# Splinting of A Fractured Sternum??



## Uller55 (Jul 27, 2012)

OK..... I'm taking paramedic classes and currently in ITLS, my instructor gave us a homework question about would you splint a sternum fracture and how??

I have researched this for a wile with no good out comes......Any thoughts?

Thanks

Scott Slaterback EMT-I


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## DesertMedic66 (Jul 27, 2012)

I wouldn't split itfor 2 reasons:
1: I have no clue how to possibly splint that. 
2: I don't think it could really be supported by any kind of prehospital splint.


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## bahnrokt (Jul 27, 2012)

Unless it was a horrific injury I'm not sure I'd even be able to ID a broken sternum from ribs.  

Place pt in position of comfort and assess/treat for flail chest if present.


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## VFlutter (Jul 27, 2012)

Not really sure how you would splint a fractured sternum, if at all possible, but I would be cautious moving to the patient due to the possibility of a bone fragment puncturing a lung or the heart.


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## NYMedic828 (Jul 27, 2012)

Don't want to put anything too tight across the chest for risk of inhibiting expansion of the chest wall.

Also need to be careful with the potential for sharp bone fragment/sternal edges shearing underlying tissue, primarily cardiac.

For a suspected sternal fracture, my treatment would be ice, position of comfort and fentanyl. (they will have a lot of pain on breathing)


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## Handsome Robb (Jul 27, 2012)

Could it be similar to a flail segment? With a fractured sternum you've effectively "destroyed" the continuity of the rib cage which is the structural basis for how breath, no structure, no breathing. In that case PPV + an ETT would be the first choice as a splint until surgical intervention can take place. Internal splinting if that makes sense?

Just my .02


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## DPM (Jul 28, 2012)

NVRob said:


> Could it be similar to a flail segment? With a fractured sternum you've effectively "destroyed" the continuity of the rib cage which is the structural basis for how breath, no structure, no breathing. In that case PPV + an ETT would be the first choice as a splint until surgical intervention can take place. Internal splinting if that makes sense?
> 
> Just my .02



That's a little bit much, I fractured mine and I could breathe  It hurt a lot but that was about it, and no worse than the broken ribs.

I wonder if your ITLS instructor is on here....


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## bigbaldguy (Jul 28, 2012)

Light pressure to alleviate pain during inhalation perhaps? Like a broken rib. A folded towel down the center of the chest and an ace bandage wrapped around the patient might help with stabilizing it.


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## mycrofft (Jul 28, 2012)

Define broken


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## Medic Tim (Jul 28, 2012)

I would use a pillow or blanket. Have the pt hold it over chest in position of comfort. Or the position that allows them to breath. Oh and fentanyl.


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## lightsandsirens5 (Jul 28, 2012)

Are we talking simply fractured, or totally separated? Fractured, I'd "splint" it with fentynal just to make breathing easier. Separated, manually stabilize it (Ie, use your hand to keep it from moving in and out), then PPV them. The biggest problem I see with a fractured sternum is pain. For a separated sternum on the other hand, you have loss of some negative pressure, as well as probably extreme pain, and trouble breathing due to chest rigidity comprimise. (As well as pain of course.)


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## Akulahawk (Jul 28, 2012)

I might simply place a pillow on the patient's chest and have the patient hold the pillow in place to allow for some comfort that the patient can control. I might also then consider CPAP to make it easier to inhale so the patient has to simply relax and inhalation occurs basically passively instead of having to create a neg pressure (that basically grinds the bone ends together) resulting in pain. If I can give the patient some opiates, carefully titrated morphine or fentanyl would be what I'd give, titrated to relieve pain to a tolerable level.


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## Handsome Robb (Jul 28, 2012)

lightsandsirens5 said:


> Are we talking simply fractured, or totally separated? Fractured, I'd "splint" it with fentynal just to make breathing easier. Separated, manually stabilize it (Ie, use your hand to keep it from moving in and out), then PPV them. The biggest problem I see with a fractured sternum is pain. For a separated sternum on the other hand, you have loss of some negative pressure, as well as probably extreme pain, and trouble breathing due to chest rigidity comprimise. (As well as pain of course.)



