Sternal Fixation with Nonspecific Plate Sternal Fixation with Nonspecific Plate

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Ann Thorac Cardiovasc Surg 2013; 19: 364–367 Online December 26, 2012 Ann Thorac Cardiovasc Surg 2013; 19: 364–367 Online December 26, 2012 Ann Thorac Cardiovasc Surg 2013; 19: 364–367 doi:Online 10.5761/atcs.oa.12.01980 December 26, 2012 doi: 10.5761/atcs.oa.12.01980 Original doi: 10.5761/atcs.oa.12.01980 Original Article Sternal Fixation with Nonspeciﬁc Plate Article Sternal Fixation with Nonspeciﬁc Plate

Gökhan Ergene, MD,1 Cumhur Murat Tulay, MD,1 and Hüseyin Anasız, MD2 Gökhan Ergene, MD,1 Cumhur Murat Tulay, MD,1 and Hüseyin Anasız, MD2

Purpose: The aim of the present study was to fixate displaced sternum fractures with a Purpose: The aim of the present study was to fixate displaced sternum fractures with a nonspecific plate, without a sternotomy procedure. nonspecific plate, without a sternotomy procedure. Method: Between May 2010 and December 2011, 15 patients with sternal fractures Method: Between May 2010 and December 2011, 15 patients with sternal fractures were included in this study. We performed fixation for 8 of 15 sternal fracture patients. were included in this study. We performed fixation for 8 of 15 sternal fracture patients. Posteroanterior and lateral chest x-rays and computed tomography were taken for Posteroanterior and lateral chest x-rays and computed tomography were taken for diagnosis of sternal fractures. Our surgical indications were severe pain, dislocation- diagnosis of sternal fractures. Our surgical indications were severe pain, dislocation- overlapping of sternal edges, and thoracic wall instability. Locked volar distal radius overlapping of sternal edges, and thoracic wall instability. Locked volar distal radius plates were used for the sternal fixation. plates were used for the sternal fixation. Results: After fixation of sternum with plate, the sternum was stable in all 8 patients. Results: After fixation of sternum with plate, the sternum was stable in all 8 patients. There were no complications intra- or postoperatively. Sternal union was observed for There were no complications intra- or postoperatively. Sternal union was observed for all. Pain relief was determined dramatically. all. Pain relief was determined dramatically. Conclusion: Locked volar distal radius plates can be used for displaced sternal fractures. Conclusion: Locked volar distal radius plates can be used for displaced sternal fractures. It is an alternative and successful method for sternal fractures. It is an alternative and successful method for sternal fractures.

Keywords: sternal fracture, trauma, ﬁxation of sternum Keywords: sternal fracture, trauma, ﬁxation of sternum

Introduction associated with sternal fractures. Also, unstable or Introduction associated with sternal fractures. Also, unstable or compound fractures may cause disruption of chest wall compound fractures may cause disruption of chest wall Sternal fractures account for 0.45% to 4% of all stability or intractable pain. Sternal fractures account for 0.45% to 4% of1 all 2 stability or intractable pain. the recorded admissions in emergency departments.1 2 The usual medical approach to sternal fractures is the recorded admissions in emergency departments. The usual medical approach to sternal fractures is They are usually caused by car accident, fall or direct conservative treatment that includes analgesics, rest, and They are usually caused by car accident, fall or direct conservative treatment that includes analgesics, rest, and blunt chest trauma. usage of a sternal corset. We think that surgical cor- blunt chest trauma. usage of a sternal corset. We think that surgical cor- Diagnosis of sternal fractures is sometimes difficult rection of sternal fractures should be made to prevent Diagnosis of sternal fractures is sometimes difficult rection of sternal fractures should be made to prevent for physicians in emergency conditions. Because a lat- intractable and chronic pain, and instability and defor- for physicians in emergency conditions. Because a lat- intractable and chronic pain, and instability and defor- eral, plain chest radiograph is not usually obtained mity of the thoracic wall.4 There is no standard sur- eral, plain chest radiograph is not usually obtained mity of the thoracic wall.4 There is no standard sur- during the initial trauma evaluation, chest computed gical technique to fix the sternum. We report fixation during the initial trauma evaluation, chest computed gical technique to fix the sternum. We report fixation tomography is an important diagnostic tool, and coex- of sternum fractures with a different material, in eight tomography is an important diagnostic tool, and coex-3 of sternum fractures with a different material, in eight istence of other problems could be determined.3 patients. istence of other problems could be determined. patients. Myocardial and pulmonary contusion, cardiac rupture, Myocardial and pulmonary contusion, cardiac rupture, pericardial tamponade, and pulmonary injury can be pericardial tamponade, and pulmonary injury can be Materials and Methods

