Ann Thorac Surg 2006;81:726-728
© 2006 The Society of Thoracic Surgeons
Case report
Surgical Repair of a Chronic Traumatic Sternal Fracture
Dominic R. Gallo, MD,
Earl D. Lett, MD,
William C. Conner, MD
*
Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, Texas
Accepted for publication November 24, 2004.
* Address correspondence to Dr Conner, Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, TX 78234 (Email: william.conner{at}amedd.army.mil).
 |
Abstract
|
|---|
Chronic sternal fracture nonunion is usually reported after median sternotomy, but rarely after blunt chest trauma. Most traumatic fractures of the sternum are managed nonoperatively if they are asymptomatic and nondisplaced. Acute surgical therapy is indicated for debilitating chest pain usually associated with fracture displacement. We report a case of debilitating chest pain associated with a chronic sternal fracture. Our surgical technique is discussed and the literature is reviewed.
|
Introduction
|
|---|
The literature is replete with reports on the treatment of sternal dehiscence and nonunion after median sternotomy [1–4]. This defect usually involves two sternal halves divided by a vertical pseudoarthrosis. There may be multiple bone fragments associated with transverse fractures and wire migration. The repair of these defects is variable and imaginative with varying degrees of success. Conversely, little is written about the surgical treatment of sternal fractures after blunt chest trauma, because most are managed nonoperatively with little morbidity and mortality. In the acute setting, surgical reduction is reserved for those with debilitating pain and fracture displacement. However, "old" sternal fractures that do not heal are associated with significant disability secondary to pain. We report a case of chronic sternal fracture associated with pain treated by open fixation.
Three years prior to presentation a 50-year-old man was treated nonoperatively for a sternal fracture sustained during a hard parachute landing. At presentation, he complained of severe, debilitating chest pain at his sternal fracture site with radiation to his neck and right shoulder. The patient could not sleep without pain, nor could he be gainfully employed. Examination revealed a tender 1-cm protuberance at the level of his sternomanubrial junction. There was no sternal instability, but the patient had severe discomfort at the fracture site when applying pressure at the xyphoid. A computed tomographic scan (Fig 1) showed a fracture through the sternum at the level of the sternomanubrial junction with abnormal osteophytic bone growth. The patient was offered surgical repair for debilitating chest pain associated with this fracture.
The sternum was exposed through a midline incision and bilateral pectoralis flaps were raised. The fracture was located at the sternomanubrial junction and was associated with dense fibrous scar. Subperiostial dissection from the midline of the sternum to its lateral border followed. Bilateral internal mammary arteries and branches were preserved during resection of the left and right second costal cartilage. Protected dissection of the retrosternal tissues was performed under direct vision and the fracture site was excised to viable bone using an oscillating saw. After resection, there was a 4-cm sternal defect that was reduced to 2-cm after application of a bone tenaculum. Autogenous bone was harvested from the iliac crest in order to fill the defect. Two identical 2.4-mm linear titanium plates (Synthes USA, West Chester, PA) were selected and contoured for rigid reconstruction. These were arranged in parallel on either side of the midline. The plates were secured with 3-mm titanium bi-cortical screws through 1.8-mm drill holes created on each side of the resected fracture site. A retrosternal malleable retractor protected the mediastinal structures throughout fixation. Screw length ranged from 14 to 18 mm. In each plate, four screws were placed in the manubrium above the defect and five screws were placed in the sternal body below the defect. The residual 2-cm defect was packed with a mixture of demineralized bone matrix (Grafton Gel, American Red Cross, Saint Paul, MN) and cancellous bone harvested from the iliac crest. The bone graft was supported in its position with a circumferentially contoured vicryl mesh (Fig 2). The pectoralis muscle flaps were closed in the midline over closed suction drainage. The postoperative course was unremarkable and the patient was discharged home in 4 days. The patient reports resolution of his chest pain and has performed unrestricted physical activity at 9 months postoperatively.
