Authors: DR HIMANSHU GUL MIRANI

Abstract

Background: Sternal fractures are most commonly associated with high-energy blunt thoracic trauma and are readily identified on computed tomography. In contrast, sternal insufficiency fractures are rare and may present insidiously, particularly in older adults with severe osteoporosis. Delayed symptom evolution and initially negative imaging can obscure diagnosis and delay appropriate management.

Case: An 84-year-old woman with hypertrophic cardiomyopathy and severe osteoporosis treated with teriparatide presented to the Emergency Department after a low-impact forward fall while gardening. Initial examination revealed facial bruising and bilateral anterior chest wall tenderness. High-resolution CT of the chest, abdomen, and pelvis demonstrated no acute traumatic injury, showing only known vertebral insufficiency fractures. She was discharged with conservative advice. Three days later, she re-presented with new-onset focal sternal pain and visible anterior chest wall swelling. She denied any further trauma. Examination now demonstrated a clear sternal deformity with marked point tenderness, findings absent during the initial assessment. This interval development raised concern for an evolving injury despite prior negative imaging.

Investigations: Laboratory testing revealed mildly elevated troponin levels, prompting consideration of cardiac injury, though this was interpreted in the context of known hypertrophic cardiomyopathy. Electrocardiography showed sinus rhythm with left axis deviation and left ventricular hypertrophy without ischemic changes. Point-of-care ultrasound demonstrated cortical disruption and buckling of the sternal body. Cardiac views showed preserved systolic function with no pericardial effusion. Sternal radiography confirmed a buckled fracture pattern consistent with insufficiency. Repeat CT imaging revealed a comminuted, displaced fracture of the sternal body with associated retrosternal haematoma.

Management: The patient was diagnosed with a sternal insufficiency fracture with delayed radiological evolution following minor trauma. She was managed conservatively with analgesia, thoracic surgical consultation, and close monitoring. She was referred to specialist osteoporosis services for transition to bisphosphonate therapy.

Conclusion: This case highlights the potential for delayed presentation of sternal insufficiency fractures in osteoporotic patients despite initially normal CT imaging. It underscores the value of point-of-care ultrasound in identifying sternal fractures.

Keywords: silver trauma Trauma Major trauma Insufficiency Fracture sternal fracture