Diagnosis and Management of Sternal Fracture at a Single Center 2019–2024: A Retrospective Study of 127 Emergency Department Patients

Introduction

Traumatic injuries are a significant global health problem, particularly affecting young people, and are associated with high morbidity and mortality rates and loss of employment. Injuries to multiple body parts due to trauma increase the severity of the condition [1,2].

Sternal fracture (SF) is an uncommon but clinically important consequence of blunt chest trauma, occurring in approximately 3–8% of patients with such injuries [3–5]. SF most frequently results from direct, high-energy forces to the anterior chest wall, particularly in motor vehicle collisions, and falls, including workplace accidents and falling from trees, are another important cause of fractures [6,7]. Although trauma may be isolated, it often serves as a marker of significant impact [8]. SF is commonly associated with concomitant thoracic and extrathoracic injuries, including rib fractures, vertebral fractures, flail chest, pulmonary contusions, and injuries to internal thoracic organs [9–11]. While isolated SFs generally have a favorable prognosis, concomitant injuries substantially increase the risk of complications and mortality. Among SFs, fractures involving the manubrium and displaced fractures are associated with more severe outcomes and may occasionally necessitate surgical intervention, although most cases are managed conservatively [4].

Early recognition of SF and associated injuries in the ED is crucial, as these patients may present with potentially life-threatening conditions such as cardiac contusion or great vessel injury. Previous studies have predominantly focused on the general epidemiology and outcomes of SF; however, data specifically comparing displaced and non-displaced SFs in terms of associated injuries, clinical characteristics, and ED outcomes remain limited. This is particularly important for emergency physicians, who are often the first to evaluate these patients and must quickly identify those at higher risk. Clinicians often diagnose these fractures using lateral chest radiographs or chest computed tomography (CT) scans [12].

This study comprehensively analyzed the demographic, clinical, biochemical, and radiological characteristics of patients with SF, focusing specifically on the differences between displaced and non-displaced fractures. By identifying patterns associated with fracture displacement, this study aims to provide new information that can aid in early risk stratification and guide management strategies in the ED.

Material and Methods

ETHICAL CONSIDERATIONS:

This study was approved by the Ankara Bilkent City Hospital TABED Ethics Committee (document number 2–25–776). The study was conducted in accordance with the Declaration of Helsinki. After obtaining approval from the hospital administration and the ethics committee, the dataset was extracted from the hospital’s electronic medical records (EMR) system. All data were anonymized before analysis; no identifying information, such as patient names or photographs, was accessible to the researchers. Informed consent was waived due to the retrospective nature of the study and the use of anonymized data.

STUDY DESIGN AND SETTING:

This retrospective cross-sectional study was conducted in the ED of Ankara Bilkent City Hospital. Medical records of patients presenting with SF between March 1, 2019, and December 31, 2024, were reviewed. Patients were identified using the International Classification of Diseases (ICD) codes S22.2 and S22.23.

STUDY POPULATION AND ELIGIBILITY CRITERIA:

Patients aged 18 years and older with a radiologically confirmed SF were eligible. Exclusion criteria were missing or incomplete clinical and imaging data, absence of thoracic computed tomography (CT) imaging, patients transferred to another hospital before imaging, and those who left the hospital against medical advice.

A total of 163 patients were initially identified, and 36 were excluded due to incomplete records or lack of imaging, leaving a final study population of 127 patients.

DATA COLLECTION:

Data were retrieved from the EMR, radiology, and laboratory information systems. Extracted variables included: Demographics (age, sex, driver/passenger status, and mechanism of injury); Clinical characteristics (Glasgow Coma Scale [GCS] score, presence of associated injuries, hospital admission status, length of stay, and in-hospital mortality); Radiological findings (fracture location (manubrium, body), fracture status (displaced or non-displaced), presence of rib fractures, hemothorax, pneumothorax, pulmonary contusion, and vertebral fractures, as confirmed by CT); Electrocardiography and echocardiography (ECG findings [normal sinus rhythm or ST-segment changes], echocardiographic assessment, and evidence of cardiac injury); Laboratory data (white blood cell count [WBC], hemoglobin [HB], red cell distribution width [RDW], mean platelet volume [MPV], platelet count [PLT], glucose, aspartate aminotransferase [AST], alanine aminotransferase [ALT], lactate dehydrogenase [LDH], creatine kinase [CK], alkaline phosphatase [ALP], troponin, CK-MB, base deficit, and lactate. All laboratory analyses were performed using automated analyzers in the hospital’s central biochemistry laboratory.

