Pediatric sternal fractures from a Level 1 trauma center

Journal of Pediatric Surgery 54 (2019) 1628–1631

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Pediatric sternal fractures from a Level 1 trauma center☆,☆☆ Sriram Ramgopal a,⁎, Shahab A. Shaffiey b, Kavitha A. Conti a a b

Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine; Children's Hospital of Pittsburgh, Pittsburgh, PA, United States Division of Pediatric General and Thoracic Surgery, Department of Surgery, University of Pittsburgh School of Medicine; Children's Hospital of Pittsburgh, Pittsburgh, PA, United States

a r t i c l e

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Article history: Received 15 June 2018 Received in revised form 26 July 2018 Accepted 16 August 2018 Key words: Trauma Pediatric Children MVA Injury Pneumothorax Pneumomediastinum Hemothorax Cardiac contusion

a b s t r a c t Background/purpose: Sternal fractures are rare in children. The purpose of this series is to document traumatic findings in pediatric patients with sternal fractures at a Level 1 trauma center. Study design: We reviewed the charts of patients with radiologically confirmed sternal fractures from a trauma database at a pediatric Level 1 trauma center between January 1, 2000 and December 31, 2015. We report mechanisms of injury, associated injuries, complications, and outcomes associated with sternal fractures. Results: Over the 16-year period, 19/25,781 (0.07%) admitted patients had radiologically confirmed sternal fractures. 15/19 (78.9%) patients were male. The median age was 14 years, with interquartile range 10–16 years. 7/19, (36.8%) were sustained owing to motor vehicle accidents. Associated injuries included substernal hematoma (n = 6), pulmonary contusion (n = 4), vertebral injury (n = 2), rib fracture (n = 4), intraabdominal injury (n = 3), pneumothorax (n = 3), long bone injury (n = 3) traumatic brain injury (n = 2), hemothorax (n = 2), pneumomediastinum (n = 2) and cardiac contusion (n = 1). Conclusions: In this series, pediatric sternal fractures were caused by high velocity mechanisms and had significant comorbidity. While patients with isolated sternal fractures may be candidates for emergency department discharge, a thorough evaluation should be performed in children with sternal fractures to identify concurrent injuries. Level of evidence: Level IV. © 2018 Elsevier Inc. All rights reserved.

Sternal fractures are unusual injuries in children. A limited number of reports have documented the presence of sternal fractures in this population [1–7]. A case series reported by Ferguson et al., documenting 12 pediatric patients with radiologically confirmed sternal fractures, identified few concurrent injuries occurring in these patients [7]. In contrast, studies of adult patients with sternal fractures associated with motor vehicle accidents have found significant associated comorbidities including pulmonary, cardiac, neurologic, and abdominal injuries [8–10]. To date, no report has documented pediatric patients with sternal fractures from a pediatric trauma center, and it is not known whether children who sustain sternal fractures are at the same risk for complications as documented in adults. In this case series, we report the findings from patients who presented to a pediatric trauma center and were found to have sternal fractures in order to understand the mechanisms, associated comorbidities, and outcomes of patients with this injury.

☆ Financial Disclosures: The authors have no relevant financial relationships to disclose. ☆☆ Conflicts of Interest: The authors have no relevant conflicts of interest to disclose. ⁎ Corresponding author at: Division of Emergency Medicine, Children's Hospital of Pittsburgh, AOB 2400, 4401 Penn Avenue, Pittsburgh, PA 15224. Tel.: + 1 412 692 7980; fax: + 412 692 7464. E-mail address: [email protected] (S. Ramgopal). https://doi.org/10.1016/j.jpedsurg.2018.08.040 0022-3468/© 2018 Elsevier Inc. All rights reserved.

