Treatment of Isolated Sternal Fracture with Ultrasound-Guided Paravertebral Nerve Block: a Case Report and Literature Review
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Kosin Medical Journal 2019;34:152-160. https://doi.org/10.7180/kmj.2019.34.2.152 &D VH 5HSRUWV Treatment of Isolated Sternal Fracture with Ultrasound-Guided Paravertebral Nerve Block: a Case Report and Literature Review Jun-Mo Park 1, Hyunjeong Kim 1 Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Kyungpook Na - tional University Hospital, Daegu, Korea In the case of isolated sternal fractures, conservative treatment with analgesics is common, but pain can persist for more than 10 weeks, which can significantly interfere with daily life. Ultrasound-guided paravertebral nerve block is reported to be a successful means of pain control in patients with chest wall injury or rib fracture. A 70-year-old female patient presented with anterior chest pain that had persisted for 2 weeks despite conservative treat - ment. Sagittal reconstruction chest computed tomography and sternum lateral oblique x-ray revealed an isolated sternal fracture. An ultrasound-guided bilateral paravertebral nerve block was performed for pain control. After performing the procedure twice at a 1-week interval, the patient reported complete pain alleviation, and no other problems were observed over the 3-month follow-up period. Ultrasound-guided bilateral paravertebral nerve block can help patients with isolated sternal fractures to manage pain and return to normal activities sooner than with oral analgesics. Key Words : Fracture, Nerve block, Pain management, Sternum, Ultrasonography Sternal fractures are not uncommon and have to the internal thoracic organs, with isolated ster - been reported to occur in 3.7% of patients hos - nal fractures considered benign lesions in the ab - pitalized after a traffic accident. 1 Before the use sence of accompanying cardio-respiratory of seatbelts became mandatory, a sternal fracture damage. 1,2 More than 95% of sternal fractures was a marker for high-energy trauma. After the are treated conservatively. 2 The most important use of safety belts was legislated, the number of factor in the treatment of isolated sternal frac - patients surviving traffic collisions increased, tures is adequate pain control, usually managed accompanied by an increase in patients present - with oral analgesics. 3 ing with sternal fractures as a result of these ac - Few studies, however, have been published re - cidents. garding the functional effects of isolated sternal The morbidity and mortality rates of sternal fractures on daily activities. According to one fractures are determined by associated injuries study, although chest pain was the most fre - Corresponding Author : Jun-Mo Park, Department of Anesthesiology and Pain Medicine, Kyungpook National Receive d: Aug. 26, 2019 University Chilgok Hospital, 807 Hoguk-ro, Buk-gu, Daegu 41404, Korea Revise d: Oct. 12, 2019 Tel: +82-53-200-2643 Fax: +82-53-200-2027 E-mail: [email protected] Accepted : Oct. 15, 2019 152 Treatment of isolated sternal fracture quently reported and persistent symptom, con - She was examined at a local clinic near her home tinuing for an average of 10.9 weeks, the dura - and was told that her sternum had cracked. That tion of pain was significantly prolonged in doctor recommended rest and prescribed an patients older than 50 years of age presenting NSAID medication. However, her symptoms had with an isolated sternal fracture. 4 This prolonged not improved, and she complained that the chest pain often necessitates the administration NSAID was causing facial swelling and heart - of oral analgesics for a relatively long period, but burn. In addition, the patient was planning an this long-term use can be limited by the side ef - overseas trip with her family in 2 weeks. She vis - fects of non-steroidal anti-inflammatory drugs ited our clinic to address her pain so she could (NSAIDs) and opioids. 5 In particular, older pa - travel unencumbered. tients may have underlying medical conditions A sternal fracture was already suspected at the that contraindicate analgesic use. Other patients other facility, and the pain had persisted even may have to return to their daily lives before the after 2 weeks of adequate treatment. We thereby pain has subsided, which can be difficult to do performed chest computed tomography (CT) in - when undergoing conservative treatment alone. cluding sagittal reconstruction, x-rays of the We report a case of successful management of sternum lateral and lateral oblique aspects, elec - pain in a patient with an isolated sternal fracture trocardiography (ECG), and a cardiac enzyme using an ultrasound-guided bilateral paraverte - test to check for any accompanying injuries. A bral nerve block. thorough physical examination was also con - ducted on the patient, and no specific abnormal signs were found other