International Orthopaedics (SICOT) DOI 10.1007/s00264-015-2801-z
ORIGINAL PAPER
The oblique fracture of the manubrium sterni caused by a seatbelt—a rare injury? Treatment options based on the experiences gained in a level I trauma centre Stefan Schulz-Drost 1,2 & Pascal Oppel 1 & Sina Grupp 1 & Dominic Taylor 3 & Sebastian Krinner 1 & Andreas Langenbach 1 & Friedrich Hennig 1 & Andreas Mauerer 3
Received: 17 March 2015 / Accepted: 21 April 2015 # SICOT aisbl 2015
Abstract Introduction Sternal fractures are rare with 3–8 % out of the total number of trauma cases mostly caused by direct impact to the anterior chest wall. Most cases described are due to motor vehicle crash either caused by direct impact to the steering wheel or by the seat belt. Fractures mainly occur to the sternal body. Only rarely are cases of manubrium fractures described in literature, for example, in relationship with a direct impact to the shoulder which caused an oblique fracture near to the sternoclavicular joint. Three patients with profoundly dislocated oblique manubrium fracture were admitted to our Level I Trauma Center in 2012 and 2013. Those patients suffered from instability of the upper sternum and the shoulder girdle. Material and methods Between January 2012 and October 2013, a total of 538 trauma patients were admitted to the emergency room and received whole body CT-scan. They were analysed retrospectively for sternal fractures. In cases of instability and dislocation, fracture stabilisation was performed by anterior plating through a medial approach using low profile titanium plates (MatrixRib®). Results Seventy-nine (14.7 %) patients showed sternal fracture, out of which 13 (2.4 %) patients showed a fracture of manubrium, ten caused by seatbelt. In three cases stabilization
* Stefan Schulz-Drost [email protected] 1
Department of Orthopaedic and Trauma Surgery, University Hospital Erlangen, Erlangen, Germany
2
Department of Pediatric Surgery, University Hospital Erlangen, Erlangen, Germany
3
Department of Orthopaedic and Trauma Surgery, St. Theresien Krankenhaus, Nürnberg, Germany
was performed. Follow up showed sufficient consolidation without complications. Discussion A total of 16.5 % of sternal fractures were localized at the manubrium, mostly caused by seat belt. Fractures without significant dislocation seemed to be stable and healed well under conservative treatment. Dislocation in this region leads to unstable shoulder girdle. Anterior plating provides sufficient stabilisation and allowed consolidation. Keywords Sternum fracture . Sternal fracture . Manubrium . Locked plate . Sternal plating . Mediatinal injury
Introduction On reviewing the total spectrum of bony injuries, one finds that the fracture of the sternum is a rare entity with an incidence of 3–8 % [1, 2]. Helal reported in his study from 1964, an even smaller incidence rate of 0.5 % after analysing the time period from the middle of the 19th century through to the 1960s in the 20th century [3]. Earlier studies described different injury mechanisms which could cause a fracture of the sternum. In 1864 Gurlt, followed by numerous authors and single-case studies thereafter, reported on sternal fractures caused by indirect trauma, for example, an injury caused by a violent compression trauma to the torso. In 1957, Fowler defined this injury as a flexion–compression injury [4, 5]. A literature review demonstrated a consensus that the most common cause by far of a sternal fracture was direct trauma. The causal incidence rate was 84 % [6]. The most common agent to cause a direct impact injury to the sternum was shown to be the steering wheel or the seatbelt [6]. Since the 19th century there has been a significant rise in the rate of fractures of all types to the sternum described in literature. Helal was
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able to prove in his study from 1964, that the rate of sternal fractures closely correlated with the rise in vehicle registrations from the second decade of the 20th century [3]. On analysing the data of the different localisations of the sternal fractures, it is noticeable that the majority occur within the corpus sterni region, followed by the dissociation fractures of the angulus ludovici. Write ups of the pure bony fracture of the manubrium sterni were rare. They can also be induced as a consequence of direct trauma, for example, as a result of a fall on the back, or as a result of a spontaneous fracture caused by muscle spasms. Manubrial fractures caused by direct trauma are in most cases associated with high speed crashes and a horizontal fracture type [5]. Oblique fractures are described only in individual cases. In 1998, Velutini reported on an oblique manubrial fracture as a consequence of an impact trauma to the ipsilateral shoulder [7]. This type of injury had already been described by Lane in 1884 after conducting biomechanical studies on cadavers, though clinically it was never described [8]. Oblique manubrial fractures as a result of direct trauma have only been found in two individual cases upon review of the literature. These two cases were interestingly enough not discovered clinically, but rather came to light as a result of a computed tomography scan. In the first case Kehdy described a multiple oblique fracture of the sternum involving the manubrium and the cranial part of the corpus sterni [9]. The second case was described by Nakae in 2002. It was an oblique fracture of the manubrium as a result of a ribcage contusion of a bicyclist [10] (Table 1). On the other hand however, it has been reported that a manubrial fracture is often associated with life-threatening and/or lethal co-injuries. In 2013, Scheyerer wrote about the higher rate of required intensive-care treatments, as well as the higher mortality rate in comparison to other fracture sites on the Sternum [11]. In 1962, Gibson highlighted the fact that the manubrium is the stablest part of the sternum and its importance in topographically protecting the following structures: major blood vessels of the mediastinum such as the superior vena cava, the innominate veins (v. brachiocephalica dextra et sinistra), the innominate artery (a. brachiocephalica), the internal thoracic artery, the aortic arch and its offshoots. As a consequence one can see that a manubrial fracture carries with it an increased risk for co-injuries to vital organs; in particular a
Table 1
massive extrapericardial and retrosternally localized haematoma has been described in the literature [12, 13]. At our institution, a level I trauma centre, in the time frame of 2012 and 2013, three patients were admitted with a substantial dislocated unstable oblique fracture of the manubrium caused by blunt force trauma as a result of being seatbelted occupants in a car accident. These patients suffered from a substantial instability of the upper part of the sternum and adjoining areas of the shoulder girdle. This posed the question whether the oblique fracture of the manubrium caused by a seatbelt was in fact such a rare occurrence and what treatment options were available for the resulting injuries.
