Working Diagnosis:
fracture of manubrium without sternoclavicular dislocation

Treatment:
Arm sling with immobilization for 4 weeks with gradual return to range of motion thereafter. Ice and multimodal pain control.

Outcome:
Essentially pain free after 2 weeks except with extreme adduction or abduction. Out of sling after 3 weeks and able to start conditioning after 6 weeks. Full return to lacrosse after 10 weeks.

Author's Comments:
High energy chest collisions are not uncommon among contact and collision sports. Fractures to the sternum and sternoclavicular joint are infrequent in this population. Sternoclavicular joint dislocations and fractures are most commonly seen in auto accidents with sports injuries being second most common.

The differential diagnosis for high energy collisions should include clavicular fracture, anterior and posterior SC joint dislocation, sternum/manubrium fracture, commotio cordis and vascular injury including subclavian artery/vein, aorta and carotid arteries.

Diagnostic modalities may include ultrasound or the 45 degree cephalic tilt plain film (serendipity view). The gold standard is CT scan.

Management consists of figure of eight brace or arm sling x 4-6 weeks. Return to conditioning once pain free with ROM and no tenderness to palpation over fracture site. Full contact sports after an additional 4 weeks. Operative management usually reserved for symptomatic adults with posterior SC dislocations.

Editor's Comments:
Most sternal fractures are caused by blunt anterior chest trauma, as seen in this case. There are rare case reports of sternal stress fractures in athletes such as wrestlers, golfers, weight lifters and gymnasts.
Evaluation of patients with blunt anterior chest trauma should include evaluation for associated injuries such as cardiac or pulmonary contusion, retrosternal hematoma, rib fractures which can result in a pneumothorax, or rarely aortic injury. Given this, many authors recommend obtaining an EKG and monitoring pulse oximetry and cardiac enzymes along with the imaging studies recommended by the authors.
Nonunion of sternal fractures is rare but may result in a painful pseudoarthrosis requiring surgical repair.

References:
DeLee JC, Drez D Jr, Miller MD. DeLee and Drez’s Orthopedic Sports Medicine, 3rd ed. c2009 Saunders. Chapter 17 – Shoulder

Harley DP, Mena I. Cardiac and Vascular Sequelae of Sternal Fractures. J Trauma. 1986;26(6):553-555

Hassan, I. et al. Sternal stress fracture in a gymnast: A case report and literature review. South African Journal of Sports Medicine. 2010; 22(2): 50-51.

Potaris K. et al. Management of sternal fractures: 239 cases. Asian Cardiovasc Thorac Ann. Jun 2002;10(2):145-9

Sadaba JR, Oswal D, Munsch CM. Management of Isolated Sternal Fractures: Determining the risk of cardiac injury. Ann R Coll Surg Engl. 2000; 82(3):162-66

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