PATIENT SELECTION:

Patients who were admitted to the ED due to a SF were included in the study. Patients were scanned from the information system using the S22.2 and S22.23 ICD codes. Patients over 18 years of age were included in the study. The patients’ thoracic computed tomography (CT) scans were used as a basis to determine whether the SF was displaced. Patients without thoracic CT scans in the system and those whose information could not be obtained (ie, those referred to another hospital and those who left the hospital of their own free will) were excluded from the study.

CHARACTERISTICS OF GROUPS:

Patients with SF were divided into 2 groups: displaced SF and non-displaced SF. This distinction was made based on the patients’ thoracic CT reports.

STATISTICAL ANALYSIS:

SPSS (IBM Corp., Armonk, NY, USA) version 25 was used for analyses. Patient demographic data are expressed as n and percentage. The Kolmogorov-Smirnov test was used to check the data for normal distribution, and nonparametric tests were used when non-normal distribution was observed. Patient data and biomarker values were compared according to whether the patients had displaced or non-displaced SF. The chi-square test and Fisher’s exact test were used in the analysis of categorical variables. The Mann-Whitney U test was used in analyses of 2 independent groups. The Kruskal-Wallis test was used in multiple-independent group analyses, and post hoc analysis was performed with the Mann-Whitney U test. The study’s alpha error was set at 0.05.

Results

DEMOGRAPHIC AND CLINICAL CHARACTERISTICS:

A total of 127 patients with SFs were included in the study. Of these, 89 (70.1%) were male and 38 (29.9%) were female. The median age was 43 years (range: 10–89). The most common mechanism of trauma was motor vehicle accidents (62.2%), followed by falls from height (15.0%), and simple falls (8.7%). Pedestrian accidents and assaults each accounted for 3.1% of cases, while electrical injuries were observed in 1.6% (Table 1).

Regarding the seating position in themotor vehicle, 51.2% of the patients were drivers and 12.6% were passengers. Hospitalization data showed that 26.0% of the patients were discharged from the ED, 55.1% were admitted to general wards, and 18.9% required intensive care unit (ICU) admission. The median length of hospital stay was 3 days (range: 0–40), and the overall mortality rate was 4.7% (Table 1).

ASSOCIATED INJURIES:

Thoracic trauma accompanied SF in 99.2% of the cases. Other commonly associated injuries included head trauma (37.8%), vertebral fractures (33.1%), upper-extremity trauma (31.5%), and lower-extremity trauma (22.8%). Abdominal trauma and pelvic trauma were observed in 20.5% and 6.3% of patients, respectively (Table 2).

THORACIC IMAGING AND CARDIAC EVALUATION:

Among thoracic imaging findings, displaced SF were present in 46.5% of cases. Rib fractures were observed in 39.7% of patients, with 21.3% having less than 2 fractured ribs and 18.4% more than 2. Hemothorax (20.5%), pneumothorax (15.7%), pulmonary contusion (7.1%), and flail chest (0.8%) were also noted (Table 3).

Echocardiography (ECO) was performed in 87.4% of patients, revealing cardiac injury in 1.6%. Electrocardiographic (ECG) evaluation showed normal sinus rhythm in 77.2% of patients, while 22.8% had ST-segment changes (Table 3).

DISPLACED VS NON-DISPLACED SF:

Comparison between patients with displaced and non-displaced SF revealed that head trauma (50.8% vs 26.5%, p=0.005), abdominal trauma (33.9% vs 8.8%, p<0.001), and upper-extremity trauma (40.7% vs 23.5%, p=0.030) were significantly more common in the displaced SF group. Additionally, ST-segment changes on ECG were more frequent in patients with displaced SF (35.6% vs 11.8%, p<0.001), while normal sinus rhythm was more prevalent in the non-displaced SF group (88.2% vs 64.4%, p<0.001) (Table 4).

Although not statistically significant, a higher mortality rate was observed in the displaced group compared to the non-displaced group (8.5% vs 1.5%, p=0.075) (Table 4).

BIOMARKER COMPARISON:

Patients with displaced SF had significantly higher levels of CK-MB (median 3.73 vs 2.30, p=0.007), blood glucose (125.00 vs 98.00, p<0.001), AST (51.00 vs 33.50, p=0.014), CK (354.00 vs 205.00, p=0.009), and WBC count (12.30 vs 9.27, p=0.002) compared to those with non-displaced fractures. Other laboratory parameters showed no statistically significant differences (Table 5).

Discussion

In this study, we analyzed the demographic features, mechanisms of injury, associated injuries, and clinical outcomes of 127 patients with SF, with a particular focus on the differences between displaced and non-displaced SF. Most patients were male (70.1%) with a median age of 43 years, and motor vehicle accidents were the leading mechanism of injury. Thoracic trauma was almost universal, and 1 in 3 patients had head or vertebral injuries. While 55% of patients required hospitalization in general wards, 18.9% were admitted to the ICU, and the overall mortality was 4.7%. Displaced SF were associated with a higher frequency of concomitant injuries, abnormal ECG findings, and elevated serum biomarkers (CK-MB, AST, CK, blood glucose, WBC). Although mortality was higher in displaced SF, this difference was not statistically significant.