Lights did a better job explaining what I was talking about than I did.


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## firetender (Jul 28, 2012)

This is simply a matter of making the patient as comfortable as possible. There's no real formula as it's dependant on the actual injury and the Pt's reaction. Keep in mind, it's not about stabilizing the injury itself so much as it's about maneuvering and supporting the patient's whole body to minimize discomfort.


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## Doczilla (Jul 28, 2012)

Splint it with ketamine


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## VFlutter (Jul 28, 2012)

Well the first thing you want to do is a thoracotomy. Then find yourself something stiff to stabilize the sternum with, preferably sterile, but in a pinch a rusty spoon will work. Then grab some tape and go crazy, don't be stingy with the tape you want that thing secure. Throw an ABD pad in top and bam your done. Pain medication optional.


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## lightsandsirens5 (Jul 28, 2012)

ChaseZ33 said:


> Well the first thing you want to do is a thoracotomy. Then find yourself something stiff to stabilize the sternum with, preferably sterile, but in a pinch a rusty spoon will work. Then grab some tape and go crazy, don't be stingy with the tape you want that thing secure. Throw an ABD pad in top and bam your done. Pain medication optional.



Whoa! Whoa! Whoa! Hold your horses buddy! Several issues here.

#1) Thoracostomy? What, what.......just automatically?
#2) Since when have splints needed to be sterile?
#3) "Going crazy" with the tape, why? So we can inhibit chest wall expansion?
#4)Pain medication optional? Oh really? I suppose TECHNICALLY it is. But answer this: You have just had your chest crushed, your sternum completely separated, you cannot breathe, someone has just shoved a 10 guage railroad spike between your few good ribs left, and applied the equivalent pressure of a Army sandbag on your chest with tape and dressings. Do you want a leetle something? Or...was that just an option?

I would not recommend the approach suggested by yourself, simply because the taping and splinting will, as aforementioned, restrict chest all movement while not doing all that much to stabilize the flailed sternum. (Unless of course you splint it tight enough to secure it to the spine.) Furthermore, the reduced expansion will reduce airflow (no duh) to an already damaged and probably swelling portion of lung tissue, greatly increasing the likelihood of developing atelectasis. 

Now then, the thoracostamy, do keep that in mind as it will come in later. (Actually, the consideration thereof will come in.)

As for the problem of reduced air movement (due to decreased airway pressures) CPAP or PPV has been shown to be marvelously effective in the cases of flail segments and separated sturnums (now THAT is an odd plural....). All these failing of course, simply RSI that poor dude (who by now would be screaming from lack of pain control. Or possibly not screaming because of near inability to move air....but would still be screaming in his head.) SO....hit him with some fentynal, or morphine, or something! (Preferably well before some of these interventions.)

The thoracostamy in my opinion really only comes into play in this case in the event the patient develops as tension pneumothorax secondary to positive airway pressure.

Side note: If I ever run across a medic who is doing needle thoracostamys arbitrarily on any chest trauma patient, I will get a bunch of firefighters to hold him down while I administer a needle thoracostamy to release all of the evil heart he has inside that chest.


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## VFlutter (Jul 28, 2012)

lightsandsirens5 said:


> Whoa! Whoa! Whoa! Hold your horses buddy! Several issues here.
> 
> #1) Thoracostomy? What, what.......just automatically?
> #2) Since when have splints needed to be sterile?
> ...



Whoa! Whoa! Not sure if you missed the sarcasm of my post or if I am missing the sarcasm in yours lol I thought the rusty spoon comment was a dead give away that it was a joke.....


Also _*Thoracotomy*_,cracking open the chest. Not Thoracostamy, needle decompression or chest tube.


