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Case Report *Corresponding author Kevin Reese, Department of Trauma, Orthopaedic Surgery and Sport-, Evangelisches The Rule of Sternal Fractures Krankenhaus, Medical Campus University of Oldenburg, Steinweg 13-17, 26122, Oldenburg, Germany, Email: in Life-Threatening Blunt- Submitted: 14 February 2017 Accepted: 28 June 2017 Chest-Trauma: Treatment Published: 29 June 2017 Copyright and Indications for Operative © 2017 Reese et al. ISSN: 2573-1246 Stabilization OPEN ACCESS K Reese*, M Breul, SJ Kamminga, and O Pieske Keywords • Department of Trauma, Medical Campus University of Oldenburg, Germany • • Pulmonary Abstract • • Thoracic spine lesion Road traffic accidents frequently result in blunt-force thoracic and concomitant including flail-chest and pulmonary fail. The severity and type of injury determines the treatment modalities and prognosis. We report the case of a 56-year- old car driver, who suffered a complex thoracic trauma following a frontal collision. His life-threatening injuries included a dislocated fracture, multiple fractures and thoracic- as well as cardio- with bilateral haemopneumothorax ( 35). We discuss the operative chest-wall strategies in context with pulmonary considerations and the literature.

INTRODUCTION Sternal fractures are observed in high-impact-accidents a cardiac arrhythmia treated by a dual-chamber pacemaker, [1,2]. The injury mechanism is usually either (a) a direct force suffered a during road-traffic-accident. The patient to the anterior chest wall most commonly seen in frontal car wheeldrove frontally of the vehicle into a deformedbarricade andat a thespeed front-airbags of approximately deployed. 50 collisions with steering-wheel/belt/airbag contact or (b) a Onkilometers presentation per hour,in our the emergency cause being department unknown. the The patient steering was disorientated and displayed signs of intermittent somnolence often combined with rib and/or spine fractures leading to an flexion-compression movement of the trunk associate most (Glasgow Coma Scale 13) although there were no obvious signs for head injuries. The patient had compression pain on the left side of the chest and on the left-front pelvic region. The initial 1.5%unstable ~18.5% but [1-4]. the Theconcomitant incidence injuries of sternal of fracturethoracic describedorgans in in literature is rare and significantly different, ranging from

examination revealed no severe tenderness on percussion severe chest trauma lead to a high mortality of up to 45% [1,5- from abrasions and there were no other pathological of the lumbar spine but frontal and dorsal . Apart 7]. Unstable thorax may result in shallow tidal volumes, collapse of alveoli, arteriovenous shunting and hypoxemia, leading to circulatory instability emergency care was performed according spine injury was reported in up to 39.1% of patients [7,9-11]. findings. Because of progredient pulmonary and cardio- pulmonary insufficiency [8]. Accompanying thoracic or lumbar concerning conservative or operative treatment including choice Therapeutic strategies are still under scientific discussion to the Advanced Trauma Life Support-guidelines [17]. Imaging of implant-type and best time between trauma and surgery not modalities displayed an unstable thoracic spine fracture (T10, AO only to treat the thoracic-wall but also pulmonary instability classification: type B3), a dislocated sternal fracture (Figure 1), a [12-16]. This paper describe a severely injured car-driver fracture of the left anterior arch of the pelvis (AO classification: type A2), an acetebular fracture on the left side (AO classification: grossly displaced sternal fracture, fractures and an unstable type B2) (Figure 2), prepectoral , and a vertebralafter frontal fracture. collision with pulmonary insufficiency as well as pneumomediastinum with fractures of the fifth throughDue toseventh these CASE PRESENTATION rib. Additionally there was evident cardiac and pulmonary Severitycontusion Score and revealed a bilateral 21 points. haemopneumothorax. life-threatening thoracic organ injuries the value of the Injury A 56-year-old male, who was generally healthy except for Cite this article: Reese K, Breul M, Kamminga SJ, Pieske O (2017) The Rule of Sternal Fractures in Life-Threatening Blunt-Chest-Trauma: Treatment and Indications for Operative Stabilization. J Trauma Care 3(3): 1027. Reese et al. (2017) Email:

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Figure 1 in the presented CT-scans). Dislocated sternal fracture and unstable thoracic spine fracture (T 10, AO classification: Type B3) (concomitant rib fractures are not seen directly to our intensive care unit. He was intubated and an last surgery he was transferred to the rehabilitation-unit. The arterialDue line to pulmonaryand a central insufficiency venous catheter the patientwere inserted was admitted as well subsequentholes) utilizing postoperative a Kocher-Langenbeck course showed approach. no 10complications days after as bilateral thoracic drains. The patient received rotational bed concerning wound and healing as well as progredient therapy (RotoRest) and catecholamines were administered. cardiac and pulmonary stabilization without infection. therapy had to be continued for 12 days before the patient DISCUSSION Because of the poor pulmonary function the rotational bed Sternal fractures are rare and associated with high-energy osteosynthesis was performed on the sternum using open impacts [1-3,6] was stable enough for surgery. In a single-stage operation an [1,5,7,18] the sternal fracture. In combination itself is no with severe rib and injury spine but fractures this fracture they reduction and internal fixation with an angle stable locking plate. commonly lead to an unstable thorax . In most cases PostoperativelyThe T10 spinal fracture the pulmonary was treated condition by means improved of percutaneous rapidly. intrathoracic cardiac and/or pulmonary organ lesions [8,9]. dorsal instrumentation bridging T8/T9 to T11/T12 (Figure 2). must be taken as a clinical sign for further life-threatening, second-stageExtubation and surgery removal was ofperformed the thoracic on the drains acetabular were possiblefracture observed,In accordance further to the intrathoracic case presented, injuries road must traffic be accidents immediately are during a 24 hour-period postoperatively. Four days later a the leading cause of such injuries [1-3]. If a sternal fracture is using open reduction and internal fixation with a Reco-Plate (9 excluded [6,10,19]. In case of minor thoracic wall instability like J Trauma Care 3(3): 1027 (2017) 2/4 Reese et al. (2017) Email:

