The sternum is the long, flat bone situated in the center of the chest that connects the ribs via cartilage and forms the front of the rib cage. A sternum fracture typically results from a high-impact, blunt force trauma to the anterior chest wall, with the most frequent cause being motor vehicle collisions, often involving rapid deceleration forces against a seatbelt or steering wheel. While less common, direct falls, high-impact sports injuries, or even chest compressions during cardiopulmonary resuscitation (CPR) can also lead to a break.
Identifying the Severity of the Fracture
The initial assessment focuses on determining the full extent of the injury. A patient typically presents with localized, severe pain over the breastbone that often worsens significantly with deep breaths, coughing, or torso movement. Tenderness upon touch, visible bruising, or a palpable deformity at the fracture site can also indicate a break. Because the force required to fracture the sternum is substantial, medical personnel must also check for associated internal injuries to organs like the heart and lungs.
Diagnostic imaging is performed to visualize the fracture pattern and check for displacement. A lateral chest X-ray is often the initial imaging tool used because it provides a clear profile view. However, computed tomography (CT) scans, especially with sagittal and three-dimensional reconstructions, are considered the most sensitive method for characterizing the exact fracture pattern. The CT scan is also invaluable for detecting potential complications, such as a pulmonary contusion or a spinal fracture, which can occur concurrently with sternal trauma.
The severity classification hinges on whether the fracture is non-displaced or displaced and unstable. An isolated, non-displaced fracture means the bone fragments remain aligned and stable, allowing for non-surgical management. A displaced fracture, where the bone fragments have shifted significantly, or one that causes chest wall instability, often requires more intervention to prevent chronic pain or respiratory compromise. An electrocardiogram (ECG) and cardiac enzyme testing are performed to rule out a myocardial contusion.
Conservative Treatment Approaches
The primary method for fixing the injury involves conservative, non-surgical management. The cornerstone of conservative treatment is rest and strict restriction of activities that put strain on the chest wall. Patients must avoid heavy lifting, pushing, pulling, or twisting motions for approximately four to six weeks.
A regimen of adequate pain control is implemented to ensure the patient can breathe normally without restriction. Unlike with some rib fractures, chest wrapping or splinting is generally avoided for sternum fractures because it can restrict the expansion of the chest. This restriction can lead to a shallow breathing pattern, increasing the risk of developing pulmonary complications like atelectasis or pneumonia. To counteract this, patients are encouraged to perform regular deep-breathing exercises and to cough periodically.
When coughing or sneezing, patients should gently hug a pillow or a rolled-up towel against the chest to provide external support, which stabilizes the fracture site and minimizes pain. Sleeping should be done in a position that avoids pressure on the sternum, such as on the back with the head and chest slightly elevated, or in a semi-reclined position. Clinical union is typically achieved within approximately six to twelve weeks.
Surgical Repair and Stabilization
Surgical intervention is reserved for a small percentage of cases where conservative treatment is insufficient. The main indications for surgical repair are severely displaced fractures, sternal instability causing respiratory distress, or the development of non-union, which is a failure of the bone to heal after several months. The goal of surgery is to anatomically align the fractured fragments and provide immediate fixation to restore the structural integrity of the chest wall.
The procedure often involves an open reduction and internal fixation (ORIF), where the surgeon makes an incision over the sternum to visualize the fracture. Specialized orthopedic hardware, such as titanium plating systems, wires, or screws, is then used to bridge the fracture gap and secure the bone fragments in their correct position. Plating systems offer rigid fixation that stabilizes the bone in multiple dimensions, which can be beneficial for complex fracture patterns.
Restoring sternal stability is paramount, as it immediately reduces pain and allows for more effective ventilation, which is particularly beneficial for patients with associated lung injuries. Surgical fixation enables a quicker and more aggressive rehabilitation schedule compared to long-term immobilization.
Managing Pain and Recovery
The recovery phase focuses on managing discomfort and safely progressing back to normal activity levels. Pain management is a cornerstone of this phase, often involving a staggered regimen of pain relievers, including non-opioid options like acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs). Adequate pain control is essential because it facilitates deep breathing, which prevents lung collapse and infection.
The overall recovery timeline varies. The initial bone healing phase typically lasts about four to six weeks, during which physical restrictions are most stringent. However, the resolution of pain and tenderness often takes longer, with many patients reporting discomfort for eight to twelve weeks. Complete recovery, including a return to strenuous activities, can take three to six months, depending on the severity of the fracture and whether surgery was performed.
Physical restrictions involve avoiding overhead reaching or lifting anything heavier than a few pounds during the initial six weeks to protect the healing bone. Patients should also refrain from driving for several weeks, as the sudden movement required to steer or the impact of an airbag could re-injure the sternum. A gradual return to work and physical activity is managed by a healthcare provider, often incorporating physical therapy to address any stiffness in the shoulder girdle or back developed due to reduced mobility during the immobilization period.