1Department of Thoracic Surgery, Sanlıurfa Teaching and Between May 2010 and December 2011, 15 patients 1Department of Thoracic Surgery, Sanlıurfa Teaching and Between May 2010 and December 2011, 15 patients Research Hospital, Turkey Research Hospital, Turkey with sternal fractures were included in this study who 2Department of Cardiovascular Surgery, Sanlıurfa Teaching and with sternal fractures were included in this study who 2Department of Cardiovascular Surgery, Sanlıurfa Teaching and had severe traumas and admitted to our hospital. The Research Hospital, Turkey had severe traumas and admitted to our hospital. The Research Hospital, Turkey mean age of patients was 38 years (range, 20–62 years). mean age of patients was 38 years (range, 20–62 years). All of the patients were seen at the emergency room. 10 Received: March 22, 2012; Accepted: June 13, 2012 All of the patients were seen at the emergency room. 10 Received: March 22, 2012; Accepted: June 13, 2012 of them had additional systemic injuries, like brain con- Corresponding author: Cumhur Murat Tulay, MD. Sanlıurfa of them had additional systemic injuries, like brain con- Corresponding author: Cumhur Murat Tulay, MD. Sanlıurfa Teaching and Research Hospital, Department of Thoracic tusion, intracranial hemorrhage, splenic rupture, liver Teaching and Research Hospital, Department of Thoracic tusion, intracranial hemorrhage, splenic rupture, liver Surgery, Sanlıurfa, Turkey and/or lung contusion, pneumothorax and/or hemotho- Surgery, Sanlıurfa, Turkey and/or lung contusion, pneumothorax and/or hemotho- Email: [email protected] Email: [email protected] rax, ﬂail chest, displaced extremity fractures. A plain ©2012 The Editorial Committee of Annals of Thoracic and Car- rax, ﬂail chest, displaced extremity fractures. A plain ©2012 The Editorial Committee of Annals of Thoracic and Car- chest radiograph and whole body computed tomography diovascular Surgery. All rights reserved. chest radiograph and whole body computed tomography diovascular Surgery. All rights reserved.