Materials and methods For this purpose a retrospective analysis was carried out on the patients taken to our level I trauma centre. The time frame from January 2012 to October 2013 was examined. Included were patients who had suffered a high-speed trauma and fulfilled the criteria for an emergency trauma room alert [14]. A further inclusion factor was the implementation of a whole-body helical CT scan (Btrauma scan^) (Somatom definition AS, 128 slice, Siemens, Munich, Germany) with a slice thickness of 1.5 mm and multiplaned reconstruction. The defined exclusion criteria were: patients under 16 years of age, the presence of only traumatic brain injury, the cases where the follow-up examinations were not executed. The elicited CT-diagnostic findings underwent a 3D reconstruction and were examined for the presence of a sternal fracture. Co-injuries were collated at the same time. On finding the presence of a sternal fracture, its precise localization and its exact course were determined by analysis of the axial-/ sagittal-/ coronal- plane slices as well as the use of the VRT-Mode of the CT-scan. Fractures of the manubrium sterni, of the angulus ludovici, and of the corpus sterni were differentiated. On finding a manubrial fracture, the case history was anonymized with regards to: the circumstances surrounding the accident, findings on admission, co-injuries, course of the illness, and treatment modalities. In addition, the findings during the outcome were analysed. These occurred, according to our in-house
Reported cases of oblique manubrium fractures
Year, first author, journal
Number of occurrences
Mechanism of injury
Therapy
Outcome
1998, Velutini, Int Orthop 2002, Nakae, J Trauma 2006, Kehdy, J Trauma
1 1 1
Impact to the ipsilateral shoulder Bicycle crash, impact to the chest wall Lap belt injury car occupant
Conservative Conservative Plate osteosynthesis
Not reported Not reported Without complications
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regulations, as part of the follow up examinations at the sixthand 12th-week marks after the accident. Surgical fixation was selected as the treatment of choice for the above described three patients with unstable oblique fractures of the manubrium. This ensued after stabilization of the overall condition of the patient had been achieved, consentform had been signed, and with an operation under general anaesthetic. Access to the manubrium sterni was achieved by a median skin incision from the fossa jugularis to the angulus ludovici, with ensuing layer by layer dissection down to the sternum. The pectoral muscles were dissected up to the manubrial margins and the fracture site was completely exposed (Fig. 1a). Any trapped soft tissues were removed from the fracture to ensure anatomical repositioning. This was achieved through the use of four compression wires, two on the left and two on the right of the fracture (Fig. 1b). By use of the requisite repositioning clamp, readaptation of the fracture fragments was achieved (Fig. 1c). Internal fixation by angularstable plate osteosynthesis was carried out by bridging between the first two ribs and the manubrium sterni. Plates of low-profile design of 1.5-mm thickness made out of titanium (MatrixRib®, DePuySynthes CMF, Switzerland) were used. These were attached to each fragment by the use of at least three locked and self-cutting screws with 2.9 mm diameter (Fig. 1d). In cases of additional dislocated fractures, for example, to the neighbouring ribs and/or other areas of the sternum, these were treated during the same procedure by using the method of a locked plate osteosynthesis. After stability had been restored to the anterior chest wall, irrigation of the wound site and insertion of a drainage tube were carried out. To achieve a by-the-layers wound closure, reconstruction of the muscular and connective tissue layers ensued by suturing the pectoral muscles and the fasciae. For optimal cosmetic results the subcutaneous and intracutaneous layers were sutured. Postoperative care included the following: close clinical monitoring, removal of the drainage tube, mobilizing the patient out of bed, and discharge after completion of wound healing. Chest X-ray check-ups in two axes were carried out: immediately postoperatively, at the sixth and 12th postoperative weeks to ascertain the status of the reduced fracture as well as the implant positioning.
Fig. 1 a Dehiscence of the fracture. b Open reduction using compression wires. c Plate osteosynthesis crossing the first pair of ribs. d Final osteosynthesis
Results From January 2012 to October 2013, a total of 538 trauma patients which fulfilled the inclusion criteria and none of the exclusion criteria were admitted to the emergency trauma room of our level I trauma centre. The evaluation of the CT-Btrauma scan^ revealed that 79 patients had a sternal fracture (corresponding to 14.7 % of the total). Thirteen (2.4 % of the total) of these 79 patients had a fracture of the manubrium sterni (Fig. 2). On analysis, three of the 13 fractures were caused indirectly by means of a fall on their back, the other ten fractures were caused by the safety belt whilst being front seat occupants. These ten fractures caused by seatbelts were oblique manubrial fractures with involvement of the ipsilateral clavicula and first rib. In contrast the three indirectly caused fractures were transverse fractures extending to the first intercostals space (Fig. 3a, b). Three of the ten oblique manubrial fractures demonstrated considerable instability with a gaping fracture, percutaneously palpable fracture cleft and a large haematoma. The fracture cleft widened according to the amount of retroversion of the shoulder, and the widest clinically measured cleft was 4 cm. On the other hand adduction of the arm and/or anteversion of the shoulder significantly narrowed the fracture cleft. In a CT-scan of the thorax performed with arms above the head and at the side revealed only a few millimetres of dehiscence. But in three cases there was considerable displacement of up to 5 mm and a malrotation of the avulsed manubrial fragment. In the context of a massive clinical instability is the indication for an operative osteosynthesis clear. This was carried out in the above mentioned manner. In one case intraoperatively, on sluicing out the haematoma, a preexisting wound of the right a. mammaria was reopened. In the first intercostals space the blood vessel was ligatured, and no further complications arose. The remaining two operations took place without complication. Complete anatomical repositioning was achieved with end-to-end readaptation of the fracture cleft and the malrotation was successfully reduced. Symmetry of the sternocostal and sternoclavicular complexes was attained, which led to the recovery of the overall symmetry of the shoulder girdle. In all three cases no disorders of wound
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Summary and conclusion Treatment
Fig. 2 Sternal fractures—overview
healing occurred. The swelling swiftly subsided, because of the low-profile-design the plates were not palpable percutaneously. The X-ray check-ups in two axes carried out immediately postoperatively and at the sixth and 12th postoperative weeks revealed correct positioning of the implants. Signs of fracture consolidation were seen after six and 12 weeks. No secondary displacement was observed. In two out of the three cases complete shoulder girdle function was reestablished without a problem. In the third case it was not assessable because of the presence of a traumatic brain injury with accompanying longterm cerebral movement disorder. However, in all cases, bony healing occurred without complication. The traumas were accompanied by the following coinjuries which are shown in Table 2. mvc motor vehicle collision Altogether 79 (14.7 %) patients of the cohort suffered from a sternal fracture. Of these fractures, 13 (16.5 %) were located at the manubrium sterni. Ten (12.7 %) were oblique manubrial fractures with avulsion of the clavicula, and first rib-insertions caused by a seatbelt.
