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Three Part Question

In [an adult with an isolated sternal fracture following a road traffic accident] is [routine admission] warranted to [detect possible cardiac events]

Clinical Scenario

A 30 year old man presents having been involved in a front end collision while driving a car at 40mph. He is found to have sternal tenderness and an x-ray reveals a fracture. There are no other significant injuries.

Search Strategy

Medline 1966 to 12/99 using the OVID interface.
[exp accidents traffic OR traffic ti.ab.sh] AND [exp sternum OR sternum ti.ab.sh] AND [exp fractures OR fractures.ti.ab.sh] LIMIT to human and English language

Search Outcome

6 papers of which one was irelevant and 2 were of insufficient quality.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Brookes et al 1993 Australia	272 fractures over 6.5 years, 124 isolated fractures, 93% from RTA's	Retrospectice review	Accident details, fracture grade, cardiac sequalae	Isolated fracture minimal complications, arrythmias seen with age>65, IHD or digoxin	Possible missed fracrtures, retrospective design
Hills et al 1993 Australia	172 fractures over 6.5 years, 89% from RTA's	Prospective cohort study	Associated injuries	No clear association with intrathoracic injury. Slight increase in thoracic spine injury	Data collection uncertain, no uniform cardiac screen
Bu'Lock et al 1994 UK	63 patients with central chest trauma, 45 seat belt related	Prospective cohort study	ECG findings and cardiac enzymes, echocardiography	None of these needed treatment and no adverse effects seen. ECG and enzymes correlated poorly with these findings. 25% of isolated seat belt injuries had pericardial effusion	Small numbers, not all had fractures

Comment(s)

Studies are not of the best quality. More rigorous prospective studies with larger numbers are required to make definite recommendations. Isolated sternal fractures caused by seat belts with no associated injuries and normal electrocardiography and chest radiology appear to be benign and can be discharged provided pain not severe. The situation with sternal fractures caused by other mechanisms is unclear.

Clinical Bottom Line

Patients with isolated sternal fractures caused by seat belts who have a normal electrocardiography, chest radiography, and stable vital signs can be discharged.

References

1. Brookes JG, Dunn RJ, Rogers IR. Sternal fractures: a retrospective analysis of 272 cases. J Trauma - Injury Infection & Critical Care 1993;35(1):46-54
2. Hills MW, Delprado AM, Deane SA. Sternal fractures associated injuries and management. J Trauma - Injury Infection & Critical Care 1993;35(1):55-60
3. Bu'Lock FA, Prothero A, Shaw C, Parry A, Dodds CA, Keenan J, Forfar JC. Cardiac involvement in seatbelt - related and direct sternal trauma: a prospective study and management implications. Eur Heart J 1994;15(12):1621-1627