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Table 1 Patients with sternal fixation Patients Age Location of fracture Associated injuries Hospitalisation 1 20 Sternal corpus None 3 days 2 41 Sternal corpus None 3 days 3 31 Sternal corpus None 3 days 4 62 Sternal corpus Hemopneumothorax rib fractures 9 days 5 50 Sternal corpus Rib fractures+ 6 days 6 24 Sternal corpus Pneumothorax lung contusion 7 days 7 25 Sternal corpus Lung contusion+ 4 days 8 47 Sternal corpus Hemothorax 5 days were taken for all patients. Only 5 of 15 patients had isolated sternal fractures. We performed fixation for 8 of 15 sternal fracture patients (Table 1). Three patients did not want to have a surgical procedure. Two patients died in the emergency room because of other severe, systemic injuries. Two patients were followed up with a non displaced sternal fracture. Our surgical indications were severe pain, dislocation-overlapping of sternal edges and thoracic wall instability (Fig. 1). All patients were evaluated for cardiac injury, and nobody had this type of injury. Informed consent was obtained from each patient. The fixation procedure was made in the operating room and under general anesthe- Fig. 1 Displaced sternum fracture. sia. Surgeries were generally performed at 2nd day of trauma because of stabilisation of vital signs. Approx- imately 6–8 cm long longitudinal incision was per- intra- or postoperatively. Sternal union was observed formed for all patients. Level of the sternal fracture was for all. We used non-steroidal anti-inflammatory drugs determined on thorax tomography before the operation. for postoperative period. Pain relief was determined dra- By the help of this knowledge and palpation of the frac- matically. Two patients who were followed for a non- ture site, incision was made at fracture level. Sternal diplaced sternal fracture needed a narcotic analgesic fracture edges were brought side to side by clamps. It (Tramadol HCl) for severe pain. The mean length of is not necessary to expose the entire sternum or to enter hospital stay was 5 days. the anterior mediastinum. Locked volar distal radius plate was flattened by bender (Fig. 2). Sternum thick- Discussion ness was measured on computed tomography and screw length was chosen, according to the sternal thickness Sternal fractures are common as a result of direct to prevent mediastinal penetration. Four or six locked trauma to the sternum. We believe that sternal frac- screws were used for plate stabilisation. Duration time tures must be evaluated carefully in emergency condi- of operation was about 20 to 30 minutes. Patients were tions, and displaced sternal fractures should be fixated extubated postoperatively in the operation room and fol- to prevent chronic pain, and deformity of the chest and lowed up in thoracic surgery service with posteroante- sternum. Displaced sternal fractures may cause some rior and lateral chest X-ray (Fig. 3). complications like ventilatory difficulties, intractable and chronic pain, instability and deformity of the tho- Results racic wall, if unrecognised in the early period of chest trauma.4 5 After fixation of sternum with plate, sternum was sta- Movement of displaced sternal fractures leads to ble for all of 8 patients. There were no complications pain with respiration. Patients with displaced sternal

Ann Thorac Cardiovasc Surg Vol. 19, No. 5 (2013) 365 Ergene G, et al. Sternal Fixation with Plate