Fig. 3 a Dislocation of the manubrium sterni showing instability. b Combined multifragmented sternal fracture and serial rib fracture following the impact of the lap belt
Undisplaced fractures, and those with an acceptable alignment without relevant instability, can be considered the domain of a conservative therapy. This was reflected by the undisplaced fracture patients of our patient cohort; post traumatically at the sixth and 12th week check-ups they demonstrated an uncomplicated healing process with complete bony consolidation and no residual symptoms. Displaced, unstable fractures need to be looked at from a different point of view. Approximation of the fracture fragments by using, for example, the positioning of the arms or an anteflexion of both shoulders for the consolidation period of about six weeks could be taken into consideration. However, a viable system for the immobilisation, for example, by means of an orthotic is not known to the authors. The clinical observations of our above-mentioned three cases showed in no uncertain terms, how simple repositioning measures can lead to large displacement of the fracture with widening of the fracture cleft and malrotation of the manubrial fragments. The result was a functional instability of the shoulder girdle. In one case the tearing apart was so severe, that the pulse of the arcus aortae could be percutaneously palpated through the fracture cleft. Thus the manubrium had lost its ability to protect the organs of the upper mediastinum. In recapitulating, the authors see the indication for the operative open reduction and internal fixation as justified, due to the combination of instability, the associated pain, the lateral displacement with widening of the fracture cleft and the malrotation of the sternocostal parts of the shoulder girdle [7, 15]. In order for a satisfactory reduction to be achieved, a surgical access point by means of an incision at the mediocranial part of the sternum was chosen. To enable a complete view of the manubrium and unimpeded access for the reduction, the fracture region was laid open to the sternal
Gender
Female
Female
Female
Female
Female
Male
Female
Female
Female
Female
Female
Male
Male
Ten female three male
1
2
3
4
5
6
7
8
9
10
11
12
13
Total
54.5
21
52
44
47
60
74
21
53
85
64
57
88
42
Age (years)
Three transverse ten oblique
Transverse
Oblique
Oblique
Oblique
Oblique
Transverse multiple
Oblique
Oblique
Transverse
Oblique manubrium und corpus
Oblique
Oblique
Oblique
Type of fracture
Patients with fracture of the manubrium sterni
Patient number
Table 2
Little dislocation
3 mm gap
No dislocation
No dislocation
No dislocation
Little dislocation
Severe
Severe
Little dislocation
Severe
No dislocation
Little dislocation
2 mm gap
Dislocation
Fall, 5 m
mvc, restrained car driver
mvc, restrained car driver
mvc, restrained car co-driver
mvc, restrained car co-driver
Fall, 3 m
mvc, restrained car driver, trapped
mvc, restrained car occupant
Low fall
mvc, restrained car driver, trapped
mvc, restrained car driver mvc, restrained car co-driver
mvc, restrained car driver
Mechanism of injury
Conservative
Conservative
Conservative
Conservative
Conservative
Conservative
ORIF plate
ORIF 2 plates transverse
Conservative
ORIF 3 plates transverse and one plate longitudinal
Conservative
Conservative
Conservative
Treatment
Ten lung contusion, six bilateral
Lung contusion monolateral, fracture of the scapula, complex fracture of the midface
Lung contusion bilateral, retrosternal haematoma, blunt abdomen injury
Lung contusion bilateral, pneumothorax monolateral, serial rib fracture monolateral
Lung contusion bilateral, pneumothorax monolateral, fracture of the femur
Lung contusion bilateral, rib fractures monolateral, fracture of clavicle, lumbar spine fracture, blunt abdomen injury, fracture of the tibia
Lung contusion, retrosternal haematoma, pelvic ring and acetabular fracture, upper limb fractures,
Polytrauma: lung contusion bilateral, pneumothorax bilateral, bilateral carotid dissection, cerebral infarction, midface fractures, rupture of liver and spleen
Severe head injury, midface fractures, vertebral column fractures (cervical-, thoracic- and lumbar spine)
Lung contusion, rib fractures monolateral
Polytrauma: vertebral column (thoracic and lumbar spine fractures), serial rib fracture monolateral, proximal fracture of the tibia, complex fracture of the distal tibia and talus opposite site
Rib fractures monolateral, contusio cerebri
Lung contusion, rib fractures
Lung contusion bilateral, serial rib fracture bilateral, haemo- and penumothorax, fracture of clavicle, retroperitoneal haematoma
Concomitant injuries
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margins and the neighbouring first and second ribs. The open reduction can be achieved in several different ways. Two methods which have been described in order to achieve reapproximation of the fracture fragments are: reduction by use of pointed pliers or reduction by installation of a wire cerclage. In our case we used depth-limited compression wires with ball-shaped ends. These allowed a very precise reduction (Fig. 1). A wiring of the sternum, as is the standard format found in cardiac surgery, was not used to achieve an absolutely stable osteosynthesis. In an experimental study, Fawzy has already shown the superiority of plate osteosynthesis of rib-to-sternum-to-rib in comparison to the wiring of the sternum [16]. The clinical results with very good healing outcomes, accurate anatomical repositioning, both during and after the healing period, confirm the validity of the anterior transverse plate osteosynthesis, even for oblique fractures of the manubrium. The stable purchase of the plate by anchoring the screw in the neighbouring costal cartilage has already been described by various authors [17, 18]. The use of depth-limited drilling once the bony thickness has been ascertained can be regarded as a very safe method, as additional mediastinal injuries can be effectively prevented [19]. A comment, at this juncture, about the absolute necessity for a careful anatomical dissection with an accurate reduction of the fracture fragments, because of the numerous important and vulnerable structures that are located around the manubrium, would not be remiss. As early as 1962, Gibson reported in a study about the precariousness of this situation [12]. In one of our above-mentioned cases (patient 7), on removal of the retrosternal haematoma and reduction of the fracture, there was bleeding out of the arteria mammaria. This injury was probably caused by the original trauma, since the injury to the artery was ipsilateral to the fracture margin. Injuries to major blood vessels did not occur in our patient cohort, although pronounced mediastinal haematomas which were not haemodynamically significant were observed [11]. Fig. 4 BMirror injury^: oblique fracture of the manubrium in a driver and a co-driver of one car
