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Journal of Trauma and Care
Case Report *Corresponding author
Kevin Reese, Department of Trauma, Orthopaedic

The Rule of Sternal Fractures Surgery and Sport-Traumatology, Evangelisches

Krankenhaus, Medical Campus University of Oldenburg,
Steinweg 13-17, 26122, Oldenburg, Germany, Email:

in Life-Threatening Blunt- Submitted: 14 February 2017

Chest-Trauma: Treatment
Accepted: 28 June 2017
Published: 29 June 2017

and Indications for Operative 2017 Reese et al.

ISSN: 2573-1246

Stabilization OPEN ACCESS

K Reese*, M Breul, SJ Kamminga, and O Pieske
Sternal fracture
Department of Trauma, Medical Campus University of Oldenburg, Germany Flail chest
Pulmonary injury
Abstract Respiratory failure
Thoracic spine lesion
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 a cardiac arrhythmia treated by a dual-chamber pacemaker,

suffered a polytrauma during road-traffic-accident. The patient
Sternal fractures are observed in high-impact-accidents
drove frontally into a barricade at a speed of approximately 50
[1,2]. The injury mechanism is usually either (a) a direct force
kilometers per hour, the cause being unknown. The steering
to the anterior chest wall most commonly seen in frontal car
wheel of the vehicle deformed and the front-airbags deployed.
collisions with steering-wheel/belt/airbag contact or (b) a
On presentation in our emergency department the patient was
flexion-compression movement of the trunk associate most
disorientated and displayed signs of intermittent somnolence
often combined with rib and/or spine fractures leading to an
(Glasgow Coma Scale 13) although there were no obvious signs
unstable thorax [1-4]. The incidence of sternal fracture described
for head injuries. The patient had compression pain on the left
in literature is rare and significantly different, ranging from
side of the chest and on the left-front pelvic region. The initial
1.5% ~18.5% but the concomitant injuries of thoracic organs in
examination revealed no severe tenderness on percussion
severe chest trauma lead to a high mortality of up to 45% [1,5-
of the lumbar spine but frontal and dorsal chest pain. Apart
7]. Unstable thorax may result in shallow tidal volumes, collapse
from abrasions and bruises there were no other pathological
of alveoli, arteriovenous shunting and hypoxemia, leading to
findings. Because of progredient pulmonary and cardio-
pulmonary insufficiency [8]. Accompanying thoracic or lumbar
spine injury was reported in up to 39.1% of patients [7,9-11]. circulatory instability emergency care was performed according
Therapeutic strategies are still under scientific discussion to the Advanced Trauma Life Support-guidelines [17]. Imaging
concerning conservative or operative treatment including choice modalities displayed an unstable thoracic spine fracture (T10, AO
of implant-type and best time between trauma and surgery not classification: type B3), a dislocated sternal fracture (Figure 1), a
only to treat the thoracic-wall but also pulmonary instability fracture of the left anterior arch of the pelvis (AO classification:
[12-16]. This paper describe a severely injured car-driver type A2), an acetebular fracture on the left side (AO classification:
after frontal collision with pulmonary insufficiency as well as type B2) (Figure 2), prepectoral subcutaneous emphysema, and a
grossly displaced sternal fracture, ribs fractures and an unstable pneumomediastinum with fractures of the fifth through seventh
vertebral fracture. rib. Additionally there was evident cardiac and pulmonary
contusion and a bilateral haemopneumothorax. Due to these
CASE PRESENTATION life-threatening thoracic organ injuries the value of the Injury
A 56-year-old male, who was generally healthy except for Severity Score revealed 21 points.

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.
Reese et al. (2017)

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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 holes) utilizing a Kocher-Langenbeck approach. 10 days after
directly to our intensive care unit. He was intubated and an last surgery he was transferred to the rehabilitation-unit. The
arterial line and a central venous catheter were inserted as well subsequent postoperative course showed no complications
as bilateral thoracic drains. The patient received rotational bed concerning wound and bone healing as well as progredient
therapy (RotoRest) and catecholamines were administered. cardiac and pulmonary stabilization without infection.
Because of the poor pulmonary function the rotational bed
therapy had to be continued for 12 days before the patient DISCUSSION
was stable enough for surgery. In a single-stage operation an Sternal fractures are rare and associated with high-energy
osteosynthesis was performed on the sternum using open impacts [1-3,6]. In combination with rib and spine fractures they
reduction and internal fixation with an angle stable locking plate. commonly lead to an unstable thorax [1,5,7,18]. In most cases
The T10 spinal fracture was treated by means of percutaneous the sternal fracture itself is no severe injury but this fracture
dorsal instrumentation bridging T8/T9 to T11/T12 (Figure 2). must be taken as a clinical sign for further life-threatening,
Postoperatively the pulmonary condition improved rapidly. intrathoracic cardiac and/or pulmonary organ lesions [8,9].
Extubation and removal of the thoracic drains were possible In accordance to the case presented, road traffic accidents are
during a 24 hour-period postoperatively. Four days later a the leading cause of such injuries [1-3]. If a sternal fracture is
second-stage surgery was performed on the acetabular fracture observed, further intrathoracic injuries must be immediately
using open reduction and internal fixation with a Reco-Plate (9 excluded [6,10,19]. In case of minor thoracic wall instability like

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

Reese et al. (2017)

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

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

Reese et al. (2017)

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ameliorate rapidly only after chest stabilization including sternal Bhren V, et al. The unstable thoracic cage injury: The concomitant
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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 Opera-
tive Stabilization. J Trauma Care 3(3): 1027.

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