1. Methods We retrospectively reviewed all trauma admissions between January 1, 2000 and December 31, 2015 to a Level 1 pediatric trauma center in Western Pennsylvania with a N2.6 million population catchment area. We conducted an electronic medical record search utilizing Collector (Digital Innovations, Forest Hills, MD), the database utilized by all trauma registrars in the State of Pennsylvania for medical record chart abstraction. Cases were identified by using search algorithms to identify variations and misspellings of terms “sternum,” “manubrium,” and “xiphoid”. We reviewed all cases of patients confirmed to have sternal fractures by a board-certified radiologist, either by radiograph or computerized tomography (CT). Key information was abstracted including demographics, mechanism of injury, method of diagnosis, associated injuries, and patient outcome. We investigated rates of presentation as compared to other trauma admissions as classified by External-Cause-of-Injury Codes (E-Codes). 2. Results 2.1. Inclusion, demographics, and mechanism During the 16-year inclusion period, 25,781 patients were admitted to the trauma service. Of these, 19 (0.07%; median age 14 years, interquartile

Table 1 Pertinent patient data for pediatric patients with radiographically confirmed sternal fractures. No Age

Gender Mechanism of Injury

Anatomic region

Initial diagnosis Modality

Pneumothorax

Rib ECG fractures

Outcome

None

Body; displaced

None

None

Normal

Concussion

Body; nondisplaced

Radiograph (AP only) Radiograph (2 view)

None

None

Not done

Discharged, 1 day Discharged, 2 days

Grade 4 liver laceration, hemoperitoneum, traumatic pancreatitis Femur fracture, pancreatic contusion

Body, nondisplaced

Radiograph (2 view) Radiograph (2 view) CT

None

None

Normal

None

None

Normal

Bilateral

Not done

Anterior manubrium, nondisplaced Midsternum, displaced

Radiograph (AP only) CT

None

Right side #9, 10 None

Radiograph (2 view)

1

16 years Female

2

12 years Male

3

8 years

4

15 years Male

Fall & trampled playing basketball MVC, restrained front seat passenger (head on collision) Bicycle accident, crashed over handlebars Crashed on dirtbike

5

9 years

Male

Rollover of all-terrain vehicle

Pulmonary contusion, clavicle fracture

6

10 years Male

None

7

16 years Male

Stabbed by pair of scissors in chest MVC, restrained backseat passenger (head on collision)

8

11 years Male

Bicycle accident, falling sideways

Substernal hematoma

Midsternum, displaced

9

17 years Female

Fell from all-terrain vehicle

Substernal hematoma

10

3 years

None

11

18 years Female

12

16 years Male

Fall, approximately 6 ft from slide MVC, restrained driver with airbag deployment (head on collision) Bicycle accident, fall onto guard rail

13

16 years Male

14

10 years Male

Thrown from all-terrain vehicle MVC, restrained backseat passenger (head on collision)

15

14 years Male

Struck by pickup truck trailer

16

11 years Male

17

15 years Male

Tackled from behind by a peer Kicked by horse

Dislocation of sternum from manubrium, retrosternal hematoma Cerebellar infarction, parietal lobe hemorrhage, atlantooccipital distraction, vertebral artery dissection, pulmonary contusion, Grade 1 splenic laceration, open chest wound, pneumomediastinum Cerebral edema with diffuse axonal injury, subdural hemorrhage, temporal bone fracture, pneumomediastinum, Retrosternal hematoma

18

17 years Male

19

3 years

Male

Male

Female

MVC rollover, front seat passenger, unknown if restrained MVC, unrestrained back seat passenger (head on collision)

T12, L1, L4 compression fracture, retrosternal hematoma Open chest laceration

Orbital roof fracture, cardiac contusion, T8 superior endplate fracture, pulmonary contusions Concussion, humeral fracture, radial fracture, retrosternal hematoma Brachial plexus avulsion, cervical and thoracic extradural hematoma, humerus and ulnar fractures, pulmonary contusion

None

Right side, #6, 7 None

Normal

Manubrium, displaced CT

None

None

Not done

Anterior cortical, nondisplaced Superolateral sternum, nondisplaced Open inferior sternal fracture, minimally displaced Depressed fracture at sternum Left lateral manubrium, displaced

Radiograph (2 view) CT

None

None

Normal

None

None

Not done

OR

Bilateral

Not done

Radiograph (2 view) CT

None

Right side, #7, 8 None

Left Left, #3, hemopnemothorax 4, 5

Low voltage complexes, echocardiogram normal

CT

None

None

Right axis deviation, echocardiogram normal

Manubrium, displaced CT

None

None

Normal

Inferior, nondisplaced

Radiograph (2 view)

None

None

Comminuted, body

CT

None

None

Right bundle branch block, echocardiogram with mitral valve insufficiency Normal

Comminuted, manubrium

CT

None

None

Normal

Body, nondisplaced

None

Not done Normal

Normal

ICU admission, discharged, 5 days Discharged, 1 day ICU admission, discharged, 17 days

ICU admission, discharged, 29 days Discharged, 2 days ICU admission, discharged, 3 days Discharged, 3 days ICU admission, discharged, 6 days 1629

MVC, motor vehicle collision; ICU, intensive care unit.

