Here's what I teach:
Sternal fractures. This injury is classically caused by a frontal road crash to a patient restrained in a seat belt. The
complaint is of chest pain which is central and usually pleuritic in nature. The sternum is exquisitely tender at one point
and this is diagnostic. The entire chest should be carefully examined to ensure that there are no associated injuries but
X-rays are not necessary if there is no clinical suspicion of them. The patient must have an ECG performed, however.
This is important as the most common complication of blunt chest trauma is myocardial contusion, and the most useful
test of this is an abnormal ECG. The following are signs of concern: new rhythm disturbances (particularly multifocal
VEs), evidence of myocardial ischaemia or frank infarction or persistent hypotension that is not related to other injuries.
Minor myocardial bruising is common and of no clinical significance, although ultrasound and enzymes are often
abnormal. This is why these should not be used as a screening test in the Emergency Unit.
If the ECG is abnormal or there are other associated features such as a suspicion of diaphragmatic rupture the patient
should be admitted for overnight observation and this must include continuous ECG monitoring. Any deterioration
should prompt ultrasound investigation. Otherwise the patient should be allowed home with an advice card. It is wise to
warn the patient that recovery from a sternal fracture can be prolonged - a month to 6 weeks of discomfort is not
uncommon.
Best wishes,
Rowley Cottingham
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http://www.emergencyunit.com
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