than intense, localized CASE tenderness at the mid portion of the sternal body. A recent fracture was observed at the sternum be - A 70-year-old female patient presented with an - tween the third and fourth ribs on the sagittal re - terior chest pain that had persisted for 2 weeks. construction chest CT and sternum lateral The patient had no pertinent medical history oblique x-ray (Fig. 1A, 1B). There was mild soft other than 10 years of anti-hypertensive drug tissue edema around the fractured area, but no medication. The patient reported a fall 2 weeks hemorrhage, and no soft tissue injury that would before visiting the pain clinic, hitting her chest indicate a pathologic fracture. No abnormalities against a stone, followed by chest pain. The pain were found on the ECG or cardiac enzyme test. was less severe when she remained still but wors - As such, we decided to perform an ultrasound- ened when she coughed or spread her arms, and guided bilateral paravertebral nerve block at the she reported difficulty with bending her chest space between the third and fourth ribs to allow forward or turning over in bed. The patient's vi - the patient to return to normal daily life sooner, sual analog scale (VAS) score was 7 out of 10. particularly, to travel abroad with her family after 153 Kosin Medical Journal 2019;34:152-160. Fig. 1. (A) Sternum lateral oblique x-ray. (B) Sagittal reconstruction chest CT. Arrows indicate fracture site. 2 weeks. The patient was placed in the prone po - direction using an in-plane technique. After it sition, the third and fourth ribs were visualized was confirmed that the needle was placed in the with C-arm guidance (Fig. 2A), and the skin was region under the transverse process and that no marked along the running direction of each rib blood or air was withdrawn during negative as - (Fig. 2B). After sterilization of the skin, a curved piration, a mixture of 10 mL of 0.5% lidocaine transducer (1.5–4.6 MHz) for a GE Logiq7 ul - and 20mg of methylprednisolone acetate was trasound machine (Tokyo, Japan) was placed slowly injected. During the injection, concomi - parallel to the direction indicated on the skin and tant anterior movement of the parietal pleura was moved medially to check the spinous and trans - checked by ultrasound to confirm that the drug verse processes of the third thoracic vertebra. was injected into the correct location (Fig. 3B). The transducer was then moved laterally along After completing this procedure on one side, it the skin markings to locate the thoracic paraver - was repeated on the other side. tebral space for injection (Fig. 2C). The trans - Thirty minutes after the procedure, the patient’s ducer was moved slightly in the cephalad and VAS score of the pain caused by coughing or caudal directions perpendicular to the direction spreading her arms was reduced to 2 out of 10, of the rib indicated on the skin to confirm that without any complications. Since the patient the rib was excluded from the path of the needle complained of side effects from the NSAID, tra - (Fig. 3A). A 10-cm, 22-gauge SonoPlex cannula madol and a skeletal muscle relaxant were pre - with facet grinding (Pajunk GmbH, Geisingen, scribed, and the patient was asked to return for a Germany) was inserted in the lateral to medial follow-up in 1 week. After 1 week, the patient 154 Treatment of isolated sternal fracture Fig. 2. (A) C-arm view showing the direction of the third and fourth ribs. (B) Skin was marked along the running direction of the third and fourth ribs. (C) Curved transducer was placed parallel to the di- rection indicated on the skin and moved medially and laterally along the skin markings and cepha- lad and caudally to locate the thoracic paravertebral space for injection. Fig. 3. (A) Ultrasound view showing the ribs were excluded from the path of the needle. (B) Ultrasound view showing anterior movement of the parietal pleura (small arrow). T: target region, TP: trans- verse process, needle (arrow head), tip of needle (large arrow). 155 Kosin Medical Journal 2019;34:152-160. reported that her VAS score was about 1 or 2 out total of 32,746 cases of injuries including sternal of 10 for most of the day. She also did not com - fracture between 2007 and 2010 using the Na - plain of any particular side effects of the pre - tional Trauma Data Bank, Yeh et al. reported that scribed drugs. Since the patient was concerned 84% of sternal fractures were associated with car that the pain would recur during the planned accidents, with sternal fracture confirmed in overseas trip with her family 1 week later, the 3.7% of all patients hospitalized due to a colli - procedure was repeated, and the same drugs were sion. 1 According to Oyetunji et al., the most com - prescribed. The patient followed up with us 2 mon cause of sternal fracture is car accidents, weeks after the trip and reported that she had not and the second most common cause is falls.