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Figure 2

Plate osteosynthesis of the sternum and percutaneous dorsal instrumentation of Th. 10. isolated sternal fracture and minor pulmonary involvement a conservative approach consisting of pulmonary support and order to achieve a stable chest [23]. Until today many different thereby the biomechanical necessity of a fixed sternum in instability of the thoracic cavity including contusion result inadequate restricted analgesia mobility is of preferred the lung with [8]. In contrast, mechanical sternal osteosynthesis techniques are described but high-profile al.,implants published like non-fixed-plates good sternal stabilization and nails resultsshowed by relatively the use high of a pathology is associated with increased pulmonaryrates of pneumonia insufficiency and mechanical complication rates [5,12,24]. Recently Krinner et and subsequent need for [20,21]. This wall including the sternum because of thoracic and pulmonary weredoubled therefore plate-system used in [13]. our studyAdditionally, [25,26]. low-profile fixed angle- sepsis. The need for an operative stabilization of the thorax plates are on the market having excellent fixation values and described as a result of lung contusion pulmonary instability surgeons have to balance between andinstability concluded is still under that operativescientific discussion thoracic stabilization[9,16]. Some authors of the the In potential summary, perioperative in case of severe negative chest effects injury of with chest/sternal bony and thoracic wallpulmonary does not insufficiencycontribute to pulmonary improvement or should only be performed when other intrathoracic procedures or metal-associated complications and the potential positive are anyhow necessary effectsosteosynthesis of optimized like ventilation,bleeding, wound pulmonary infection, recovery anesthesiological and reduced reported already 1995 that patients with thoracic stabilization [16]. In contrast Ahmed and Mohyuddin Numerous authors reported post-chest-stabilization a reduced patients without stabilization having mean ventilation time of respiratory complication-rate like pneumonia [12,13,23]. showed reduced mean ventilation time of 4 days compared to morbidity and mortality of severe injured patients [7,25,27]. In 15 days [22]. Similar results were confirmed some years later described already in 1996 the anterior wall with sternal-rib- the case demonstrated here, pulmonary insufficiency caused by by Voggenreiter et al. and several other authors [7,12,13]. Berg blunt-chest-trauma-bilateral haemopneumothorax because of unstable thorax with fractures of sternum, ribs and thoracic spine complex as the “fourth column” of the spine and highlighted J Trauma Care 3(3): 1027 (2017) 3/4 Reese et al. (2017) Email:

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B hren V, et al. The unstable thoracic cage injury: The concomitant plate-fixation. Thereby, within 24 hours postoperatively the sternal fracture indicates a severe thoracic spine fracture. Injury. 13. 2016; 47: 2465-2472. patient could be extubatedth and recovered without complication after low-profile single locking plate sternal fixation and Krinner S, Grupp S, Oppel P, Langenbach A, Hennig FF, Schulz-Drost S. stabilization of the 10 thoracic with an internal fixator. ThoracDo low Disprofile. implants provide reliable stability in fixing the sternal wall by trauma surgeons in case of unstable thoracic injury fractures as a “fourth vertebral column” in sternovertebral injuries? J withIn sternal conclusion, fractures we suggest not only operative to treat stabilization mechanical of instability the chest 2017; 9: 1054-1064. but also to treat and/or prevent the development of pulmonary 14. Taylor BC, Fowler TT, French BG, Dominguez N. Clinical Outcomes of Surgical Stabilization of Flail . J Am Acad Orthop Surg. patient’s status allows. Thereby, the sternal fracture should be 15. 2016; 24: 575-580. insufficiency in case of initial respiratory problems as early as Talbot BS, Gange CP Jr, Chaturvedi A, Klionsky N, Hobbs SK, Chaturvedi A. Traumatic Rib Injury: Patterns, Imaging Pitfalls, Complications, and addressed.reduced and stabilized by a low-profile locking plate as well as 16. Treatment. Radiographics. 2017; 37: 628-651. additional biomechanical problems like spine fracture must be REFERENCES Swart E, Laratta J, Slobogean G, Mehta S. Operative Treatment of Rib Fractures in Flail Chest Injuries: A Meta-analysis and Cost- 1. 17. EffectivenessStyner JK. The Analysis. birth of Jadvanced Orthop Trauma. trauma 2017;life support. 31: 64-70. J Trauma Nurs.

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Cite this article Reese K, Breul M, Kamminga SJ, Pieske O (2017) The Rule of Sternal Fractures in Life-Threatening Blunt-Chest-Trauma: Treatment and Indications for Opera- tive Stabilization. J Trauma Care 3(3): 1027.

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