Concussion, right hemothorax

Cartilage, nondisplaced Body, nondisplaced

Discharged, 4 days Discharged, 4 days ICU admission, discharged, 9 days Discharged, 1 day ICU admission, discharged, 7 days ICU admission, discharged, 4 days Discharged, 1 day Discharged, 1 day Discharged, 3 days

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Associated Injury

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S. Ramgopal et al. / Journal of Pediatric Surgery 54 (2019) 1628–1631

range 10–16 years) patients were found to have radiographically confirmed sternal fractures (Table 1). The majority of patients had blunt trauma, with only one patient having penetrating injury (patient 6.) Most patients in this series (15/19, 78.9%) were male. In the entire series of patients admitted to the trauma service, 16,777/25,781 were male (65.1%) and the median age was 9 years (interquartile range, 5–14 years). Common mechanisms for sternal fracture included motor vehicle accidents (7/19, 36.8%), all-terrain vehicle/dirtbike accidents (4/ 19, 21.1%), and bicycle accidents (3/19, 15.8%). Among all traumas classified by E-Code, the percentage of injuries that caused sternal fractures was low: 7/4283 (0.2%) motor vehicle accidents (E810–819), 4/2005 (0.2%) off-road motor vehicle accidents (E821) and 3/1834 (0.2%) pedal cycle accidents (E826). Of those patients who were passengers involved in motor vehicle collisions (MVCs), 4/6 patients were restrained, one was unrestrained, and for one it was unknown. The majority of patients who sustained injuries from MVCs were from head-on collisions (5/6). 2.2. Method of diagnosis Radiographic diagnosis of sternal fracture was made on plain films for 9/19 (47.4%, Fig. 1) patients, with the remainder identified on CT imaging (Fig. 2). Some patients had normal chest radiography and the sternal fracture was subsequently diagnosed on CT (patients 5, 7, 9, 11, 14, 15, 16). Most patients who had CT imaging did so in the context of other chest-related injuries such as rib fractures and hemothorax. In patient 12, the diagnosis of sternal fracture was made after the patient was taken to the operating room for exploration of a penetrating chest wall wound. 2.3. Associated injuries and complications Associated chest wall injuries included substernal hematoma (n = 6), pulmonary contusion (n = 4), rib fracture (n = 4), pneumothorax (n = 3), hemothorax (n = 2), and pneumomediastinum (n = 2). Other injuries included intraabdominal injury (n = 3), vertebral injury (n = 2), traumatic brain injury (n = 2), and long bone injury (n = 3). One patient (patient 17) had a cardiac contusion. This patient had an elevated troponin of 7.52 ng/mL and a right bundle branch block on electrocardiogram. An echocardiogram revealed moderate mitral valve insufficiency which improved on serial echocardiograms.

Fig. 1. Lateral chest radiograph showing a posteriorly displaced sternal fracture in a 16year-old male (patient 13 in this series).

of sternal fractures in children was MVCs [9]. In one large series reported by Porter, et al., rate of sternal injuries in seatbelt restrained adults in MVCs was 4% [11]. Although this figure is higher than that

2.4. Outcomes No fatalities occurred in this series. In patients where an ECG was available for review, no arrhythmias were noted. Patient 12 underwent an exploration of a chest wound and patient 6 required operative removal of an object from the sternum. Other patients required operative management for orthopedic (patient 4, 12 and 18) or neurosurgical (patient 14 and 15) interventions. Eight patients (42.1%) required admission to the intensive care unit for management of associated injuries. 3. Discussion We report a series of pediatric patients with sternal fractures diagnosed in a Level 1 pediatric trauma center. We identified that the overall rate of sternal fractures in patients admitted for traumatic injury is low, but that sternal fractures have a high association with major thoracic, intracranial, and intraabdominal injury. In contrast to prior studies on pediatric sternal fractures, our study is notable for the number of concurrent injuries identified. This study highlights the need for careful evaluation for concurrent injury in patients diagnosed with a sternal fracture. The rate of sternal injuries noted in this series is lower than rates provided for adults. Lower rates of chest wall injury (rib fractures and/ or sternal fractures) have been noted in comparisons of children and adults [3,4]. Similar to adults, we found that the most common cause

Fig. 2. Sagittal CT imaging of an 18-year-old female with a nondisplaced sternal fracture and a T12 compression fracture (patient 11 in this series).