would not be used, because of extrapleural fixation of 5) Chou SS, Sena MJ, Wong MS. Use of SternaLock 9) van Sterkenburg SM, Brutel de la Rivière A, Ver- sternum in this technique. plating system in acute treatment of unstable trau- meulen FE. Sternal fixation with resorbable suture Although wiring technique with median sternotomy matic sternal fractures. Ann Thorac Surg 2011; 91: material. Eur J Cardiothorac Surg 1990; 4: 345. is less expensive than plating system, secondary sternal 597-9. 10) Athanassiadi K, Gerazounis M, Moustardas M, et al. 6) Brookes JG, Dunn RJ, Rogers IR. Sternal fractures: Sternal fractures: retrospective analysis of 100 cases. fractures or sternal nonunion can be seen because a retrospective analysis of 272 cases. J Trauma 1993; World J Surg 2002; 26: 1243-6. of the nonrigid nature of the wires. Sternal fixation 35: 46-54. 11) Hendrickson SC, Koger KE, Morea CJ, et al. Sternal using a plate minimizes these risks and the potential 7) Fowler AW. Flexion-compression injury of the ster- plating for the treatment of sternal nonunion. Ann Tho- advantages are more cosmetically acceptable incision, num. J Bone Joint Surg Br 1957; 39-B: 487-97. rac Surg 1996; 62: 512-8. more secure reduction, faster healing, and lower risk of 8) Hills MW, Delprado AM, Deane SA. Sternal fractures: 12) Pai S, Gunja NJ, Dupak EL, et al. In vitro compari- associated injuries and management. J Trauma 1993; son of wire and plate fixation for midline sternotomies. nonunion.1112 35: 55-60. Ann Thorac Surg 2005; 80: 962-8. The optimal timing of sternal fixation is not cer- Fig. 2 Volar distal radius plate, screws and bender. tain, but we think that fixation in the early period of trauma prevents some pulmonary complications because of intractable pain. When the thoracic surgeon prefers to follow the patient who has displaced sternal fracture with medical treatment, it will be very difficult to cor- rect and fix the sternum in the late period because of difficult reduction and local inflammatory response to trauma. The SternaLock plating system is a good way to fix the sternum, as explained by Chou and colleagues5 but it can not be found in every hospital and emergency conditions. It is specific equipment for the sternum, but our locked volar radius plate system can be generally obtained at most hospitals, where orthopedic surgeries are performed. Because of this, it is very easy for mul- Fig. 3 Fixated sternum with volar distal radius plate. tidisciplinary hospitals to get these plates. In conclusion, our advice was to fixate the displaced sternal fracture, as were done in earlier studies. Volar endings almost always avoid deep breathing to pre- distal radius plate usage is an alternative and successful vent more pain, and this causes some pulmonary method for sternal fractures. complications. Therefore, to minimize pain and prevent the development of pulmonary complications, Disclosure Statement our advice was to fix the displaced sternal fractures with a plating system during the early period of chest We have no financial or other interest in the manu- trauma. facture or distribution of the device. Among the techniques suggested for closure of displaced sternal fractures are hyperextension of the tho- References racic spine, figure-of-eight periosteal wiring or suturing, 6–10 and internal fixation using plates. 1) Potaris K, Gakidis J, Mihos P, et al. Management of Our current technique with locked volar distal radius sternal fractures: 239 cases. Asian Cardiovasc Thorac plate is safe and very effective for fixation. Sternal plat- Ann 2002; 10: 145-9. ing with locked volar distal radius plate provides sta- 2) Harley DP, Mena I. Cardiac and vascular sequelae of ble sternum with faster healing period and less pain. In sternal fractures. J Trauma 1986; 26: 553-5. 3) Al-Qudah A. Operative treatment of sternal fractures. addition, the incision is cosmetically acceptable. Sternal Asian Cardiovasc Thorac Ann 2006; 14: 399-401. plating system does not need to enter the mediastinum, 4) Molina JE. Evaluation and operative technique to by this way major vascular structures would not be repair isolated sternal fractures. J Thorac Cardiovasc injured.34 Intrapleural chest tubes or mediastinal tubes Surg 2005; 130: 445-8.

366 Ann Thorac Cardiovasc Surg Vol. 19, No. 5 (2013) Ann Thorac Cardiovasc Surg Vol. 19, No. 5 (2013) 367 Sternal Fixation with Plate

5) Chou SS, Sena MJ, Wong MS. Use of SternaLock 9) van Sterkenburg SM, Brutel de la Rivière A, Ver- plating system in acute treatment of unstable trau- meulen FE. Sternal ﬁxation with resorbable suture matic sternal fractures. Ann Thorac Surg 2011; 91: material. Eur J Cardiothorac Surg 1990; 4: 345. 597-9. 10) Athanassiadi K, Gerazounis M, Moustardas M, et al. 6) Brookes JG, Dunn RJ, Rogers IR. Sternal fractures: Sternal fractures: retrospective analysis of 100 cases. a retrospective analysis of 272 cases. J Trauma 1993; World J Surg 2002; 26: 1243-6. 35: 46-54. 11) Hendrickson SC, Koger KE, Morea CJ, et al. Sternal 7) Fowler AW. Flexion-compression injury of the ster- plating for the treatment of sternal nonunion. Ann Tho- num. J Bone Joint Surg Br 1957; 39-B: 487-97. rac Surg 1996; 62: 512-8. 8) Hills MW, Delprado AM, Deane SA. Sternal fractures: 12) Pai S, Gunja NJ, Dupak EL, et al. In vitro compari- associated injuries and management. J Trauma 1993; son of wire and plate ﬁxation for midline sternotomies. 35: 55-60. Ann Thorac Surg 2005; 80: 962-8.

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