Injury Extra 42 (2011) 85–87

Case report

Non-union of an intra-articular fracture of the sternum

Amit K. Gupta a,c,*, Alan Getgood b,c, Graham Tytherleigh-Strong b,c

a Barts and the London NHS Trust, UKb Cambridge University Hospital NHS Trust, Cambridge, UKc Department of Trauma and Orthopaedics, Cambridge University Hospital NHS Trust, Cambridge, UK

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Injury Extra

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A R T I C L E I N F O

Article history:

Accepted 18 April 2011

1. Introduction

Traumatic fractures around the sternum are almost exclusivelyof a transverse pattern, resulting from significant direct injury andheal with conservative measures.3,4,12 Injuries involving thesternoclavicular (SC) joint usually result in dislocation or fractureof the medial end of the clavicle.10,11 Both vertical sternal fracturesas well as non-union secondary to any fracture configuration areextremely rare.3,5,8

We report the unique finding of a vertical fracture of thesternum extending into the sterno-clavicular (SC) joint whichresulted in a non-union. This was treated with open reduction andinternal fixation with bone grafting. To our knowledge this is thefirst report of a non-union of a traumatic vertical sternal fracture.Furthermore, we believe it is the first report of an intra-articularfracture of the sternal side of the SC joint.

2. Case report

A 31 year old professional equestrian presented to the accidentand emergency (A&E) department with right shoulder, chest andpelvic pain having fallen from her horse. At the time of impact, herarm was elevated above her right shoulder but there was no reportof a direct injury to the chest. Radiographs of the pelvis were onlyperformed and revealed a fracture of the pubic ramus. The patientwas discharged with a further diagnosis of soft tissue injuries ofboth the right shoulder and chest.

She subsequently represented to the A&E department twoweeks later with continuing right shoulder and chest pain. Aradiograph of the shoulder was performed but revealed no bonyabnormality. She was referred for physiotherapy and encouragedto mobilise.

* Corresponding author at: 4 Kingston Hill, Cheadle, Cheshire SK8 1JS, UK.

Tel.: +44 07826 855560.

E-mail address: amitgupta@doctors.org.uk (A.K. Gupta).

1572-3461/$ – see front matter � 2011 Elsevier Ltd. All rights reserved.

doi:10.1016/j.injury.2011.04.007

Six months following the initial injury, the patient presented tothe shoulder clinic with generalised shoulder pain which was mostsevere over the SC joint. There was tenderness on palpation of theSC joint but no swelling was apparent. Internal rotation, abductiongreater than 908 and adduction of the affected shoulder causedpain localised to the SC region. Plain radiographs of the sternumand SC joint revealed no bony abnormality. A MRI scan wasperformed which revealed a non-union of a vertical sternalfracture extending into the SC joint (Fig. 1).

In view of the patient’s persistent level of symptoms and herhigh functional demands, it was felt that the only therapeuticoption was to proceed to an open reduction and internal fixationwith bone grafting of the non-union.

The surgery was undertaken as a combined case by the seniorauthor and a consultant cardiothoracic surgeon. An incision wasmade from the medial end of the clavicle curving medially andinferiorly over the sternoclavicular joint and manubrium. Anobvious fracture non-union was identified running vertically downfrom the base of the sternal articular surface of the manubrium(Fig. 2). This was exposed and curetted. Bone graft was harvestedfrom the ipsilateral iliac crest and inserted into the fracture. Thefracture was then was then fixed using two 4 mm, cannulated,partially threaded, cancellous screws. The entry points for thescrews were exposed by careful dissection down onto the lateraledge of the sternum with minimal disturbance to the overlyingligamentous structures (Fig. 3). Good compression was obtained atthe fracture.

Post-operatively, the patient was immobilised in a sling for 4weeks and then began a graded rehabilitation programme. At 6months following surgery, the patient’s fracture had clinicallyunited. Bony union was confirmed on MRI (Fig. 4). She was painfree and had regained a full range of motion and had returned toher pre-injury level of activity.

3. Discussion

Traumatic sternal fractures account for between 5 and 10% of allthoracic injuries.4 They are most commonly caused by directtrauma in road traffic accidents and are almost always transversein nature.3,4,12,1,9 It is widely reported that both traumatic verticalfractures of the sternum and non-union of traumatic sternalfractures, of any configuration, are extremely rare.3,5,8 To ourknowledge this is the first report of a non-union of a traumaticvertical fracture of the sternum.

Fig. 1. Coronal MRI scan of the sternum demonstrating a vertical intra-articular

fracture on the right side.

Fig. 2. Intra-operative image of the fracture.

Fig. 3. Post-operative plain radiograph with internal fixation.

Fig. 4. Coronal MRI scan 6 months post surgery demonstrating fracture union with

titanium screws in situ.

A.K. Gupta et al. / Injury Extra 42 (2011) 85–8786

Traumatic injuries around the SC joint are rare and are due toeither a direct impact or a longitudinal force transmitted throughthe clavicle.10 These result in either anterior or posteriordislocation of the joint or fracture of the medial end of theclavicle.10,11

Most reported non-unions have been related to longitudinalmedian sternotomies following cardiothoracic surgery.10,5,2,6,7 Alack of compression, a degree of movement during respiration andinfection have all been implicated as possible causes. Fixationusing various types of compression plates, wires or cables havebeen reported.6,7,13

We suspect that the reported sternal fracture was caused by thepatient landing with her shoulder in an elevated position relativeto the SC joint. This would have resulted in a vertical shear forcebeing transmitted longitudinally through the clavicle, across thejoint and onto the sternum leading to a vertical split fracture.

Although the fracture was not grossly unstable it is likely thatthe shear pattern and the strong soft tissue attachments of theclavicle to the lateral edge of the sternum may have led toexcessive movement at the fracture site post injury. This, coupledwith a possible communication with the SC joint resulting inextravasation of synovial fluid, may have attributed to the non-union. Successful management of the fracture by applying the

orthopaedic principles of removing fibrous tissue, bone grafting,compression and rigid stabilisation lend to this theory.

With the arm in certain positions, the force of an injuryanywhere along the upper limb may be transmitted directlythrough the clavicle to the SC joint. Plain radiographs around the SCjoint may be difficult to interpret. We recommend that patientswith persistent localised symptoms around their SC joint followingan upper limb injury should undergo either a CT or an MRI scan.

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