Sternal Fracture
Sternal fractures most commonly result from blunt trauma to the chest, particularly in motor-vehicle collisions in which the chest strikes the steering wheel during rapid deceleration. The incidence has been reported at between 3% and 6.8% in frontal road-traffic collisions. In newer vehicles, the risk is reduced by airbags, whereas older vehicles without these safety systems carry a higher risk of sternal injury. Other common causes include falls, sports injuries and assault.
Diagnosis is usually made with a lateral chest radiograph or CT of the thorax, which provides better visualization of the fracture line. Sternal fractures are rarely isolated and may occur together with other serious thoracic injuries such as pneumothorax, hemothorax, cardiac contusion and rib fractures. Assessment of the patient's overall condition and any comorbidities is essential for further management.
Clinically Relevant Anatomy
The sternum is a flat, vertically oriented bone that forms the midline of the anterior chest wall. It consists of three main parts:
Manubrium: the broad upper part that articulates with the clavicles and the first two ribs.
Body of the sternum: the middle and longest part, where most costal cartilages attach.
Xiphoid process: the pointed lower part, which varies anatomically in size and angulation.
Causes and Risk Factors
The most common cause of sternal fracture is direct blunt force to the chest. This is typically seen in motor-vehicle collisions, particularly when there is no airbag deployment. Other traumatic causes include:
Falls and sports injuries
Assault and direct blows to the chest
CPR (cardiopulmonary resuscitation), where compressions may cause fracture
Specific risk groups include:
Patients with osteoporosis, particularly postmenopausal women
Older adults with kyphosis or reduced bone mass
People receiving long-term corticosteroid therapy
Athletes exposed to repeated upper-body loading, for example in golf and weightlifting, may develop sternal stress fractures
Epidemiology
Sternal fractures account for a substantial proportion of thoracic injuries after road-traffic collisions, and their occurrence has been associated with shoulder-belt restraint because force can be concentrated over the sternum during sudden deceleration. The condition is somewhat more common in women and occurs more often in older adults because of reduced chest-wall elasticity. Younger patients have a more flexible thoracic cage and may sustain internal injury rather than fracture of the sternum itself.
Clinical Presentation
Patients often report severe, localized pain over or behind the breastbone after trauma. Pain is aggravated by deep inspiration, coughing or movement. Palpation commonly reveals tenderness and bruising over the sternum, and in some cases a palpable step deformity may indicate the fracture line. Dyspnea can occur and may suggest associated cardiopulmonary contusion. Arrhythmias are uncommon and are usually related to concomitant cardiac injury.
In spontaneous fractures without clear trauma, symptoms may be more diffuse and difficult to diagnose. This is particularly relevant in older women with osteoporosis, where pain may be mistaken for another thoracic or cardiovascular condition.
Differential Diagnoses
When a sternal fracture is suspected, other serious conditions must be excluded:
Rib fracture
Flail chest
Sternoclavicular dislocation
Pneumothorax and hemothorax
Aortic dissection
Spinal compression fracture
Costochondritis
Shoulder injuries
Myocardial infarction or angina
Assessment should always include respiratory status, hemodynamic stability and signs of possible intrathoracic injury. Imaging such as lateral radiography and CT of the thorax is used to identify the fracture and assess for associated complications.
Sternal Fracture: Diagnosis and Treatment
When sternal fracture is suspected, potential associated injuries to the heart, great vessels and lungs must be considered. Fractures involving the manubrium require particular attention to possible injury to the aorta and brachiocephalic vessels. With depression or displacement of the sternal body, myocardial involvement has been reported in a small proportion of cases⁴. Echocardiography, CT of the thorax and relevant cardiac investigations may therefore be indicated to exclude pericardial effusion or other cardiac injury.
Diagnostic Procedures
CT is commonly used to identify sternal fractures and associated intrathoracic injury. It provides good visualization of the fracture, displacement, retrosternal hematoma and other injuries⁴. In some cases, however, dedicated radiographic projections may still be helpful. A lateral chest radiograph or dedicated sternal views can reveal fractures that are not visible on frontal images, particularly when there is no obvious transverse displacement⁶.
