56-year-old male, who was generally healthy except for
Cite this article: Reese K, Breul M, Kamminga SJ, Pieske O (2017) The Rule of Sternal Fractures in Life-Threatening Blunt-Chest-Trauma: Treatment and
Indications for Operative Stabilization. J Trauma Care 3(3): 1027.
Journal of Trauma and Care
*Corresponding author
Kevin Reese, Department of Trauma, Orthopaedic
Surgery and Sport-Traumatology, Evangelisches
Krankenhaus, Medical Campus University of Oldenburg,
Steinweg 13-17, 26122, Oldenburg, Germany, Email:
Submitted: 14 February 2017
Accepted: 28 June 2017
Published: 29 June 2017
Copyright
2017 Reese et al.
ISSN: 2573-1246
OPEN ACCESS
Keywords
Sternal fracture
Flail chest
Pulmonary injury
Respiratory failure
Thoracic spine lesion
a cardiac arrhythmia treated by a dual-chamber pacemaker,
suffered a polytrauma during road-traffic-accident. The patient
drove frontally into a barricade at a speed of approximately 50
kilometers per hour, the cause being unknown. The steering
wheel of the vehicle deformed and the front-airbags deployed.
On presentation in our emergency department the patient was
disorientated and displayed signs of intermittent somnolence
(Glasgow Coma Scale 13) although there were no obvious signs
for head injuries. The patient had compression pain on the left
side of the chest and on the left-front pelvic region. The initial
examination revealed no severe tenderness on percussion
of the lumbar spine but frontal and dorsal chest pain. Apart
from abrasions and bruises there were no other pathological
findings. Because of progredient pulmonary and cardio-
circulatory instability emergency care was performed according
to the Advanced Trauma Life Support-guidelines [17]. Imaging
modalities displayed an unstable thoracic spine fracture (T10, AO
classification: type B3), a dislocated sternal fracture (Figure 1), a
fracture of the left anterior arch of the pelvis (AO classification:
type A2), an acetebular fracture on the left side (AO classification:
type B2) (Figure 2), prepectoral subcutaneous emphysema, and a
pneumomediastinum with fractures of the fifth through seventh
rib. Additionally there was evident cardiac and pulmonary
contusion and a bilateral haemopneumothorax. Due to these
life-threatening thoracic organ injuries the value of the Injury
Severity Score revealed 21 points.

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Figure 1 Dislocated sternal fracture and unstable thoracic spine fracture (T 10, AO classification: Type B3) (concomitant rib fractures are not seen
in the presented CT-scans).
Due to pulmonary insufficiency the patient was admitted
directly to our intensive care unit. He was intubated and an
arterial line and a central venous catheter were inserted as well
as bilateral thoracic drains. The patient received rotational bed
therapy (RotoRest) and catecholamines were administered.
Because of the poor pulmonary function the rotational bed
therapy had to be continued for 12 days before the patient
was stable enough for surgery. In a single-stage operation an
osteosynthesis was performed on the sternum using open
reduction and internal fixation with an angle stable locking plate.
The T10 spinal fracture was treated by means of percutaneous
dorsal instrumentation bridging T8/T9 to T11/T12 (Figure 2).
Postoperatively the pulmonary condition improved rapidly.
Extubation and removal of the thoracic drains were possible
during a 24 hour-period postoperatively. Four days later a
second-stage surgery was performed on the acetabular fracture
using open reduction and internal fixation with a Reco-Plate (9
J Trauma Care 3(3): 1027 (2017)
Reese et al. (2017)
Email:
holes) utilizing a Kocher-Langenbeck approach. 10 days after
last surgery he was transferred to the rehabilitation-unit. The
subsequent postoperative course showed no complications
concerning wound and bone healing as well as progredient
cardiac and pulmonary stabilization without infection.
DISCUSSION
Sternal fractures are rare and associated with high-energy
impacts [1-3,6]. In combination with rib and spine fractures they
commonly lead to an unstable thorax [1,5,7,18]. In most cases
the sternal fracture itself is no severe injury but this fracture
must be taken as a clinical sign for further life-threatening,
intrathoracic cardiac and/or pulmonary organ lesions [8,9].
In accordance to the case presented, road traffic accidents are
the leading cause of such injuries [1-3]. If a sternal fracture is
observed, further intrathoracic injuries must be immediately
excluded [6,10,19]. In case of minor thoracic wall instability like
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Figure 2 Plate osteosynthesis of the sternum and percutaneous dorsal instrumentation of Th. 10.

