ORIGINAL RESEARCH RECHERCHE ORIGINALE Delayed complications and functional outcome of isolated sternal fracture after emergency department discharge: a prospective, multicentre cohort study Samuel Racine, MD*†**; Marcel Émond, MD, MSc*†**; Jean-Sébastien Audette-Côté, MD¶; Natalie Le Sage, MD, PhD*†**; Chantal Guimont, MD, PhD†**; Lynne Moore, PhD***; Jean-Marc Chauny, MD, MSc‡; Éric Bergeron, MD, MSc*§; Laurent Vanier, MD, PhD§ ABSTRACT cliniques fonctionnels chez des patients ayant subi une fracture isolée du sternum, et ce après le congé du Objective: The aim of this study was to determine the département d’urgence (DU), comparativement à des patients incidence of delayed complications, specifically hemothorax, ayant subi d’autres traumas thoraciques mineurs. and functional outcome in patients with isolated sternal Méthode: Il s’agit d’une étude prospective de cohorte qui a fracture discharged from the emergency department (ED) été menée dans quatre DU rattachés à des centres hospita- compared to patients with other minor thoracic trauma. liers universitaires au Canada. Des patients âgés de 16 ans et Methods: This prospective cohort study was conducted in plus ayant obtenu leur congé du DU après avoir subi un four university-affiliated Canadian EDs. Patients ages 16 and traumatisme thoracique mineur isolé ont participé à cette older discharged from the ED with an isolated minor thoracic étude; leur état a été catégorisé comme suit : fracture isolée du injury were included and categorized as isolated sternal sternum, fracture(s) de côte(s) ou aucune fracture. Un suivi fracture, rib fracture, or no fracture. A standardized clinical clinique et radiologique standardisé a été effectué au 7e et 14e and radiological follow-up was performed at 7 and 14 days as jour, ainsi qu’un suivi téléphonique au 30e et 90e jour après well as a phone follow-up at 30 and 90 days post-injury. l’accident. Les résultats cliniques fonctionnels ont été évalués Functional outcome was determined using the Medical selon le questionnaire Medical Outcomes Short-Form Health Outcome Short-Form Health Survey (SF-12). Survey (SF-12). Results: A total of 969 patients were included, of whom 32 Résultats: Au total, 969 patients ont participé à l’étude, dont (3.3%) had an isolated sternal fracture, 304 (31.3%) had rib 32 (3,3%) souffraient d’une fracture isolée du sternum; 304 fracture, and 633 (65.3%) had no fracture. Within 14 days, (31,3%), d’une fracture(s) de côte(s) et 633 (65,3%), d’aucune 112 patients presented with a delayed hemothorax: 12.5% of fracture. Au cours des 14 jours suivants, 112 patients ont sternal fracture patients, 23% of rib fracture(s) patients, and consulté pour un hémothorax retardé : 12,5% à la suite d’une 6% of minor thoracic injury patients without fracture fracture du sternum; 23% à la suite d’une fracture(s) de côte(s) (p < 0.05). At 90 days, 57.1% of patients with sternal fracture et 6% à la suite de traumatisme thoracique mineur sans had moderate to severe disability compared to 25.4% and fracture (p < 0,05). Au bout de 90 jours, 57,1% des patients 21.2% for both of the other groups, respectively (p < 0.001). ayant subi une fracture du sternum présentaient une incapa- Conclusion: In this prospective study, we found that 12.5% cité modérée ou grave par rapport à 25,4% et 21,2% dans les (n = 4, p < 0.05) of patients with sternal fracture developed a deux autres groupes, respectivement (p < 0,001). delayed hemothorax, but the clinical significance of this remains Conclusions: Les résultats de cette étude prospective questionable. The proportion of patients with sternal fracture démontrent qu’un hémothorax retardé s’est formé chez who had moderate to severe disability was significantly higher 12,5% (n = 4; p < 0,05) des patients ayant subi une fracture than that of patients with other minor thoracic trauma. du sternum, mais la portée clinique de cette complication RÉSUMÉ reste discutable. Une incapacité modérée ou grave a été observée dans une proportion significativement plus grande Objectif: L’étude visait à déterminer l’incidence de complica- de patients ayant subi une fracture du sternum que de tions tardives, précisément de l’hémothorax, et de résultats patients ayant subi d’autres traumas thoraciques mineurs. From the *Axe santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec, Hôpital de l’Enfant-Jésus, Québec, QC; †Département de médecine familiale et de médecine d’urgence, Université Laval, Québec, QC; ‡Centre hospitalier du Sacré-Cœur de Montréal, Montréal, QC; §Centre hospitalier de Charles-LeMoyne, Greenfield Park, Longueuil, QC; ¶Centre hospitalier régional de Lanaudière, Joliette, QC; and; and **CHU de Québec, Québec, QC. Correspondence to: Dr. Marcel Émond, Emergency Department, CHU de Québec, Hôpital de l’Enfant-Jésus, 1401, 18e Rue, Room H-607, Québec, QC G1J 1Z4; Email: [email protected]. © Canadian Association of Emergency Physicians CJEM 2016;18(5):349-357 DOI 10.1017/cem.2016.326 CJEM JCMU 