These observations support the findings of other authors, for example, Scheyerer in 2013. He pointed out the impact of violent trauma on the body by a direct fracture of the manubrium [13]. The associated co-injuries, including those of the upper mediastinum, led to an increase in the incidence of intensive care unit stays and in mortality. In particular, a direct impact to the sternum should lead to an immediate investigation of the mediastinal structures. The authors of this study see the employment of a helical CT-scan of the chest with depiction of the blood vessels as an absolute requirement. Hereby one can detect large leaks of the blood vessels. In cases such as the one above, with the a. mammaria injury that was not visible in the CT-scan, the extent of the retrosternal haematoma can give one at least an indication of the possible co-injuries and a possible estimate of the severity of the injury. Close monitoring in the presence of a manubrium fracture of also the cardiac output is to be regarded as indispensable. So that one does not overlook the existence of a compromised cardiac output due to an extracardial compression of the heart caused by a retrosternal haematoma [13]. Another reason to run a CT-diagnosis particularly with the relevant injury mechanisms and/or clinical symptoms was reported in 2004 by the authors Kehdy and Richardson, Nakae et al., as well as by Alkadhi et al. [9, 10, 20]. The radiological diagnostic without contrast medium through the use of chest X-ray in two axes cannot reliably and effectively detect a manubrial fracture. Thus such injuries could be missed under certain circumstances. Velutini and Tarazona described the presence of an asymmetrical sternoclavicular complex as part of an oblique fracture of the manubrium in a single case study. It was caused by an indirect trauma, namely, a strike to the ipsilateral shoulder [7]. Direct impact to the manubrium, in addition to the oblique manubrium fracture, induces a domino-effect injury mechanism following the impact pathway, whereby the neighbouring ribs are also injured. Nakae et al. reported the result of an impact to the ribcage of a cyclist, with the resulting oblique manubrial fracture on
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the left with its Bknock on^ injuries to the ribs II–VII parasternally [10]. Starting at the second rib close to the sternum, the fracture line ran obliquely and laterally to the other ribs. Similar findings were observed in two of our patients who received surgical treatment of their injuries. In two cases the right sternocostal attachment of the second rib was surgically stabilized along with the manubrium, in one case along with the third rib as well. The oblique manubrium fracture can be an indicator for the presence of a transsection of the thorax caused by the seatbelt. In 2002, Byard described injuries of this sort, although the seatbelt left a trail of destruction which went from the clavicle shaft through the corpus sterni and into the neighbouring ribs [21]. At this juncture, one can reflect upon whether in cases of an oblique manubrial fracture that the seatbelt was positioned too high, because the injury pattern was not of the claviculacorpus sterni sort. Two of our patients demonstrated the above impressively; with a height of 161 and 158 cm they were on the small size, both were passengers involved in frontal car crashes, both wearing seatbelts, and both suffered an oblique fracture of the manubrium which was the exact mirror image of the fracture suffered by the driver and the co-driver (Fig. 4). Byard also described such B mirror image injuries^ upon two seatbelted occupants, who after being involved in a very severe frontal crash, died of their injuries due to a transsection of the thorax and its associated ramifications [21]. These observations should highlight the need to carefully examine for peristernal injuries, car occupants involved in high speed car crashes, so that one does not overlook any serious injuries. The current guidelines for the care of patients admitted to the emergency trauma room underline this [14]. In summing up, one can regard the oblique manubrium fracture as an injury to be taken seriously. Non-displaced fractures can be treated conservatively after co-injuries have been ruled out. Displaced fractures and unstable injuries should be surgically stabilised. The transverse angular stable plate osteosynthesis offers a safe and satisfactory method of treatment. As the injury can easily be missed in chest X-ray examinations, it is strongly recommended that a computed tomography is carried out when the relevant injury mechanism is present. The CT-scans should also depict the cervical and thoracic blood vessels, in order to detect at an early stage the presence of any possible life threatening co-injuries. In total almost 15 % of our trauma cohort of patients demonstrated an injury to the sternum, of which 16.5 % were manubrium fractures. The oblique fracture of the manubrium with its ten cases (12.7 %) was markedly more diagnosed as previously described in the literature up until now. This injury differs from the more common corpus sterni fractures and angulus ludovici dislocations with respect to its co-injuries and its treatment strategies [22].
Conflict of interest The first author has a consultant agreement with SynthesCMF. No funds were received in connection to the presented study. The coauthors declare that they have no competing interests.
References 1.
2.
3. 4. 5. 6.
7.
8. 9.
10.
11.
12. 13.
14.
15. 16.
17.
18.
19.
Athanassiadi K, Gerazounis M, Moustardas M, Metaxas E (2002) Sternal fractures: retrospective analysis of 100 cases. World J Surg 26(10):1243–1246 Yeh DD, Hwabejire JO, DeMoya MA, Alam HB, King DR, Velmahos GC (2014) Sternal fracture–an analysis of the National Trauma Data Bank. J Surg Res 186(1):39–43 Helal B (1964) Fracture of the manubrium sterni. J Bone Joint Surg (Br) 46:602–607 Gurlt E (1864) Handbuch der Lehre von den Knochenbrüchen, Band II, Kap. III. Grot‘sche Buchhandlung, C. Müller, pp 264–315 Fowler AW (1957) Flexion-compression injury of the sternum. J Bone Joint Surg (Br) 39-B(3):487–497 Knobloch K, Wagner S, Haasper C, Probst C, Krettek C, Otte D, Richter M (2006) Sternal fractures occur most often in old cars to seat-belted drivers without any airbag often with concomitant spinal injuries: clinical findings and technical collision variables among 42,055 crash victims. Ann Thorac Surg 82(2):444–450 Velutini JA, Tarazona PF (1998) Fracture of the manubrium with posterior displacement of the clavicle and first rib. A case report. Int Orthop 22(4):269–271 Lane WA (1884) One mode of fracture of the sternum. Trans Pathol Soc London 35:253 Kehdy F, Richardson JD (2006) The utility of 3-D CT scan in the diagnosis and evaluation of sternal fractures. J Trauma 60(3):635– 636 Nakae H, Tajimi K, Kodama H (2003) Diagnosis of a fractured manubrium aided by three-dimensional computed tomographic scanning. J Trauma 55(1):139–140 Scheyerer MJ, Zimmermann SM, Bouaicha S, Simmen HP, Wanner GA, Werner CM (2013) Location of sternal fractures as a possible marker for associated injuries. Emerg Med Int 2013:407589 Gibson LD, Carter R, Hinshaw DB (1962) Surgical significance of sternal fracture. Surg Gynecol Obstet 114:443–448 Rambaud G, Desachy A, François B, Allot V, Cornu E, Vignon P (2001) Extrapericardial cardiac tamponade caused by traumatic retrosternal hematoma. J Cardiovasc Surg (Torino) 42(5):621–624 Deutsche Gesellschaft für Unfallchirurgie (federführend) (2012) S3 – Leitlinie Polytrauma/Schwerverletzten-Behandlung; AWMF Register-Nr. 012/019; S71. http://www.awmf.org . Accessed 25 Nov 2014 Harston A, Roberts C (2011) Fixation of sternal fractures: a systematic review. J Trauma 71(6):1875–1879 Fawzy H, Alhodaib N, Mazer CD, Harrington A, Latter D, Bonneau D, Errett L, Mahoney J (2009) Sternal plating for primary and secondary sternal closure; can it improve sternal stability? J Cardiothorac Surg 4:19 Schulz-Drost S, Syed J, Besendoerfer M, Carbon RT (2014) Sternocostal dislocation following open correction of pectus excavatum-Bstairway phenomenon^: complication management by means of sternocostal locking titanium plate osteosynthesis. Thorac Cardiovasc Surg 62(3):245–252 Bottlang M, Long WB, Phelan D, Fielder D, Madey SM (2013) Surgical stabilization of flail chest injuries with MatrixRIB implants: a prospective observational study. Injury 44(2):232–238 Schulz-Drost S, Mauerer A, Grupp S, Hennig FF, Blanke M (2014) Surgical fixation of sternal fractures: locked plate fixation by low-
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20.
profile titanium plates–surgical safety through depth limited drilling. Int Orthop 38(1):133–139 Alkadhi H, Wildermuth S, Marincek B, Boehm TJ (2004) Accuracy and time efficiency for the detection of thoracic cage fractures: volume rendering compared with transverse computed tomography images. Comput Assist Tomogr 28(3):378–385
21. 22.