S. Ramgopal et al. / Journal of Pediatric Surgery 54 (2019) 1628–1631

suggested by our series, we also found that the majority of pediatric patients with MVC-related sternal injuries were also restrained with seat belts. There are several possible reasons for the lower rate of pediatric sternal fractures identified in this series. First, children are hypothesized to have a lower rate of sternal fractures owing to greater chest wall compliance. This increased compliance may allow for better recoil, lowering the rate of bony fractures [12]. Second, radiographic interpretation of sternal injuries in children is complicated by their osseous development. The sternum originates from multiple ossification centers, and a fracture may be misinterpreted as normal development [13]. Finally, children are less likely to obtain CT imaging of their chest following trauma in pediatric centers owing to concerns of excessive radiation exposure [14]. Routinely, the trauma series radiographs obtained for trauma evaluations include only an anteroposterior chest film. It is possible that a sternal fracture may have been missed if the patient did not also receive a lateral chest radiograph or CT scan. However, as the majority of these patients also had complaints of chest wall pain, many in this series had a 2-view chest film and not just the anteroposterior view. CT is a superior modality in the diagnosis of sternal fractures [15,16], as also suggested by patients in our series who had normal radiography but abnormal CT findings. Notably, our dataset had 42 patients with contusions or pain over their sternum but who did not have sternal fractures. Some of these patients may have had fractures that were missed given the above limitations in imaging. Recent reports have documented success in the use of ultrasonography in the diagnosis of sternal fractures, and this may allow for evaluation of sternal injuries in patients presenting with concerning symptoms but with a low suspicion for other intrathoracic injury [17]. Given the high sensitivity and specificity of ultrasound in diagnosing sternal fractures [18], this imaging modality may be an option for providers with access to ultrasonography when evaluating those patients who do not otherwise require CT imaging. Reports of sternal fractures in children are limited. Hechter, et al., identified two patients, ≤2 years of age, with sternal fractures without known injury and which were concerning for child abuse [19]. While nonaccidental trauma is recognized as a cause for sternal fractures in young children [20], no patient in this series fell into this category, with the exception of one child who sustained a fracture in the setting of peer on peer assault (patient 6). Isolated reports have also documented sternal fractures in children from falls [2], hyperflexion injury [1], repetitive sports-related exercise [5], tetanic spasms [3], and a Boston brace-related injury [4]. A series of 12 children with sternal fractures reported by Ferguson, et al., identified that 11/12 patients had an isolated sternal fracture, with only one patient having an additional finding of thoracic compression fractures [7]. It is possible that children with isolated sternal fractures can be safely discharged from the emergency department once a thorough evaluation has occurred for other injuries, a practice that is advocated for in adults [21]. In contrast to other pediatric reports, our series demonstrated a high rate of associated injuries. The high rate of associated injuries identified in our study is similar to adult studies and likely reflects our data collection source from a large pediatric trauma registry and more significant mechanisms of injury. Reports of injured adults have found concomitant injuries of flail chest, head injury, limb fractures, pneumothorax, spinal fractures, abdominal injuries, and cardiac contusion [9,10]. Our study demonstrates similar findings and suggests that children with sternal fractures should be evaluated for potential cardiac and pulmonary pathology, with additional evaluation for vertebral, abdominal, and neurologic injury as guided by initial findings. The findings from this study are subject to limitations of a retrospective chart review. This study only evaluated the outcomes of patients who were admitted to the trauma service and, thereby, had a higher-

