Sternal fracture

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A 16-year-old male football player presented five days after an injury to his chest. He described sustaining a direct blow to his anterior chest from another player’s shoulder. He was aware of an acute onset of chest pain and was unable to continue. He has experienced localised pain and tenderness since the injury with difficulty coughing, sneezing and with deep breaths.

On examination he had localised tenderness over the sternum and anterior chest wall. There was a normal cardio respiratory exam.

On a lateral x-ray image there is a subtle fracture through the mid sternum with cortical interruption anteriorly. This corresponds well with the patients area of tenderness. An AP x-ray of the chest is normal with no associated injuries.

After a thorough clinical evaluation and a normal ECG this player was diagnosed with an isolated sternal fracture. They were managed with an initial period of rest. He did very little training during the first four weeks post-injury due to pain with deep breathing and an associated limitation in exercise tolerance. From this point he was able to progress his aerobic training and resume non-contact drills. At eight weeks post-injury he had no significant tenderness and was able to resume normal training.

Sternal fractures can either occur in isolation, or with other associated injuries. Compared with other causes of trauma, like motor vehicle accidents, the sternal injuries sustained during football typically involve less force. As a result, the majority of football-related sternal injuries are not associated with other pathology. The prognosis is very good for these isolated sternal fractures, with most patients recovering completely over a period of 2-3 months. Some sternal fractures have concomitant injuries including soft tissue injuries, injuries to the chest wall and injuries to the spine, limbs and cranium.

A lateral chest x-ray is the best investigation for diagnosing sternal fractures, as the fracture and any displacement or dislocation occurs in the sagittal plane. An AP chest x-ray is useful for detecting associated injuries including rib fractures, pulmonary contusions, and haemothoraces/pneumothoraces. An ECG is suggested as part of the clinical assessment of patients with sternal injuries. Clinicians should look for features that could suggest a myocardial contusion, including sinus tachycardia, arrhythmias, conduction disturbances, or ST-segment changes.

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