2016;18(5) 349 Downloaded from https://www.cambridge.org/core. IP address: 170.106.35.93, on 01 Oct 2021 at 04:08:25, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/cem.2016.326 Racine et al Keywords: isolated sternal fracture, minor thoracic trauma, METHODS delayed complications, funtionnal outcome, delayed hemothorax Study setting and population This prospective observational cohort study was INTRODUCTION conducted in four Canadian university-affiliated EDs (Hôpitaux l’Enfant-Jésus and CHUL of the CHU de fi Sternal fracture is usually the result of signi cant blunt Québec, Centre Hospitalier du Sacré-Cœur de thoracic trauma and occurs more frequently in drivers Montréal, Centre hospitalier Charles-Lemoyne), wearing three-point restraint who are involved in a motor between March 25, 2006 and November 2, 2010 and 1 vehicle crash. Its reported incidence varies between was a preplanned subanalysis of a larger project with 2 0.33% of trauma patients and 3.7% of patients admitted prior publications involving the follow-up of patients 3 after a motor vehicle crash and increases with age. It can with minor thoracic injury.13,14,17 Patients ages 16 years be present in up to 27.7% of thoracic injuries associated and over who presented to the ED with a minor thor- with motor vehicle crashes in the extreme elderly popu- acic injury were screened for eligibility. Minor thoracic > 4 lation ( 80 years of age). Sternal fractures are often injury was defined by the presence of chest abrasion or associated with other injuries, most commonly soft tissue contusion, or suspected or radiographically confirmed 2 contusions (56%) and rib fractures (49.6%). When rib fracture. All participants were discharged from the isolated, they are associated with a reported mortality rate ED after receiving care by the attending physician of between 0.7% and 3.5%. Poor outcomes are associated (primary care physician, emergency physician, or other with the severity of other injuries, complications, and specialist). Patients were excluded if 1) they had a 3,5 pre-existing comorbidity. hemothorax, pneumothorax, lung contusion, or any fi Knowledge regarding the clinical signi cance of significant cerebral, thoracic, abdominal, or extremity isolated sternal fracture has evolved, and many studies injury diagnosed on their initial ED visit; or 2) a follow- have demonstrated that patients with this injury can up was not possible due to geographic or social safely be discharged from the emergency department circumstances; or 3) there was a delay greater than 6-9 (ED) after investigation. A retrospective cohort study 3 days between the injury and the ED visit (a cut-off found that cardiac complications were present in 0.8% of based on a previous publication showed that 90% of 5 fi isolated sternal fracture cases. Clinically signi cant patients seeking medical attention in an acute care cardiac complications associated with isolated sternal setting do so within 72 hours of injury).18 The study fracture have been shown to be essentially nonexistent was approved by the Research Ethics Board of all four when an initial electrocardiogram and cardiac biomarker involved institutions, and written consent was obtained 7 levels are normal. Current literature suggests that rou- from study participants. tine admission is no longer required for isolated sternal 9,10 11 fracture ; however, this practice remains widespread. Study protocol Delayed hemothorax has been reported as an important complication with patients with minor thoracic injuries Initial ED care, evaluation, and data collection were left discharged from the ED, with an incidence of 7.4% of to the discretion of the attending physicians, who were 12 blunt thoracic injuries reported in Europe and 11.8% in blinded to the research protocol and study outcomes. 13 North America. However, the only published prospective Participants thus received usual care and standard studies addressing delayed complications of minor thoracic discharge instructions. Participants then returned for fi injuries did not speci cally assess isolated sternal frac- standardized medical outpatient evaluations at 7 and 12-14 tures. Moreover, very few authors have studied func- 14 days post-injury. Assessment at these visits included tional outcome or pain experienced by patients with minor pain severity, clinical examination, and an upright chest 14-17 thoracic injuries or sternal fracture after ED discharge. X-ray. There was no specific protocol regarding pain The purpose of this study was to determine and regimen, and this, too, was left to the discretion of compare complications and outcomes of patients with the physician involved. Information on potentially sig- isolated sternal fracture discharged from the ED to nificant delayed complications, including hemothorax, those with other minor thoracic injury. pneumothorax, atelectasis, and lung contusion, were 350 2016;18(5) CJEM JCMU Downloaded from https://www.cambridge.org/core.