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## lightsandsirens5 (Jul 28, 2012)

ChaseZ33 said:


> Whoa! Whoa! Not sure if you missed the sarcasm of my post or if I am missing the sarcasm in yours lol I thought the rusty spoon comment was a dead give away that it was a joke....



Ahhhh....ok. Sorry about that.




> Also _*Thoracotomy*_,cracking open the chest. Not Thoracostamy, needle decompression or chest tube.




Even worse! I misread that one. Therefore I will amend my treatment of the paramedic who randomly does that to include a thoracotamy to do a direct debriedment of his evil heart. :lol:


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## Anjel (Jul 28, 2012)

> > Originally Posted by ChaseZ33<br />
> > Well the first thing you want to do is a thoracotomy. Then find yourself something stiff to stabilize the sternum with, preferably sterile, but in a pinch a rusty spoon will work. Then grab some tape and go crazy, don't be stingy with the tape you want that thing secure. Throw an ABD pad in top and bam your done. Pain medication optional.
> 
> 
> ...



Let it all out lights. Tell us how you really feel. Lol poor dear. Maybe some sleep would do you well.


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## bigbaldguy (Jul 28, 2012)

lightsandsirens5 said:


> Whoa! Whoa! Whoa! Hold your horses buddy! Several issues here.
> 
> #1) Thoracostomy? What, what.......just automatically?
> #2) Since when have splints needed to be sterile?
> ...



Somebody needs a nap


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## LondonMedic (Jul 29, 2012)

I've only seen a couple of these; one rugby, one motorcyclist. Both were very hard to diagnose, there were no clues from examination, plain CXR revealed nothing, lateral sternum gave the diagnosis in the first and a very close look at a CT traumagram gave the latter.

As with a broken rib, there's no specific treatment. Analgesia immediately with chest physio in the medium term to prevent atelectasis and the complications associated with that.

What's important is that a sternal fracture is a high energy injury and carries a high association with thoracic vertebral injury. Injuries to the mediastinum, including pericardial effusion and aortic disruption, are also worth considering as is pneumothorax and pulmonary contusion. Most people recommend admitting these people for observation on a cardiac monitor.

So, in answer to your question. If a paramedic has a patient with a fractured sternum there are three things to do; analgesia, transport and bring your x-ray eyes to hossie where we can make better use of them. I suspect that your instructor is asking about whether you'd splint the spine, to which the answer is probably.

http://emedicine.medscape.com/article/826169-overview
http://lifeinthefastlane.com/2010/10/sternal-fractures/


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## mycrofft (Jul 29, 2012)

"Both were very hard to diagnose, there were no clues from examination, plain CXR revealed nothing, lateral sternum gave the diagnosis in the first and a very close look at a CT traumagram gave the latter."

Not really a field issue then.


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## AnthonyM83 (Jul 31, 2012)

I would imagine splint it similar to flail chest, depending on severity.
The problem then is, how do you treat a flail chest. There's a range of recommendations from position of comfort only to bulky dressings to lying on affected side to PPV, etc.


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## Uller55 (Aug 1, 2012)

WOW.....did't think I would get these responses.......thanks to every one for your reply.... I passed my ITLS...yay....as for the Fx...no splinting......just cardiac monitoring......


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## hummingbird (Aug 3, 2012)

*Fx. sternum*



DPM said:


> That's a little bit much, I fractured mine and I could breathe  It hurt a lot but that was about it, and no worse than the broken ribs.
> 
> I wonder if your ITLS instructor is on here....