The demographic profile of our cohort, comprising 70% male patients with a median age of 43 years, is consistent with previous studies [13,14]. The predominance of men likely reflects greater exposure to high-energy mechanisms, such as occupational risks and driving behaviors. This concentration in the middle-aged population underscores the economic and social impact of trauma in this age group. Most patients had a GCS of 15 on admission, which aligns with prior studies showing that many SF patients present with mild head trauma and generally favorable initial neurological status [15].

Displacement of the SF was observed in nearly half of our cohort (46.5%), which is higher than the 11% reported by Velissaris et al [16]. This difference may be explained by the routine use of chest CT in our study population, enabling more accurate detection of even subtle displacement.

Consistent with WHO data and other national and international reports, motor vehicle accidents were the leading cause of injury in our study [17]. Falls, both from height and at ground level, were the next most frequent mechanisms, a finding similar to that reported by Balzer et al [18]. These mechanisms, particularly in older adults, remain an important target for injury prevention strategies.

Our findings support prior studies indicating that displacement is a marker of more severe injury, as evidenced by the higher rates of associated injuries, ECG abnormalities, and abnormal biochemical parameters [19,20]. Specifically, head trauma, abdominal trauma, and upper-extremity injuries were significantly more frequent among patients with displaced fractures, suggesting a greater transfer of kinetic energy during the injury event.

The associated injury patterns in our series are comparable to those described in previous research, with head injuries (37.8%) and vertebral fractures (33.1%) occurring commonly, particularly after high-energy trauma [21]. Thoracic injuries such as rib fractures, hemothorax, and pneumothorax were also frequent, emphasizing the need for systematic chest imaging in all patients with suspected SF. Recinos et al found that 49.6% of SF cases had associated rib fractures, similar to our finding of 39.7% [14]. A review by Oyetunji et al found 33.7% of SF cases had lung contusion, while our study found 7.1%; this difference might be due to our study covering a smaller geographic area [22]. While the incidence of echocardiographically confirmed cardiac injury was low (1.6%), our findings corroborate the results of Nair et al [23], who also reported that structural cardiac damage is relatively uncommon. Nevertheless, ECG abnormalities, particularly ST-segment changes, were more prevalent in the displaced fracture group, suggesting that cardiac monitoring remains an important part of the evaluation. Elevated levels of CKMB, CK, and AST in patients with displaced fractures further support the hypothesis that these injuries are associated with more severe musculoskeletal and potential myocardial damage, as previously described [24]. Aamir et al found a mortality rate of 7.63%, which is similar to our finding of 4.7% [25].

These findings have several important clinical implications. The identification of a displaced SF on CT should alert clinicians to the possibility of associated multi-system trauma. A structured approach, including thorough imaging, cardiac evaluation, and monitoring, should be considered in this patient group. In addition, the strong associations between fracture displacement, ECG changes, and biomarker elevations suggest that these readily available parameters could serve as early indicators of increased injury severity in emergency settings.

This study has limitations that warrant consideration. Its retrospective, single-center design introduces potential selection bias and limits generalizability. Data were extracted from electronic hospital records, which are subject to documentation variability, and some important variables may have been incompletely recorded. The number of outcome events, particularly deaths and cardiac injuries, was relatively small, limiting the power to detect differences and precluding advanced multivariable analysis. Additionally, CT, while highly sensitive for detecting fracture displacement, can overestimate minor positional changes, and echocardiography can miss subtle or late-onset cardiac injuries. Finally, the absence of long-term follow-up data prevented assessment of late complications and functional recovery. Future multicenter, prospective studies with standardized imaging and cardiac evaluation protocols are needed to validate these findings and to assess their prognostic implications.

Conclusions

SF most often result from motor vehicle accidents and are rarely isolated injuries. Displaced fractures, in particular, are strongly associated with multi-system trauma, abnormal ECG findings, and elevated biomarkers (troponin, CK-MB, CK, AST, WBC, and glucose), all of which indicate a greater injury severity. These results highlight the importance of recognizing displaced SF as a marker of high-energy trauma and suggest that such patients require comprehensive imaging, cardiac monitoring, and close observation in the ED. Although mortality was higher in the displaced fracture group, this difference was not statistically significant. Future prospective multicenter studies are warranted to validate these findings and to incorporate fracture displacement into early risk stratification tools.