On physical examination, a step deformity may be palpable along the sternum, and the patient commonly reports tenderness and pain with palpation of the anterior chest wall.
Medical Treatment
Most patients with sternal fracture do not require surgery when the fracture is stable and not significantly displaced. Conservative treatment primarily consists of activity modification and avoidance of provocative movements for approximately 4–6 weeks¹⁶. Taping or rigid immobilization of the chest wall is contraindicated because it restricts normal chest expansion and may increase the risk of atelectasis and respiratory complications.
Deep breathing is recommended to help prevent pulmonary complications, with adequate analgesia when pain restricts respiratory movement.
Surgical stabilization is rarely required, but selected painful or unstable fractures may benefit from operative fixation when conservative management is insufficient⁷.
Physiotherapy Management
Once serious associated injuries have been excluded and the fracture is confirmed as uncomplicated and stable, physiotherapy can begin. Treatment should be adapted to the phase of healing and the patient's functional level.
During the acute phase, the goals are to reduce pain, prevent respiratory complications and preserve movement and function. The patient should avoid:
Overhead activities
Pushing, pulling and lifting loads greater than approximately 2–3 kg
Direct pressure on the chest, such as prone lying
Recommended early-phase interventions include:
Local heat or cold for pain relief
Analgesia in consultation with a physician
Deep-breathing exercises to maintain lung volume and mobilize secretions
Early mobilization of the shoulder and thorax through gentle movement and stretching
Attention to posture and optimal function of the shoulder girdle and chest wall
As pain decreases and healing progresses, mobility and strengthening exercises can gradually be introduced. These may focus on:
Shoulder mobility in all planes
Chest-opening movements and thoracic stretching
Strengthening of shoulder stabilizers, the upper back and deep core musculature
Rehabilitation should also include exercises to restore postural control, normalize breathing patterns and prevent stiffness. When appropriate, therapeutic taping, manual techniques and proprioceptive neuromuscular facilitation (PNF) may be used to support mobility and stability.
Return to Activity
After healing, daily activities should be resumed gradually according to pain and function. Persistent or worsening symptoms should not be ignored, as this may delay or prevent full recovery. Return to sport should be progressive and coordinated with the treating clinician. Chest protection may be considered for contact sports to reduce reinjury risk.
In severe fractures, particularly after surgical stabilization or when associated injuries are present, rehabilitation may extend over several months. These patients may require multidisciplinary follow-up and an individualized exercise program with gradual progression.
Sources:
Bentley TP, Journey JD. Sternal Fracture. InStatPearls [Internet] 2019 Jan 5. StatPearls .:https://www.ncbi.nlm.nih.gov/books/NBK507790/
Gray’s Anatomy of the Human Body, fig. 115 – anterior surface of sternum and costa cartilages.
Karen Mulloy Restifo, Gabor D. Kelen,1994, “Case report: sternal fracture from a seatbelt”, The Journal of Emergency Medicine, Volume 12, Issue 3, May–June 1994, Pages 321-323
Anne Grethe Jurik, 2007, “Imaging of the Sternocostoclavicular Region”
Scott Felten, American College of Emergency Physicians, 2012, Medscape, “Sternal fracture”, presentation, history
Scott Felten, American College of Emergency Physicians, 2012, Medscape, “Sternal fracture”, Workup, Imaging studies
Scott Felten, American College of Emergency Physicians, 2012, Medscape, “Sternal fracture”, Treatment, Consultations
Athletic edge Sternal Fracture :http://www.athleticedge.biz/Sternal_Fracture.html
Seconde referention of MDGuidelines (http://www.mdguidelines.com/fracture-sternum-closed) Collins, J., 2000, "Chest Wall Trauma.", Journal of Thoracic Imaging 15 2: 112-119. Salter, Robert, ed., 1999, Textbook of Disorders and Injuries of the Musculoskeletal System. 3rd ed.