Response
My sister suffered a fractured sternum in a head-on auto collision. I would have to disagree that it is no worse than broken ribs.  One year later my sister still has problems, cannot lift a child, needs to see a pulmonologist on a fairly regular basis, continues to have a coughing problem and recently an upper respiratory infection.  Has been advised it would not be wise to visit me in Florida at this time because of the heat and humidity, which would likely make it difficult for her to breathe.
Olive - EMT (NYS)


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## VFlutter (Aug 3, 2012)

hummingbird said:


> Response
> My sister suffered a fractured sternum in a head-on auto collision. I would have to disagree that it is no worse than broken ribs.  One year later my sister still has problems, cannot lift a child, needs to see a pulmonologist on a fairly regular basis, continues to have a coughing problem and recently an upper respiratory infection.  Has been advised it would not be wise to visit me in Florida at this time because of the heat and humidity, which would likely make it difficult for her to breathe.
> Olive - EMT (NYS)



But are these problems a direct result of the fractured sternum or some other injury such as a pulmonary contusion that occurred at the same time? Sounds more like the sternum fracture was a simultaneous injury.


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## hummingbird (Aug 3, 2012)

*Fx. sternum*



ChaseZ33 said:


> But are these problems a direct result of the fractured sternum or some other injury such as a pulmonary contusion that occurred at the same time? Sounds more like the sternum fracture was a simultaneous injury.



I am not sure what you mean by a simultaneous injury.  She was told that she suffered a fracture of her sternum (which by the way was very painful,) past that I don't know.  All I do know is that it has quite changed her life and her abilities, she loves to lift up and play with her grandchildren but she is unable to do so now.  My point was merely to comment that it is much worse than a rib injury, someone had stated it was no big deal nothing more than a broken rib.  Again, I have to disagree.  By the way I would imagine it is quite difficult to splint.  Thank you.
Olive


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## Aidey (Aug 3, 2012)

He means another injury besides the fractured sternum. A fractured sternum, once healed, should not cause long term lung problems unless the lungs were also injured. If she got pneumonia after fracturing her sternum that could potentially cause long term problems too.


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## hummingbird (Aug 3, 2012)

*Fx. sternum*



Aidey said:


> He means another injury besides the fractured sternum. A fractured sternum, once healed, should not cause long term lung problems unless the lungs were also injured. If she got pneumonia after fracturing her sternum that could potentially cause long term problems too.



I do realize simultaneous means at the same time, it was just in how he phrased it, didn't make sense to me.  Yes, she obviously is suffering long-term problems.  Thank you.
Olive


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## VFlutter (Aug 3, 2012)

hummingbird said:


> I do realize simultaneous means at the same time, it was just in how he phrased it, didn't make sense to me.  Yes, she obviously is suffering long-term problems.  Thank you.
> Olive



Sorry if I worded that weird. What I meant was the long term problems she is having is most likely not the direct result of the fracture. I am assuming it takes a decent amount of direct force to fracture the sternum which would also cause various other problems. I think a pulmonary contusion or something like that also occurred as a result of the accident and is what is contributing to the chronic conditons.  


Kind of like a broken scapula, it's takes an excessive amount of force to break one which undoubtably will also result in internal damage however the broken scapula probably has nothing to do with the complications.


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## hummingbird (Aug 4, 2012)

ChaseZ33 said:


> Sorry if I worded that weird. What I meant was the long term problems she is having is most likely not the direct result of the fracture. I am assuming it takes a decent amount of direct force to fracture the sternum which would also cause various other problems. I think a pulmonary contusion or something like that also occurred as a result of the accident and is what is contributing to the chronic conditons.
> 
> 
> Kind of like a broken scapula, it's takes an excessive amount of force to break one which undoubtably will also result in internal damage however the broken scapula probably has nothing to do with the complications.



She was a front-seat passenger in a head-on collision truck -v- car so yes there would have been much direct force and car loses.  You are probably correct in your assumption about internal injuries but I do not know the answer to that.  She lives in New Jersey and I live in Florida.  Thank you for your help.
Olive Devine EMT (NYS)


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## vbasulto (Aug 7, 2012)

What about a KED, extrication device. Don't cinch it too much and it would support the whole rib cage and make moving the patient a lot easier.


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## mycrofft (Aug 8, 2012)

Associated injuries...the sternum lies over the mediastinum....


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