http://emedicine.medscape.

com/article/826169-overview

sterna fracture

background
Sternal fractures are predominantly associated with deceleration injuries and blunt
anterior chest trauma (incidence of 3-6.8% in motor vehicle collisions). Lateral chest
radiograph is considered the gold standard for making the diagnosis, because fracture
and displacement or dislocation occurs in the sagittal plane. An anteroposterior chest
radiograph can be helpful in detecting other injuries, such as rib fracture, pulmonary
contusion, hematothorax, and pneumothorax. Mortality associated with sternal fracture
is 0.7%.[1]
patofisiologi
Most sternal fractures are caused by blunt anterior chest trauma, although stress
fractures have been noted in golfers, weight lifters, and other participants in noncontact
sports. Insufficiency fractures caused by abnormally decreased bone density or
weakened bone can occur spontaneously in patients with osteoporosis or osteopenia
(particularly in older persons, especially women), those on long-term steroid therapy, or
those with severe thoracic kyphosis. Cardiopulmonary resuscitation commonly causes
rib and sternal fractures, something that must be considered during the recovery
process from the illness that led to the cardiac arrest.
Fractures usually occur at the body or the manubrium. In one study of 79 patients with
sternal fracture, 13 (16.5%) had a fracture of the manubrium, 10 caused by seat-belt
injury. In 3 cases stabilization was performed, and follow-up showed sufficient
consolidation without complications.[2]
Surface anatomy of the sternum is shown in the illustration below.
Posterior surface of the sternum.

epidemiologi
Motor vehicle collisions account for 60-90% of sternal fractures. [3] Most of these are in
older vehicles in which a seat belt is used but no airbag deploys. [4] Those who were
unrestrained generally sustained injury from ejection from the vehicle or impact with the
steering wheel or dashboard. Direct impact sports, falls, vehicle-to-pedestrian accidents,
and assaults account for most of the rest. Spontaneous fractures and stress fractures
are rare.

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.
Sternal fractures are slightly more common in females than in males, possibly because
of shoulder restraint positioning; however, the difference is small. Sternal fractures are
more common in patients older than 50 years, possibly because of a weaker or inelastic
bony thorax. Because of the elasticity of their chest walls, children less commonly have
sternal fractures; however, when present, the underlying injuries may be more severe. [5]
Because of the lack of substantial change in size or shape of the sternum between ages
30 and 100 years, the increased incidence of sternal fracture in the elderly may be the
result of cortical thickness or bone mineral density changes in the sternum, as opposed
to changes in morphology.[5]
prognosis
The prognosis is excellent for isolated sternal fractures. Most patients recover
completely over a period of several weeks.
In rare cases of nonunion and chronic sternal pain, surgical fixation can be considered.
During pregnancy, shield the abdomen and pelvis with a lead apron prior to obtaining
required chest radiographs. NSAIDs for analgesia are contraindicated outside the first
trimester, though several category B opiate combinations exist for pain management.
In older people, provide adequate analgesia; however, consider that a patient's baseline
level of independent function may be compromised by adequate analgesics. Consider
appropriate arrangements for assistance. Consideration for admission is supported by
current trauma literature.
Although no evidence specifically links sternal fractures to abuse in this age group,
[6]
they are unusual injuries in children. Just like long bone fractures and rib fractures,
sternal fractures should heighten the suspicion of child abuse. Sternal fractures are also
more difficult to recognize on radiographs in the pediatric population and should be
suspected if deformity, crepitus and significant pain are present.