Surgical Fixation of Sternal Fractures: Preoperative Planning and a Safe Surgical Technique Using Locked Titanium Plates and Depth Limited Drilling

Abstract

Different ways to stabilize a sternal fracture are described in literature. Respecting different mechanisms of trauma such as the direct impact to the anterior chest wall or the flexion-compression injury of the trunk, there is a need to retain each sternal fragment in the correct position while neutralizing shearing forces to the sternum. Anterior sternal plating provides the best stability and is therefore increasingly used in most cases. However, many surgeons are reluctant to perform sternal osteosynthesis due to possible complications such as difficulties in preoperative planning, severe injuries to mediastinal organs, or failure of the performed method.This manuscript describes one possible safe way to stabilize different types of sternal fractures in a step by step guidance for anterior sternal plating using low profile locking titanium plates. Before surgical treatment, a detailed survey of the patient and a three dimensional reconstructed computed tomography is taken out to get detailed information of the fracture's morphology. The surgical approach is usually a midline incision. Its position can be described by measuring the distance from upper sternal edge to the fracture and its length can be approximated by the summation of 60 mm for the basis incision, the thickness of presternal soft tissue and the greatest distance between the fragments in case of multiple fractures.Performing subperiosteal dissection along the sternum while reducing the fracture, using depth limited drilling, and fixing the plates prevents injuries to mediastinal organs and vessels.Transverse fractures and oblique fractures at the corpus sterni are plated longitudinally, whereas oblique fractures of manubrium, sternocostal separation and any longitudinally fracture needs to be stabilized by a transverse plate from rib to sternum to rib. Usually the high convenience of a patient is seen during follow up as well as a precise reconstruction of the sternal morphology.

Do low profile implants provide reliable stability in fixing the sternal fractures as a “fourth vertebral column” in sternovertebral injuries?

“…The sternum was stabilized through an open median approach and an anterior locked plate osteosynthesis in a low profile design (Matrix Rib® 1.5 mm thickness, 2.9 mm diameter of screws; DePuy Synthes CMF, Switzerland) following a standard protocol of our department (9). After the elevation of the posterior depressed fragment, the fracture could be reduced exact and subsequently the plate has been fixed with at least three screws to each fragment in order to fix it properly.…”

“…Sternal fractures are described with a rare incidence of 3-8% out of the whole number of traumatic bone injuries with a mortality of 24-45% associated to concomitant injuries of thoracic organs and less caused by the sternal fracture itself (3)(4)(5)(6)(7)(8)(9)(10)(11). However, the most frequently seen concomitant injuries are fractures of the ribs and the vertebral column followed by pulmonary injuries (6).…”

The Operative Management of Flail Chest Injuries with Concomitant Sternal Fracture

“…The more frequent transverse fractures nearby the angulus can be supplied very well by means of longitudinal plate osteosynthesis, while oblique manubrium fractures can be adequately stabilized by transverse plate osteosynthesis (9,10). The latter occur frequently also with rib fractures, as a rule caused by a belt trauma to the car occupant.…”

Fractures of the manubrium sterni: treatment options and a possible classification of different types of fractures

“…Transverse fractures were fixed by longitudinal plating, and oblique fractures were fixed by transverse plating crossing the first pair of the ribs (Figure 3) (17).…”

“…Sagittal dislocations can be avoided by applying a longitudinal plate. Oblique fractures of the manubrium tend to dislocate laterally and can be stabilized by transversal plates (8,17). Indications for plate osteosynthesis have been summarized by Harston: displaced and overlapped fractures that cannot be corrected by closed reduction, sternal instability, chronic nonunion and severe pain making with restriction of respiratory movements (15).…”