Sternal Fracture: Car Crashes, Sports, and Chest Compressions as Possible Causes

Sternal fractures occur in about 5% of blunt chest trauma. The manubrium is the most commonly injured part, seen in 3–6.8% of all motor-vehicle collisions. CPR is another frequent cause: one cadaver study found that 18% of subjects had a sternal fracture, 85% of them in the sternal body. (That said, when performing CPR, saving the person comes first; a sternal fracture can be dealt with afterward.)

The sternum is a flat bone in the center of the anterior chest wall. It is made of three parts: the manubrium (upper), the body (middle), and the xiphoid process (lower).

Mechanisms of injury

• Direct injury:

  • Caused by a direct force acting on the sternum, most commonly from a blow to the lower sternal body
  • The fracture usually occurs near the manubrium

• Indirect injury:

  • Caused by flexion-compression injury of the cervicothoracic spine, usually when the neck is forced into flexion, so that the upper two ribs push the manubrium backward
  • Can be worsened by the chin striking the manubrium
  • Usually involves the upper two segments of the sternum

• Stress fracture:

  • Caused by repetitive motion of the chest-wall muscles, ribs, and clavicle, transmitting stress to the sternum

• Muscle-induced fracture:

• Caused by vigorous muscle action producing a fracture between opposing muscle groups

• Extremely rare

Epidemiology

• Sternal fractures are uncommon, especially in children and adolescents, because the sternum and costal cartilage are elastic
• They occur more often in men (60–80%)
• Incidence varies by location

Etiology

• Adults:

  • Most often related to motor-vehicle collisions (68–84%), usually from direct mechanisms
    • Striking the steering wheel or dashboard
    • Flexion of the sternum over a diagonal shoulder-belt
  • Although seat belts reduce the risk of serious injury, they do not appear to reduce the incidence of sternal fracture; they do, however, reduce the risk of internal injury
  • Other causes of direct trauma include:
    • Motor-vehicle crashes (car striking a pedestrian), CPR, direct-contact sports, falls, and assault

• Children:

• Most often from falling off a bicycle (direct) or falling from a height (indirect)

• Indirect forces are more likely to trigger a pathological or insufficiency fracture

Risk factors

• Patients with reduced bone density or weakened bone may develop a spontaneous insufficiency fracture, commonly seen in:
  • Women, long-term corticosteroid users, and those with severe thoracic kyphosis
• Repetitive upper-body sports (such as golf, wrestling, and weightlifting) can lead to stress fractures

History

• Typical symptoms include anterior chest pain that often worsens with breathing, moving, coughing, or sneezing
• The injured person often has a clear history of trauma, such as a traffic accident, direct blow, or fall
• A chronic stress fracture may present as persistent or recurrent anterior chest pain related to activity

Physical examination

• Inspection:
  • Check for chest deformity, bruising, or swelling
• Palpation:
  • Tenderness may localize to specific areas of the manubrium or sternal body
  • There may be a sense of sternal instability or crepitus
• Movement testing:
  • Deep breathing, coughing, or chest-wall expansion may aggravate the pain
• Associated evaluation:
  • Confirm whether the chest has an associated rib fracture or other injury
  • Ensure cardiopulmonary function is normal and rule out organ injury

Diagnostic tools

• Initial evaluation

  • X-ray
    • Used first to check for a sternal fracture; it may show a fracture line or deformity
    • A sternal fracture is easier to detect on the lateral view
  • Ultrasound
    • Can be used to detect chest-wall soft-tissue injury or hematoma, and may show a cortical fracture or step-off

• Further evaluation

  • CT scan
    • The best imaging tool for assessing a sternal fracture, clearly showing the fracture details
  • MRI:
    • Used to rule out soft-tissue injury or organ damage

• Other tests:

• For a suspected combined injury, an ECG or echocardiography may be needed

Initial treatment

• Immediate management:

  • Have the patient avoid further activity and provide analgesics to relieve pain
  • Ensure the patient is stable and watch for signs of organ injury

• Conservative treatment:

  • Most patients with a non-displaced fracture need only conservative treatment, avoiding overly strenuous movements for four to six weeks
  • Avoid overhead activities, pushing, pulling, and lifting objects heavier than 2 to 3 kg, as well as activities that place large amounts of pressure on the sternum
  • Analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs) can relieve pain; if pain is marked, short-term opioids may be needed
  • Once pain improves, deep breathing and coughing can be encouraged to avoid atelectasis

• Inpatient treatment:

• If the patient has an associated organ injury, hospital observation or surgical treatment may be needed

Medications

• Acute treatment:

• Non-steroidal anti-inflammatory drugs (NSAIDs) are the first-line medication; commonly used ones include naproxen 500 mg twice daily or indomethacin 50 mg three times daily

• COX-2 inhibitors such as celecoxib are comparable in efficacy to traditional NSAIDs with fewer side effects

• If NSAIDs are contraindicated, corticosteroids such as prednisone or methylprednisolone may be considered

• Severe pain may require short-term opioids such as tramadol

• To prevent lung infection, deep-breathing and coughing exercises should be added

Other treatments

• Physical therapy or breathing training

  • In the acute phase, reduce forceful breathing or repeated impact to prevent worsening pain
  • In the recovery phase, aim to restore chest-wall function and stability, including improving deep breathing and chest movement

• Other conservative therapies

• Heat or cold application can relieve pain effectively and promote local blood circulation

Surgery

• Indications

  • If a sternal fracture causes significant displacement, instability, or is accompanied by organ injury, surgical treatment may be needed
  • Common methods include plate internal fixation or wire fixation

• Considerations

• Patients with severe trauma usually need combined surgery to manage multiple-site injuries

• After surgery, infection should be prevented and regular imaging follow-up performed

Follow-up

• Sternal pain lasts 8 to 12 weeks in almost everyone, but the pain is worst early on. Most patients with a sternal fracture become symptom-free within 3 months, and about 70% fully recover within 1 year

• An isolated sternal fracture has a very good prognosis under conservative treatment; most heal within a few months, and mortality is very low (under 1%)

• A follow-up visit is recommended after 4–8 weeks to assess the patient’s range of motion and chest-wall stability; if symptoms persist, further imaging (such as ultrasound or X-ray) may be needed

• Long-term prognosis mainly depends on whether there is organ or cardiovascular injury. In rare cases, chronic pain or limited respiratory function may affect quality of life

• Poor prognostic indicators

• Older age, female sex, a fracture with associated organ injury, and irregular fracture displacement

This article is general medical health education, not individual medical advice, and makes no guarantee of any treatment outcome. The actual assessment and management still depend on a physician’s evaluation of the individual injury.

References

• https://radiopaedia.org/articles/sternal-fracture
• https://www.radiologymasterclass.co.uk/gallery/trauma/x-ray_spinal_2/fractures_1
• Sternal fractures and their management. J Emerg Trauma Shock. 2013 Apr-Jun;6(2):113–116.
• Current treatment and outcomes of traumatic sternal fractures-a systematic review. Int Orthop. 2019 Jun;43(6):1455-1464.

Further reading

• Sports Injuries Overview
• PRP Prolotherapy
• Rehabilitation Exercise Prescription
• Pain Management