|
Comment
|
|---|
A sternal fracture after blunt chest trauma can cause significant pain and disability. In the acute setting, operative reduction is classically reserved for severe chest pain associated with fracture displacement or instability. Richardson and colleagues [5] outlined the benchmark for this management strategy in 1975 when they reported their experience with 11 patients after automobile accidents. All of their patients were operated on within hours to weeks after their injury. The operative technique included simple fragment fixation with sternal wires. Because the patients were explored early after injury, little bone resection was necessary. The authors described the presence of dense scar tissue when surgery was performed greater than 1 week after injury. This reportedly made surgical dissection more difficult. The authors report their results as good, but long-term follow-up was not available. Kitchens and Richardson [6] reported a similar experience with two patients in 1993. Their operative technique incorporated a tibial plateau "T" plate across the fracture site. Again, early exploration reduced the amount of bone resection and facilitated the surgical procedure. Our review of the literature yielded little available experience in the management of chronic sternal fracture nonunion after blunt chest trauma.
A single report by Bertin and colleagues [7] in 2002 describes the treatment of chronic sternal fractures associated with nonunion. In their series, 3 patients were treated for sternal fracture nonunion. Two had had previous partial sternotomy and the third had a history of remote fracture. All had debilitating chest pain. The authors' surgical technique included excision of the fracture site to clinically normal bone, rigid internal fixation with two parallel fracture fixation plates, and cancellous bone grafting of the residual sternal defect. They report excellent results at 6 weeks postoperatively. We report a similar case to the report just previously described; our patient's fracture occurred 3 years prior to presentation. He also had debilitating chest pain, and at exploration his sternal nonunion was associated with perifracture osteophytic bone growth surrounded by cicatrix. Extensive bone resection left a large sternal defect (4 cm). Appropriate surgical debridement and rigid internal fixation of the remaining bone with the use of autogenous bone graft resulted in a similar excellent result. We advocate these operative principles in the surgical treatment of chronic traumatic sternal fracture nonunion.
Chronic traumatic sternal fracture nonunion is uncommonly encountered. When its presence is associated with debilitating chest pain, it should be repaired bearing in mind the principles of (1) excision of abnormal bone, (2) rigid internal fixation, and (3) liberal use of autogenous bone graft.
|
References
|
|---|
- Smoot CE, Weiman D. Paramedian sternal bone plate reinforcement and wiring for difficult sternotomy wounds Ann Plast Surg 1998;41:464-467.[Medline]
- Chase CW, Franklin JD, Guest DP, Barker DE. Internal fixation of the sternum in median sternotomy dehiscence Plast Reconstr Surg 1999;103:1667-1672.[Medline]
- Gotlieb LJ, Pielet RW, Karp RB, Krieger LM, Smith DJ, Deeb GM. Rigid internal fixation of the sternum in postoperative mediastinitis Arch Surg 1994;129:489-493.[Abstract/Free Full Text]
- Hendrickson SC, Koger KE, Morea CJ, Aponte RL, Smith PK, Levin LS. Sternal plating for the treatment of sternal nonunion Ann Thorac Surg 1996;62:512-518.[Abstract/Free Full Text]
- Richardson JD, Grover FL, Trinkle JK. Early operative management of isolated sternal fractures J Trauma 1975;15:156-158.[Medline]
- Kitchens J, Richardson JD. Open fixation of sternal fracture Surg Gynecol Obstet 1993;177(4):423-424.[Medline]
- Bertin KC, Rice RS, Doty DB, Jones KW. Repair of transverse sternal nonunions using metal plates and autogenous bone graft Ann Thorac Surg 2002;73:1661-1662.[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
R. Raghunathan and K. Porter
Sternal fractures
Trauma,
April 1, 2009;
11(2):
77 - 92.
[Abstract]
[PDF]
|
|
|
|
|
|
|
A. I. Irani, T.-Y. Lee, A. L. Estrera, and H. J. Safi
Repair of a traumatic sternal deformity.
J. Thorac. Cardiovasc. Surg.,
November 1, 2008;
136(5):
1371 - 1372.
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