Byard RW (2002) Shoulder-lap seat belts and thoracic transection. J Clin Forensic Med 9(2):92–95 Schulz-Drost S, Oppel P, Grupp S, Schmitt S, Carbon RT, Mauerer A, Hennig FF, Buder T (2015) Surgical fixation of sternal fractures: preoperative planning and a safe surgical technique using locked titanium plates and depth limited drilling. J Vis Exp 95:e52124. doi: 10.3791/52124
ORIGINAL PAPER
The oblique fracture of the manubrium sterni caused by a seatbelt—a rare injury? Treatment options based on the experiences gained in a level I trauma centre Stefan Schulz-Drost 1,2 & Pascal Oppel 1 & Sina Grupp 1 & Dominic Taylor 3 & Sebastian Krinner 1 & Andreas Langenbach 1 & Friedrich Hennig 1 & Andreas Mauerer 3
Received: 17 March 2015 / Accepted: 21 April 2015 # SICOT aisbl 2015
Abstract Introduction Sternal fractures are rare with 3–8 % out of the total number of trauma cases mostly caused by direct impact to the anterior chest wall. Most cases described are due to motor vehicle crash either caused by direct impact to the steering wheel or by the seat belt. Fractures mainly occur to the sternal body. Only rarely are cases of manubrium fractures described in literature, for example, in relationship with a direct impact to the shoulder which caused an oblique fracture near to the sternoclavicular joint. Three patients with profoundly dislocated oblique manubrium fracture were admitted to our Level I Trauma Center in 2012 and 2013. Those patients suffered from instability of the upper sternum and the shoulder girdle. Material and methods Between January 2012 and October 2013, a total of 538 trauma patients were admitted to the emergency room and received whole body CT-scan. They were analysed retrospectively for sternal fractures. In cases of instability and dislocation, fracture stabilisation was performed by anterior plating through a medial approach using low profile titanium plates (MatrixRib®). Results Seventy-nine (14.7 %) patients showed sternal fracture, out of which 13 (2.4 %) patients showed a fracture of manubrium, ten caused by seatbelt. In three cases stabilization
* Stefan Schulz-Drost [email protected] 1
Department of Orthopaedic and Trauma Surgery, University Hospital Erlangen, Erlangen, Germany
2
Department of Pediatric Surgery, University Hospital Erlangen, Erlangen, Germany
3
Department of Orthopaedic and Trauma Surgery, St. Theresien Krankenhaus, Nürnberg, Germany
was performed. Follow up showed sufficient consolidation without complications. Discussion A total of 16.5 % of sternal fractures were localized at the manubrium, mostly caused by seat belt. Fractures without significant dislocation seemed to be stable and healed well under conservative treatment. Dislocation in this region leads to unstable shoulder girdle. Anterior plating provides sufficient stabilisation and allowed consolidation. Keywords Sternum fracture . Sternal fracture . Manubrium . Locked plate . Sternal plating . Mediatinal injury
Introduction On reviewing the total spectrum of bony injuries, one finds that the fracture of the sternum is a rare entity with an incidence of 3–8 % [1, 2]. Helal reported in his study from 1964, an even smaller incidence rate of 0.5 % after analysing the time period from the middle of the 19th century through to the 1960s in the 20th century [3]. Earlier studies described different injury mechanisms which could cause a fracture of the sternum. In 1864 Gurlt, followed by numerous authors and single-case studies thereafter, reported on sternal fractures caused by indirect trauma, for example, an injury caused by a violent compression trauma to the torso. In 1957, Fowler defined this injury as a flexion–compression injury [4, 5]. A literature review demonstrated a consensus that the most common cause by far of a sternal fracture was direct trauma. The causal incidence rate was 84 % [6]. The most common agent to cause a direct impact injury to the sternum was shown to be the steering wheel or the seatbelt [6]. Since the 19th century there has been a significant rise in the rate of fractures of all types to the sternum described in literature. Helal was
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able to prove in his study from 1964, that the rate of sternal fractures closely correlated with the rise in vehicle registrations from the second decade of the 20th century [3]. On analysing the data of the different localisations of the sternal fractures, it is noticeable that the majority occur within the corpus sterni region, followed by the dissociation fractures of the angulus ludovici. Write ups of the pure bony fracture of the manubrium sterni were rare. They can also be induced as a consequence of direct trauma, for example, as a result of a fall on the back, or as a result of a spontaneous fracture caused by muscle spasms. Manubrial fractures caused by direct trauma are in most cases associated with high speed crashes and a horizontal fracture type [5]. Oblique fractures are described only in individual cases. In 1998, Velutini reported on an oblique manubrial fracture as a consequence of an impact trauma to the ipsilateral shoulder [7]. This type of injury had already been described by Lane in 1884 after conducting biomechanical studies on cadavers, though clinically it was never described [8]. Oblique manubrial fractures as a result of direct trauma have only been found in two individual cases upon review of the literature. These two cases were interestingly enough not discovered clinically, but rather came to light as a result of a computed tomography scan. In the first case Kehdy described a multiple oblique fracture of the sternum involving the manubrium and the cranial part of the corpus sterni [9]. The second case was described by Nakae in 2002. It was an oblique fracture of the manubrium as a result of a ribcage contusion of a bicyclist [10] (Table 1). On the other hand however, it has been reported that a manubrial fracture is often associated with life-threatening and/or lethal co-injuries. In 2013, Scheyerer wrote about the higher rate of required intensive-care treatments, as well as the higher mortality rate in comparison to other fracture sites on the Sternum [11]. In 1962, Gibson highlighted the fact that the manubrium is the stablest part of the sternum and its importance in topographically protecting the following structures: major blood vessels of the mediastinum such as the superior vena cava, the innominate veins (v. brachiocephalica dextra et sinistra), the innominate artery (a. brachiocephalica), the internal thoracic artery, the aortic arch and its offshoots. As a consequence one can see that a manubrial fracture carries with it an increased risk for co-injuries to vital organs; in particular a
Table 1
massive extrapericardial and retrosternally localized haematoma has been described in the literature [12, 13]. At our institution, a level I trauma centre, in the time frame of 2012 and 2013, three patients were admitted with a substantial dislocated unstable oblique fracture of the manubrium caused by blunt force trauma as a result of being seatbelted occupants in a car accident. These patients suffered from a substantial instability of the upper part of the sternum and adjoining areas of the shoulder girdle. This posed the question whether the oblique fracture of the manubrium caused by a seatbelt was in fact such a rare occurrence and what treatment options were available for the resulting injuries.
