A fractured sternum (breastbone) is an injury to the flat bone in the center of the chest where the ribs and collarbone connect. This bone shields the heart and lungs. Fractures are typically caused by high-impact, blunt force trauma, most commonly seen in motor vehicle accidents when the chest strikes a steering wheel or seatbelt. Although the resulting pain can be severe, the prognosis for an isolated sternal fracture is favorable, with most cases healing without surgery.
Identifying the Injury and Initial Medical Assessment
A sternal fracture presents with distinct symptoms, primarily sharp and intense pain localized to the center of the chest. The pain often worsens with movements that engage the chest wall, such as deep breathing, coughing, or sneezing. Patients may also notice swelling, visible bruising (ecchymosis), and tenderness when the area is lightly touched.
The initial medical assessment focuses on confirming the fracture and ruling out potential life-threatening internal injuries. The force required to break the sternum suggests the possibility of associated damage to the heart or lungs, such as a cardiac contusion, pneumothorax, or pulmonary contusion. Therefore, a 12-lead electrocardiogram (ECG) and blood tests, like troponin levels, are often performed to check for blunt cardiac injury.
Diagnostic imaging is crucial for assessing the fracture’s severity and internal complications. A lateral chest X-ray is typically the first step to visualize the break. However, a Computed Tomography (CT) scan of the chest is frequently used. A CT scan provides a more detailed, three-dimensional view of the fracture and its fragments, while also identifying any injuries to surrounding organs.
Conservative Management (Non-Surgical Treatment)
Most non-displaced or minimally displaced sternal fractures are managed conservatively, allowing the bone to heal naturally. The primary focus is managing significant pain and preventing respiratory complications. Adequate pain control is necessary because severe chest pain can cause shallow breathing, raising the risk of developing pneumonia or lung collapse (atelectasis).
Pain management typically involves nonsteroidal anti-inflammatory drugs (NSAIDs) or, for intense pain, short-term use of opioid medications. Patients should continue practicing deep breathing exercises, often using an incentive spirometer, to ensure full lung expansion despite discomfort. Supporting the chest with a pillow when coughing or sneezing (splinting) helps stabilize the fracture site and reduce pain.
Activity restriction is fundamental to allow the fracture fragments to knit together. For the first six to eight weeks, patients must avoid heavy lifting, pushing, or pulling. Limiting these movements prevents undue stress on the chest wall, which could displace the fracture or delay healing. Unlike other fractures, splinting or taping the sternum is generally avoided because it can restrict chest expansion and worsen breathing function.
Surgical Intervention and Stabilization
Surgical intervention is reserved for a small percentage of sternal fractures when conservative methods are insufficient or the injury is complex. Indications for surgery include severely displaced fractures, sternal instability, or flail chest, where a segment of the chest wall moves independently during breathing. Surgery may also be necessary if the fracture fails to heal (nonunion) or if chronic, debilitating pain persists despite appropriate conservative care.
The standard procedure for stabilizing a sternal fracture is Open Reduction and Internal Fixation (ORIF). This involves manually realigning the bone fragments (open reduction) and then securing them in place (internal fixation). Fixation is typically achieved using low-profile titanium plates and screws, which are placed directly over the sternum to provide immediate, rigid stability.
The goal of surgical stabilization is to restore the normal anatomy of the chest wall, which helps reduce pain and improve respiratory mechanics. Although ORIF offers superior stability compared to older techniques like wiring, it is a more invasive procedure and carries the risks of major surgery. The decision to operate is carefully weighed against the patient’s overall health and the specific characteristics of the injury.
Recovery Timeline and Return to Activity
The recovery timeline varies depending on the injury’s severity and the treatment type. For most isolated, conservatively managed fractures, significant improvement is typically seen within six to eight weeks, though bone healing can take up to 10 to 12 weeks. Surgical patients may face a longer recovery period, especially if they have multiple associated injuries.
A gradual return to normal daily activities is encouraged as soon as pain allows, but specific restrictions must be followed. Heavy lifting, strenuous pushing, or pulling should be avoided for the first six weeks to three months to protect the healing bone. Physical therapy is often incorporated to address potential stiffness in the shoulders and back caused by guarding the chest.
Driving is restricted until the patient is pain-free and can safely perform maneuvers like turning the steering wheel or reacting quickly, which may take several weeks. Full, strenuous activities, including contact sports or heavy manual labor, are typically restricted for at least three months, or until a physician confirms complete bone union through follow-up imaging.