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acuity injury. The decision to obtain CT imaging was made at the discretion of the treating physicians on the basis of mechanism of injury or physical examination findings. Patients may have been missed if documentation was insufficient. Despite these limitations, our findings demonstrate that sternal fractures, while rare in children, can be associated with significant comorbidity based on the mechanism of injury. 4. Conclusion Sternal fractures are rare injuries in children, even among those evaluated at a pediatric trauma center. While previous reports suggest that children with isolated sternal fractures can likely be discharged from the emergency department, findings presented in this series suggest that children with sternal fractures often have significant concomitant traumatic injuries that might warrant more careful observation. We recommend that in pediatric patients with sternal fractures owing to a concerning mechanism of injury, careful evaluation should be performed to identify traumatic comorbidities. Acknowledgments None. References [1] Swarup S, Bonomally K, Ansari MZ. Fracture of the sternum—an unusual case. Eur J Emerg Med 1999;6:71–2. [2] DeFriend DE, Franklin K. Isolated sternal fracture—a swing-related injury in two children. Pediatr Radiol 2001;31:200–2. https://doi.org/10.1007/s002470000397. [3] Helal B. Fracture of the manubrium sterni. J Bone Joint Surg Br 1964;46:602–7. [4] Korovessis P, Sdougos G, Dimas T. Spontaneous fracture of the sternum in a child being treated in a Boston brace for kyphoscoliosis. A case report and review of the literature. Eur Spine J 1994;3:112–4. [5] Hill PF, Chatterji S, DeMello WF, Gibbons JR. Stress fracture of the sternum: an unusual injury? Injury 1997;28:359–61. [6] Perez FL, Coddington RC. A fracture of the sternum in a child. J Pediatr Orthop 1983; 3:513–5. [7] Ferguson LP, Wilkinson AG, Beattie TF. Fracture of the sternum in children. Emerg Med J 2003;20:518–20. [8] Brookes JG, Dunn RJ, Rogers IR. Sternal fractures: a retrospective analysis of 272 cases. J Trauma 1993;35:46–54. [9] von Garrel T, Ince A, Junge A, et al. The sternal fracture: radiographic analysis of 200 fractures with special reference to concomitant injuries. J Trauma 2004;57:837–44. [10] Athanassiadi K, Gerazounis M, Moustardas M, et al. Sternal fractures: retrospective analysis of 100 cases. World J Surg 2002;26:1243–6. https://doi.org/10.1007/ s00268-002-6511-5. [11] Porter RS, Zhao N. Patterns of injury in belted and unbelted individuals presenting to a trauma center after motor vehicle crash: seat belt syndrome revisited. Ann Emerg Med 1998;32:418–24. [12] Eisenberg M, Mooney DP. Chest wall injuries. In: Bachur RG, Shaw KN, editors. Fleisher Ludwig's Textb. Pediatr. Emerg. Med.Philadelphia: Wolters Kluwer Health; 2015. [13] Delgado J, Jaimes C, Gwal K, et al. Sternal development in the pediatric population: evaluation using computed tomography. Pediatr Radiol 2014;44:425–33. https:// doi.org/10.1007/s00247-013-2841-8. [14] Matsushima K, Schaefer EW, Won EJ, et al. Injured adolescents, not just large children: difference in care and outcome between adult and pediatric trauma centers. Am Surg 2013;79:267–73. [15] Kehdy F, Richardson JD. The utility of 3-D CT scan in the diagnosis and evaluation of sternal fractures. J Trauma Inj Infect Crit Care 2006;60:635–6. https://doi.org/10. 1097/01.ta.0000204938.46034.f4. [16] Perez MR, Rodriguez RM, Baumann BM, et al. Sternal fracture in the age of pan-scan. Injury 2015;46:1324–7. https://doi.org/10.1016/j.injury.2015.03.015. [17] Sesia SB, Prüfer F, Mayr J. Sternal fracture in children: diagnosis by ultrasonography. Eur J Pediatr Surg Rep 2017;5:e39–42. https://doi.org/10.1055/s-0037-1606197. [18] You JS, Chung YE, Kim D, et al. Role of sonography in the emergency room to diagnose sternal fractures. J Clin Ultrasound 2010;38. https://doi.org/10.1002/jcu. 20669 [NA-NA]. [19] Hechter S, Huyer D, Manson D. Sternal fractures as a manifestation of abusive injury in children. Pediatr Radiol 2002;32:902–6. https://doi.org/10.1007/s00247-0020807-3. [20] Bullock DP, Koval KJ, Moen KY, et al. Hospitalized cases of child abuse in America. J Pediatr Orthop 2009;29:231–7. https://doi.org/10.1097/BPO.0b013e31819aad44. [21] Kouritas VK, Zisis C, Vahlas K, et al. Isolated sternal fractures treated on an outpatient basis. Am J Emerg Med 2013;31:227–30. https://doi.org/10.1016/j.ajem.2012.05.027.