Materials and methods For this purpose a retrospective analysis was carried out on the patients taken to our level I trauma centre. The time frame from January 2012 to October 2013 was examined. Included were patients who had suffered a high-speed trauma and fulfilled the criteria for an emergency trauma room alert [14]. A further inclusion factor was the implementation of a whole-body helical CT scan (Btrauma scan^) (Somatom definition AS, 128 slice, Siemens, Munich, Germany) with a slice thickness of 1.5 mm and multiplaned reconstruction. The defined exclusion criteria were: patients under 16 years of age, the presence of only traumatic brain injury, the cases where the follow-up examinations were not executed. The elicited CT-diagnostic findings underwent a 3D reconstruction and were examined for the presence of a sternal fracture. Co-injuries were collated at the same time. On finding the presence of a sternal fracture, its precise localization and its exact course were determined by analysis of the axial-/ sagittal-/ coronal- plane slices as well as the use of the VRT-Mode of the CT-scan. Fractures of the manubrium sterni, of the angulus ludovici, and of the corpus sterni were differentiated. On finding a manubrial fracture, the case history was anonymized with regards to: the circumstances surrounding the accident, findings on admission, co-injuries, course of the illness, and treatment modalities. In addition, the findings during the outcome were analysed. These occurred, according to our in-house
Reported cases of oblique manubrium fractures
Year, first author, journal
Number of occurrences
Mechanism of injury
Therapy
Outcome
1998, Velutini, Int Orthop 2002, Nakae, J Trauma 2006, Kehdy, J Trauma
1 1 1
Impact to the ipsilateral shoulder Bicycle crash, impact to the chest wall Lap belt injury car occupant
Conservative Conservative Plate osteosynthesis
Not reported Not reported Without complications
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regulations, as part of the follow up examinations at the sixthand 12th-week marks after the accident. Surgical fixation was selected as the treatment of choice for the above described three patients with unstable oblique fractures of the manubrium. This ensued after stabilization of the overall condition of the patient had been achieved, consentform had been signed, and with an operation under general anaesthetic. Access to the manubrium sterni was achieved by a median skin incision from the fossa jugularis to the angulus ludovici, with ensuing layer by layer dissection down to the sternum. The pectoral muscles were dissected up to the manubrial margins and the fracture site was completely exposed (Fig. 1a). Any trapped soft tissues were removed from the fracture to ensure anatomical repositioning. This was achieved through the use of four compression wires, two on the left and two on the right of the fracture (Fig. 1b). By use of the requisite repositioning clamp, readaptation of the fracture fragments was achieved (Fig. 1c). Internal fixation by angularstable plate osteosynthesis was carried out by bridging between the first two ribs and the manubrium sterni. Plates of low-profile design of 1.5-mm thickness made out of titanium (MatrixRib®, DePuySynthes CMF, Switzerland) were used. These were attached to each fragment by the use of at least three locked and self-cutting screws with 2.9 mm diameter (Fig. 1d). In cases of additional dislocated fractures, for example, to the neighbouring ribs and/or other areas of the sternum, these were treated during the same procedure by using the method of a locked plate osteosynthesis. After stability had been restored to the anterior chest wall, irrigation of the wound site and insertion of a drainage tube were carried out. To achieve a by-the-layers wound closure, reconstruction of the muscular and connective tissue layers ensued by suturing the pectoral muscles and the fasciae. For optimal cosmetic results the subcutaneous and intracutaneous layers were sutured. Postoperative care included the following: close clinical monitoring, removal of the drainage tube, mobilizing the patient out of bed, and discharge after completion of wound healing. Chest X-ray check-ups in two axes were carried out: immediately postoperatively, at the sixth and 12th postoperative weeks to ascertain the status of the reduced fracture as well as the implant positioning.
Fig. 1 a Dehiscence of the fracture. b Open reduction using compression wires. c Plate osteosynthesis crossing the first pair of ribs. d Final osteosynthesis
Results From January 2012 to October 2013, a total of 538 trauma patients which fulfilled the inclusion criteria and none of the exclusion criteria were admitted to the emergency trauma room of our level I trauma centre. The evaluation of the CT-Btrauma scan^ revealed that 79 patients had a sternal fracture (corresponding to 14.7 % of the total). Thirteen (2.4 % of the total) of these 79 patients had a fracture of the manubrium sterni (Fig. 2). On analysis, three of the 13 fractures were caused indirectly by means of a fall on their back, the other ten fractures were caused by the safety belt whilst being front seat occupants. These ten fractures caused by seatbelts were oblique manubrial fractures with involvement of the ipsilateral clavicula and first rib. In contrast the three indirectly caused fractures were transverse fractures extending to the first intercostals space (Fig. 3a, b). Three of the ten oblique manubrial fractures demonstrated considerable instability with a gaping fracture, percutaneously palpable fracture cleft and a large haematoma. The fracture cleft widened according to the amount of retroversion of the shoulder, and the widest clinically measured cleft was 4 cm. On the other hand adduction of the arm and/or anteversion of the shoulder significantly narrowed the fracture cleft. In a CT-scan of the thorax performed with arms above the head and at the side revealed only a few millimetres of dehiscence. But in three cases there was considerable displacement of up to 5 mm and a malrotation of the avulsed manubrial fragment. In the context of a massive clinical instability is the indication for an operative osteosynthesis clear. This was carried out in the above mentioned manner. In one case intraoperatively, on sluicing out the haematoma, a preexisting wound of the right a. mammaria was reopened. In the first intercostals space the blood vessel was ligatured, and no further complications arose. The remaining two operations took place without complication. Complete anatomical repositioning was achieved with end-to-end readaptation of the fracture cleft and the malrotation was successfully reduced. Symmetry of the sternocostal and sternoclavicular complexes was attained, which led to the recovery of the overall symmetry of the shoulder girdle. In all three cases no disorders of wound
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Summary and conclusion Treatment
Fig. 2 Sternal fractures—overview
healing occurred. The swelling swiftly subsided, because of the low-profile-design the plates were not palpable percutaneously. The X-ray check-ups in two axes carried out immediately postoperatively and at the sixth and 12th postoperative weeks revealed correct positioning of the implants. Signs of fracture consolidation were seen after six and 12 weeks. No secondary displacement was observed. In two out of the three cases complete shoulder girdle function was reestablished without a problem. In the third case it was not assessable because of the presence of a traumatic brain injury with accompanying longterm cerebral movement disorder. However, in all cases, bony healing occurred without complication. The traumas were accompanied by the following coinjuries which are shown in Table 2. mvc motor vehicle collision Altogether 79 (14.7 %) patients of the cohort suffered from a sternal fracture. Of these fractures, 13 (16.5 %) were located at the manubrium sterni. Ten (12.7 %) were oblique manubrial fractures with avulsion of the clavicula, and first rib-insertions caused by a seatbelt.
