(Also known as a Fractured Sternum, Sternum Fracture, Broken Sternum)
What is a sternal fracture?
A sternal fracture is a condition characterized by a break in the sternum bone (breast bone) situated at the front of the chest (figure 1).
The chest comprises of 12 rib bones on each side of the body in addition to the sternum (breast bone) forming the front wall of the chest. The sternum (breast bone) provides the attachment point for the 2 clavicles (collar bones) on either side of the upper chest and the upper 7 ribs (figure 1).
Following a direct blow to the chest, stress is placed on the sternum bone, which may cause injury. This can result in a bruised sternum, or, if the impact is traumatic and beyond what the bone can withstand, a break in the sternum may occur. When the latter occurs, the condition is known as a sternal fracture.
Due to the large forces required to break the sternum bone, a sternal fracture may be associated with damage to other structures and organs of the body such as the ribs, vertebrae, heart, lungs, soft tissue and local blood vessels. These injuries (particularly to the heart and lungs) may be very serious and are more common if the fracture is severe and / or displaced.
Cause of a sternal fracture
A sternal fracture usually occurs following a traumatic, direct blow to the chest from an object or person. This most commonly occurs due to a motor vehicle accident whereby the moving chest strikes the steering wheel or seat belt. Occasionally it may occur due to a collision with another player during contact sports, such as football or rugby, or, from an impact from a ball in sports such as hockey or cricket.
Signs and symptoms of a sternal fracture
Patients with a sternal fracture typically experience a sudden onset of chest pain at the time of injury. Pain is often sharp and intense and may increase during deep breathing, coughing, laughing or sneezing. Patients may also experience an ache in the front of the chest that is particularly prominent at night or first thing in the morning (particularly in the first few days following injury). Pain may increase when lying down in certain positions (such as face down or on your side) and on firmly touching the sternum at the site of injury. Swelling and / or bruising may also be evident. In severe sternal fractures with bony displacement, an obvious deformity may be present. Patients with this condition may also experience pain with certain movements of the upper back and chest (such as twisting, bending forwards or sideways, or arching backwards) and with certain movements of the upper limb (such as pushing, pulling, heavy lifting or with overhead activities).
Diagnosis of a sternal fracture
A thorough subjective and objective examination from a physiotherapist or doctor is important to assist with diagnosis of a sternal fracture and to determine the likelihood of associated damage to other organs such as the lungs (e.g. a pneumothorax) or heart. An X-ray is required to confirm diagnosis. Other investigations such as an MRI or CT scan may also be performed to confirm diagnosis and assess the severity of injury, as well as other tests to assess heart and lung function.
Treatment for a sternal fracture
Before commencing treatment, patients with a sternal fracture should undergo a thorough medical examination to exclude serious conditions such as damage to the heart, lungs, local blood vessels or other vital organs. Once these conditions have been excluded, and the sternal fracture has been confirmed as only minor and non-displaced, treatment will typically consists of rest from aggravating activities, pain relieving medication and the encouragement of pain free deep breathing exercises to prevent localized collapse of the lungs.
In more severe sternal fractures, such as those with bony displacement, surgical intervention may be required to restore bony alignment and fixate the bones using pins or plates.
It is important that all patients with a fractured sternum rest sufficiently from any activity that increases their pain. Activities which place large amounts of stress through the sternum should also be avoided, particularly lying face down and applying direct pressure or impact to the chest. Rest from aggravating activities allows the healing process to take place in the absence of further damage. Once the patient can perform these particular activities pain free, and, once fracture healing has been confirmed, a gradual return to these activities is indicated provided there is no increase in symptoms. This should take place over a period of weeks to months with direction from the treating physiotherapist or surgeon.
Ignoring symptoms or adopting a 'no pain no gain' attitude is likely to cause further damage and may slow healing or prevent healing of the sternal fracture altogether.
Gently icing the sternum in the initial phase of injury (first 72 hours) can assist in reducing pain and swelling. This should generally be applied on the way to receiving urgent medical attention and can be maintained for 20 minutes every 2 hours.
Exercises to improve posture, flexibility and strength should also be performed to prevent stiffness and weakness from developing. The treating physiotherapist can advise which exercises are appropriate and when they should be commenced.
In the final stages of rehabilitation, a gradual return to activity or sport can occur as guided by the treating physiotherapist and provided symptoms do not increase. The use of protective padding or chest guards may be required when returning to contact sports or ball sports following a sternal fracture to prevent further injury.
Prognosis of a sternal fracture
Patients with an isolated sternal fracture in the absence of damage to other structures or organs of the body usually make a full recovery with appropriate management. Patients can usually return to activity or sport in weeks to months although care must be taken when returning to contact sports as the sternum is unlikely to regain full strength for many months. Patients with more severe sternal fractures, particularly those which require surgical correction, or when other structures have been involved, will usually require a prolonged period of management over many months before recovery can take place.
Physiotherapy for a sternal fracture
Physiotherapy treatment can assist patients with this condition and help to ensure they have a safe return to activity. Treatment may comprise:
- electrotherapy (e.g. ultrasound)
- protective padding
- soft tissue massage
- joint mobilization (following completion of fracture healing)
- exercises to improve posture, flexibility and strength
- breathing exercises to prevent localized lung collapse
- activity modification advice
- a graduated return to activity plan
Other intervention for a sternal fracture
Despite appropriate management, some patients with a fractured sternum do not improve and require other intervention to ensure an optimal outcome. The treating physiotherapist or doctor can advise on the best course of management when this is the case. This may include further investigations such as X-rays, CT scan or MRI or referral to appropriate medical authorities who can advise on any intervention that may be appropriate to improve the condition.
Exercises for a sternal fracture
The following exercises are commonly prescribed to patients with a fractured sternum throughout varying stages of the recovery process. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 3 times daily and only provided they do not cause or increase symptoms.
Shoulder Blade Squeezes
Begin sitting or standing tall with your back straight (figure 2). Squeeze your shoulder blades together as far as possible pain-free. Hold for 1-2 seconds and repeat 10 times provided there is no increase in symptoms.
Figure 2 – Shoulder Blade Squeezes
Begin sitting or standing tall with your back straight (figure 3). Breathe in as deeply as possible without increasing symptoms and then relax. Focus on breathing with your lower lungs (instead of elevating your shoulders) and allow your stomach to gently expand. Repeat 5 times.
Figure 3 – Deep Breathing (in standing)
Rotation in Sitting
Begin sitting tall, with your arms across your chest. Keeping your legs still, gently rotate to one side until you feel a mild to moderate stretch pain free (figure 4). Hold for 1 - 2 seconds and repeat 10 times to each side.
Figure 4 – Rotation in Sitting (left side)
Find a Physio for a sternal fracture
Find a physiotherapist in your local area who can treat patients with a fractured sternum.
Physiotherapy products for a sternal fracture
Occasionally, physiotherapists may recommend products to patients with a sternal fracture to improve posture and/or to protect the sternum from further damage. These products may include:
- Posture Supports
- Sports Tape (for postural taping)
- Protective Padding
- Chest Guards
To purchase physiotherapy products for a fractured sternum click on one of the above links or visit the PhysioAdvisor Shop.
Download the 'PhysioAdvisor Exercises' iPhone App to your iPhone.
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