isolated sternal fracture and minor pulmonary involvement a
conservative approach consisting of pulmonary support and
adequate analgesia is preferred [8]. In contrast, mechanical
instability of the thoracic cavity including lung contusion result
in restricted mobility of the lung with pulmonary insufficiency
and subsequent need for mechanical ventilation [20,21]. This
pathology is associated with increased rates of pneumonia and
sepsis. The need for an operative stabilization of the thorax
wall including the sternum because of thoracic and pulmonary
instability is still under scientific discussion [9,16]. Some authors
described pulmonary insufficiency as a result of lung contusion
and concluded that operative thoracic stabilization of the
thoracic wall does not contribute to pulmonary improvement or
should only be performed when other intrathoracic procedures
are anyhow necessary [16]. In contrast Ahmed and Mohyuddin
reported already 1995 that patients with thoracic stabilization
showed reduced mean ventilation time of 4 days compared to
patients without stabilization having mean ventilation time of
15 days [22]. Similar results were confirmed some years later
by Voggenreiter et al. and several other authors [7,12,13]. Berg
described already in 1996 the anterior wall with sternal-rib-
complex as the fourth column of the spine and highlighted
thereby the biomechanical necessity of a fixed sternum in
order to achieve a stable chest [23]. Until today many different
sternal osteosynthesis techniques are described but high-profile
implants like non-fixed-plates and nails showed relatively high
mechanical complication rates [5,12,24]. Recently Krinner et
al., published good sternal stabilization results by the use of a
doubled plate-system [13]. Additionally, low-profile fixed angle-
plates are on the market having excellent fixation values and
were therefore used in our study [25,26].
In summary, in case of severe chest injury with bony and
pulmonary instability surgeons have to balance between
the potential perioperative negative effects of chest/sternal
osteosynthesis like bleeding, wound infection, anesthesiological
or metal-associated complications and the potential positive
effects of optimized ventilation, pulmonary recovery and reduced
respiratory complication-rate like pneumonia [12,13,23].
Numerous authors reported post-chest-stabilization a reduced
morbidity and mortality of severe injured patients [7,25,27]. In
the case demonstrated here, pulmonary insufficiency caused by
blunt-chest-trauma-bilateral haemopneumothorax because of
unstable thorax with fractures of sternum, ribs and thoracic spine

J Trauma Care 3(3): 1027 (2017)

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ameliorate rapidly only after chest stabilization including sternal
plate-fixation. Thereby, within 24 hours postoperatively the
patient could be extubated and recovered without complication
after low-profile single locking plate sternal fixation and
stabilization of the 10th thoracic vertebra with an internal fixator.
In conclusion, we suggest operative stabilization of the chest
wall by trauma surgeons in case of unstable thoracic injury
with sternal fractures not only to treat mechanical instability
but also to treat and/or prevent the development of pulmonary
insufficiency in case of initial respiratory problems as early as
patients status allows. Thereby, the sternal fracture should be
reduced and stabilized by a low-profile locking plate as well as
additional biomechanical problems like spine fracture must be
addressed.
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Reese K, Breul M, Kamminga SJ, Pieske O (2017) The Rule of Sternal Fractures in Life-Threatening Blunt-Chest-Trauma: Treatment and Indications for Opera-
tive Stabilization. J Trauma Care 3(3): 1027.
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