Fig. 3 a Dislocation of the manubrium sterni showing instability. b Combined multifragmented sternal fracture and serial rib fracture following the impact of the lap belt
Undisplaced fractures, and those with an acceptable alignment without relevant instability, can be considered the domain of a conservative therapy. This was reflected by the undisplaced fracture patients of our patient cohort; post traumatically at the sixth and 12th week check-ups they demonstrated an uncomplicated healing process with complete bony consolidation and no residual symptoms. Displaced, unstable fractures need to be looked at from a different point of view. Approximation of the fracture fragments by using, for example, the positioning of the arms or an anteflexion of both shoulders for the consolidation period of about six weeks could be taken into consideration. However, a viable system for the immobilisation, for example, by means of an orthotic is not known to the authors. The clinical observations of our above-mentioned three cases showed in no uncertain terms, how simple repositioning measures can lead to large displacement of the fracture with widening of the fracture cleft and malrotation of the manubrial fragments. The result was a functional instability of the shoulder girdle. In one case the tearing apart was so severe, that the pulse of the arcus aortae could be percutaneously palpated through the fracture cleft. Thus the manubrium had lost its ability to protect the organs of the upper mediastinum. In recapitulating, the authors see the indication for the operative open reduction and internal fixation as justified, due to the combination of instability, the associated pain, the lateral displacement with widening of the fracture cleft and the malrotation of the sternocostal parts of the shoulder girdle [7, 15]. In order for a satisfactory reduction to be achieved, a surgical access point by means of an incision at the mediocranial part of the sternum was chosen. To enable a complete view of the manubrium and unimpeded access for the reduction, the fracture region was laid open to the sternal
Gender
Female
Female
Female
Female
Female
Male
Female
Female
Female
Female
Female
Male
Male
Ten female three male
1
2
3
4
5
6
7
8
9
10
11
12
13
Total
54.5
21
52
44
47
60
74
21
53
85
64
57
88
42
Age (years)
Three transverse ten oblique
Transverse
Oblique
Oblique
Oblique
Oblique
Transverse multiple
Oblique
Oblique
Transverse
Oblique manubrium und corpus
Oblique
Oblique
Oblique
Type of fracture
Patients with fracture of the manubrium sterni
Patient number
Table 2
Little dislocation
3 mm gap
No dislocation
No dislocation
No dislocation
Little dislocation
Severe
Severe
Little dislocation
Severe
No dislocation
Little dislocation
2 mm gap
Dislocation
Fall, 5 m
mvc, restrained car driver
mvc, restrained car driver
mvc, restrained car co-driver
mvc, restrained car co-driver
Fall, 3 m
mvc, restrained car driver, trapped
mvc, restrained car occupant
Low fall
mvc, restrained car driver, trapped
mvc, restrained car driver mvc, restrained car co-driver
mvc, restrained car driver
Mechanism of injury
Conservative
Conservative
Conservative
Conservative
Conservative
Conservative
ORIF plate
ORIF 2 plates transverse
Conservative
ORIF 3 plates transverse and one plate longitudinal
Conservative
Conservative
Conservative
Treatment
Ten lung contusion, six bilateral
Lung contusion monolateral, fracture of the scapula, complex fracture of the midface
Lung contusion bilateral, retrosternal haematoma, blunt abdomen injury
Lung contusion bilateral, pneumothorax monolateral, serial rib fracture monolateral
Lung contusion bilateral, pneumothorax monolateral, fracture of the femur
Lung contusion bilateral, rib fractures monolateral, fracture of clavicle, lumbar spine fracture, blunt abdomen injury, fracture of the tibia
Lung contusion, retrosternal haematoma, pelvic ring and acetabular fracture, upper limb fractures,
Polytrauma: lung contusion bilateral, pneumothorax bilateral, bilateral carotid dissection, cerebral infarction, midface fractures, rupture of liver and spleen
Severe head injury, midface fractures, vertebral column fractures (cervical-, thoracic- and lumbar spine)
Lung contusion, rib fractures monolateral
Polytrauma: vertebral column (thoracic and lumbar spine fractures), serial rib fracture monolateral, proximal fracture of the tibia, complex fracture of the distal tibia and talus opposite site
Rib fractures monolateral, contusio cerebri
Lung contusion, rib fractures
Lung contusion bilateral, serial rib fracture bilateral, haemo- and penumothorax, fracture of clavicle, retroperitoneal haematoma
Concomitant injuries
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margins and the neighbouring first and second ribs. The open reduction can be achieved in several different ways. Two methods which have been described in order to achieve reapproximation of the fracture fragments are: reduction by use of pointed pliers or reduction by installation of a wire cerclage. In our case we used depth-limited compression wires with ball-shaped ends. These allowed a very precise reduction (Fig. 1). A wiring of the sternum, as is the standard format found in cardiac surgery, was not used to achieve an absolutely stable osteosynthesis. In an experimental study, Fawzy has already shown the superiority of plate osteosynthesis of rib-to-sternum-to-rib in comparison to the wiring of the sternum [16]. The clinical results with very good healing outcomes, accurate anatomical repositioning, both during and after the healing period, confirm the validity of the anterior transverse plate osteosynthesis, even for oblique fractures of the manubrium. The stable purchase of the plate by anchoring the screw in the neighbouring costal cartilage has already been described by various authors [17, 18]. The use of depth-limited drilling once the bony thickness has been ascertained can be regarded as a very safe method, as additional mediastinal injuries can be effectively prevented [19]. A comment, at this juncture, about the absolute necessity for a careful anatomical dissection with an accurate reduction of the fracture fragments, because of the numerous important and vulnerable structures that are located around the manubrium, would not be remiss. As early as 1962, Gibson reported in a study about the precariousness of this situation [12]. In one of our above-mentioned cases (patient 7), on removal of the retrosternal haematoma and reduction of the fracture, there was bleeding out of the arteria mammaria. This injury was probably caused by the original trauma, since the injury to the artery was ipsilateral to the fracture margin. Injuries to major blood vessels did not occur in our patient cohort, although pronounced mediastinal haematomas which were not haemodynamically significant were observed [11]. Fig. 4 BMirror injury^: oblique fracture of the manubrium in a driver and a co-driver of one car
These observations support the findings of other authors, for example, Scheyerer in 2013. He pointed out the impact of violent trauma on the body by a direct fracture of the manubrium [13]. The associated co-injuries, including those of the upper mediastinum, led to an increase in the incidence of intensive care unit stays and in mortality. In particular, a direct impact to the sternum should lead to an immediate investigation of the mediastinal structures. The authors of this study see the employment of a helical CT-scan of the chest with depiction of the blood vessels as an absolute requirement. Hereby one can detect large leaks of the blood vessels. In cases such as the one above, with the a. mammaria injury that was not visible in the CT-scan, the extent of the retrosternal haematoma can give one at least an indication of the possible co-injuries and a possible estimate of the severity of the injury. Close monitoring in the presence of a manubrium fracture of also the cardiac output is to be regarded as indispensable. So that one does not overlook the existence of a compromised cardiac output due to an extracardial compression of the heart caused by a retrosternal haematoma [13]. Another reason to run a CT-diagnosis particularly with the relevant injury mechanisms and/or clinical symptoms was reported in 2004 by the authors Kehdy and Richardson, Nakae et al., as well as by Alkadhi et al. [9, 10, 20]. The radiological diagnostic without contrast medium through the use of chest X-ray in two axes cannot reliably and effectively detect a manubrial fracture. Thus such injuries could be missed under certain circumstances. Velutini and Tarazona described the presence of an asymmetrical sternoclavicular complex as part of an oblique fracture of the manubrium in a single case study. It was caused by an indirect trauma, namely, a strike to the ipsilateral shoulder [7]. Direct impact to the manubrium, in addition to the oblique manubrium fracture, induces a domino-effect injury mechanism following the impact pathway, whereby the neighbouring ribs are also injured. Nakae et al. reported the result of an impact to the ribcage of a cyclist, with the resulting oblique manubrial fracture on
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the left with its Bknock on^ injuries to the ribs II–VII parasternally [10]. Starting at the second rib close to the sternum, the fracture line ran obliquely and laterally to the other ribs. Similar findings were observed in two of our patients who received surgical treatment of their injuries. In two cases the right sternocostal attachment of the second rib was surgically stabilized along with the manubrium, in one case along with the third rib as well. The oblique manubrium fracture can be an indicator for the presence of a transsection of the thorax caused by the seatbelt. In 2002, Byard described injuries of this sort, although the seatbelt left a trail of destruction which went from the clavicle shaft through the corpus sterni and into the neighbouring ribs [21]. At this juncture, one can reflect upon whether in cases of an oblique manubrial fracture that the seatbelt was positioned too high, because the injury pattern was not of the claviculacorpus sterni sort. Two of our patients demonstrated the above impressively; with a height of 161 and 158 cm they were on the small size, both were passengers involved in frontal car crashes, both wearing seatbelts, and both suffered an oblique fracture of the manubrium which was the exact mirror image of the fracture suffered by the driver and the co-driver (Fig. 4). Byard also described such B mirror image injuries^ upon two seatbelted occupants, who after being involved in a very severe frontal crash, died of their injuries due to a transsection of the thorax and its associated ramifications [21]. These observations should highlight the need to carefully examine for peristernal injuries, car occupants involved in high speed car crashes, so that one does not overlook any serious injuries. The current guidelines for the care of patients admitted to the emergency trauma room underline this [14]. In summing up, one can regard the oblique manubrium fracture as an injury to be taken seriously. Non-displaced fractures can be treated conservatively after co-injuries have been ruled out. Displaced fractures and unstable injuries should be surgically stabilised. The transverse angular stable plate osteosynthesis offers a safe and satisfactory method of treatment. As the injury can easily be missed in chest X-ray examinations, it is strongly recommended that a computed tomography is carried out when the relevant injury mechanism is present. The CT-scans should also depict the cervical and thoracic blood vessels, in order to detect at an early stage the presence of any possible life threatening co-injuries. In total almost 15 % of our trauma cohort of patients demonstrated an injury to the sternum, of which 16.5 % were manubrium fractures. The oblique fracture of the manubrium with its ten cases (12.7 %) was markedly more diagnosed as previously described in the literature up until now. This injury differs from the more common corpus sterni fractures and angulus ludovici dislocations with respect to its co-injuries and its treatment strategies [22].
Conflict of interest The first author has a consultant agreement with SynthesCMF. No funds were received in connection to the presented study. The coauthors declare that they have no competing interests.
References 1.
2.
3. 4. 5. 6.
7.
8. 9.
10.
11.
12. 13.
14.
15. 16.
17.
18.
19.
Athanassiadi K, Gerazounis M, Moustardas M, Metaxas E (2002) Sternal fractures: retrospective analysis of 100 cases. World J Surg 26(10):1243–1246 Yeh DD, Hwabejire JO, DeMoya MA, Alam HB, King DR, Velmahos GC (2014) Sternal fracture–an analysis of the National Trauma Data Bank. J Surg Res 186(1):39–43 Helal B (1964) Fracture of the manubrium sterni. J Bone Joint Surg (Br) 46:602–607 Gurlt E (1864) Handbuch der Lehre von den Knochenbrüchen, Band II, Kap. III. Grot‘sche Buchhandlung, C. Müller, pp 264–315 Fowler AW (1957) Flexion-compression injury of the sternum. J Bone Joint Surg (Br) 39-B(3):487–497 Knobloch K, Wagner S, Haasper C, Probst C, Krettek C, Otte D, Richter M (2006) Sternal fractures occur most often in old cars to seat-belted drivers without any airbag often with concomitant spinal injuries: clinical findings and technical collision variables among 42,055 crash victims. Ann Thorac Surg 82(2):444–450 Velutini JA, Tarazona PF (1998) Fracture of the manubrium with posterior displacement of the clavicle and first rib. A case report. Int Orthop 22(4):269–271 Lane WA (1884) One mode of fracture of the sternum. Trans Pathol Soc London 35:253 Kehdy F, Richardson JD (2006) The utility of 3-D CT scan in the diagnosis and evaluation of sternal fractures. J Trauma 60(3):635– 636 Nakae H, Tajimi K, Kodama H (2003) Diagnosis of a fractured manubrium aided by three-dimensional computed tomographic scanning. J Trauma 55(1):139–140 Scheyerer MJ, Zimmermann SM, Bouaicha S, Simmen HP, Wanner GA, Werner CM (2013) Location of sternal fractures as a possible marker for associated injuries. Emerg Med Int 2013:407589 Gibson LD, Carter R, Hinshaw DB (1962) Surgical significance of sternal fracture. Surg Gynecol Obstet 114:443–448 Rambaud G, Desachy A, François B, Allot V, Cornu E, Vignon P (2001) Extrapericardial cardiac tamponade caused by traumatic retrosternal hematoma. J Cardiovasc Surg (Torino) 42(5):621–624 Deutsche Gesellschaft für Unfallchirurgie (federführend) (2012) S3 – Leitlinie Polytrauma/Schwerverletzten-Behandlung; AWMF Register-Nr. 012/019; S71. http://www.awmf.org . Accessed 25 Nov 2014 Harston A, Roberts C (2011) Fixation of sternal fractures: a systematic review. J Trauma 71(6):1875–1879 Fawzy H, Alhodaib N, Mazer CD, Harrington A, Latter D, Bonneau D, Errett L, Mahoney J (2009) Sternal plating for primary and secondary sternal closure; can it improve sternal stability? J Cardiothorac Surg 4:19 Schulz-Drost S, Syed J, Besendoerfer M, Carbon RT (2014) Sternocostal dislocation following open correction of pectus excavatum-Bstairway phenomenon^: complication management by means of sternocostal locking titanium plate osteosynthesis. Thorac Cardiovasc Surg 62(3):245–252 Bottlang M, Long WB, Phelan D, Fielder D, Madey SM (2013) Surgical stabilization of flail chest injuries with MatrixRIB implants: a prospective observational study. Injury 44(2):232–238 Schulz-Drost S, Mauerer A, Grupp S, Hennig FF, Blanke M (2014) Surgical fixation of sternal fractures: locked plate fixation by low-
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20.
profile titanium plates–surgical safety through depth limited drilling. Int Orthop 38(1):133–139 Alkadhi H, Wildermuth S, Marincek B, Boehm TJ (2004) Accuracy and time efficiency for the detection of thoracic cage fractures: volume rendering compared with transverse computed tomography images. Comput Assist Tomogr 28(3):378–385
21. 22.
Byard RW (2002) Shoulder-lap seat belts and thoracic transection. J Clin Forensic Med 9(2):92–95 Schulz-Drost S, Oppel P, Grupp S, Schmitt S, Carbon RT, Mauerer A, Hennig FF, Buder T (2015) Surgical fixation of sternal fractures: preoperative planning and a safe surgical technique using locked titanium plates and depth limited drilling. J Vis Exp 95:e52124. doi: 10.3791/52124
