Sternomanubrial reduction with plating for fully displaced sternal fracture: A systematic review

Key Clinical Message Sternal fractures are commonly due to blunt force trauma and reduction is an invasive surgical procedure typically indicated for refractory pain sternal instability. There were various modalities used for treatment and fixation of the sternal fractures. Sternal displacement fractures are traumatic injuries that may require surgical correction.

All selected articles were reviewed, and the following data were retrieved: age, sex, presenting symptoms, cause of injury, hospital workup, and surgical treatment modality.We also extracted authors' names and year of publication of the papers.

| STATISTICAL ANALYSIS
Descriptive statistics were used to present the demographic and clinical features of the pooled data from all the selected studies.Continuous variables were presented as mean with standard deviation while categorical variables were presented as proportions.Statistical analysis was performed using GraphPad version 8.0 software.

| CASE PRESENTATION
A 24-year-old female was admitted to the emergency department (ED) after a motor vehicle accident with a severely displaced sternomanubrial joint with persistent pain despite maximal pain control.Patient had an initial Glasgow Coma Scale (GCS) score of 15 upon presentation to the ED.The initial diagnostic workup with chest radiographs and computerized tomographic (CT) scans of the chest, abdomen, and pelvis showed small right-sided pneumothorax which was treated conservatively without a chest tube, bilateral lung parenchymal hemorrhages, and an isolated fully displaced sternomanubrial joint without rib fractures (Figure 2).Trauma workup resulted in elevated cardiac enzymes with normal 12-lead electrocardiogram, and transthoracic echocardiography.The patient did not have any rib fractures.On Day 2 of admission, the patient was transferred to the intensive care unit (ICU) for respiratory support after experiencing difficulty with breathing secondary to pain.Due to refractory pain and persistent requirement of respiratory support the patient was taken to the operating room for a sternomanubrial joint reduction with fixation and plating.A 6 cm incision was made over the sternomanubrial joint at the location of the dislocation.The dissection was carried down onto the sternum and the pectoralis muscle was elevated off the sternum using a bone elevator.Penetrating towel clips were applied to the manubrium and elevated to manually reduce the dislocation.The sternum was secured using two 12-hole SternaLock straight fixation plates which were applied longitudinally bridging the sternomanubrial junction and secured with 12, 14, and 15 mm screws (Figure 3).The incision was then closed in multiple layers with a muscle layer placed over the instrumentation.Post-procedure the patient required decreasing narcotics and ultimately was discharged home on room air.

| SYSTEMIC REVIEW
Our literature search began with searching for key phrases "Plating for Displaced sternal fractures" and "Displaced Sternal fracture fixation" on the pubmed database.No articles were found on the Cochrane library.Of the 88 total articles, 15 met our selection criteria.Further decision was made to exclude four articles that had large sample sizes where pertinent patient characteristics were not transparent.The final number of articles included in our systemic review was 11.The PRISMA flowchart in Figure 1  the cases reported were diagnosed in individuals less than 50 years of age (15 out of 21, 71.4%).Most cases were reported in male gender which constituted of 85.7% the cases (Table 2).
The most common cause of injury was trauma (61.9%).Trauma included motor vehicle accidents (MVA), surfing accident, chest compression injury, and collapse.Sternal tumors were the cause of injury in six patients (28.6%).Multiple myeloma and gymnastics were the cause of injury in one patient (4.8%) each.
Workup at the hospital predominantly comprised of imaging.Specifically, computer tomography scan (CT) comprised of 71.4% of the imaging modality with plain radiographs comprising of 42.9%.CT and radiographs were used simultaneously in multiple patients, and we did not distinguish it here by patient.Bone scintigraphy, EKG, and cardiac enzymes were used in one patient (4.8%).
There were various modalities used for treatment and fixation of the sternal fractures.The most common treatment was titanium plate fixation (33.3%).Stainless steel plating was the second most common used in five patients (23.8%).Longitudinal rigid polymer fixation and Modified Robicsek wire fixation & SternaLock was used in two patients (9.5%) each.Distal Clavicle J plates, Longitudinal compression plates, MatrixRIB Fixation System, SternaLock plates, and L-shaped plates were used in one patient (4.8%) each.Nonunion sternal dislocations can occur anywhere along the sternum.These dislocations are relatively uncommon due to need of a high velocity force.Due to the nature of injury, blunt force trauma is the most common cause of sternal dislocations.Whereas sternal fractures are benign in nature and require symptomatic therapy, sternal dislocations are almost always treated with surgery. 14Patients require reunion procedures that provide support and stability for the dislocated sternum to realign and heal.
The most common symptoms associated with sternal dislocations are chest pain, which is exasperated by the type of blunt trauma. 1 Depending on the severity of the trauma, rib fractures, hemothorax, and pneumothorax can contribute to the chest pain and further complicate the patient's respiratory status.It therefore becomes imperative to act quickly and stabilize the patient.
Multiple protocols have been proposed for sternal reduction and fixation each with its advantages and disadvantages.Plating has been considered a superior choice of treatment requiring minimal dissection of the soft tissue, bringing about a closer approximation of bone and being more biomechanical compared to other reduction techniques. 15However, plating has also not been the preferred treatment by many cardiothoracic surgeons possibly due to their prior training or comfort with the technique. 15ften, plating creates a dilemma where it limits the patient's respiratory drive due to pain on the anterior chest upon inspiration. 16his study is limited by the nature of the previous studies used in this review.The articles used were case reports and case series that were searched on databases using the phrase "Displaced Sternal Fracture Fixation" and "Plating for Displaced Sternal Fractures".These are level IV evidence according to the Oxford's levels of evidence.Many case reports had been excluded because of incomplete data and language other than English.Despite these challenges, this study has generated significant and relevant data about sternal dislocations and fractures with the goal of facilitating better understanding of surgical management.

| CONCLUSION
Sternal displacement and fractures are traumatic injuries that may require surgical correction and necessitate an expedited hospital care of plan for patient survival and recovery.To date, there are only a few protocols for the usage of titanium fixation systems.We reckon that treatment consisting of a standardized fixation system will allow for summarizes the selection process.The systemic review articles were selected for sternal fractures; therefore, 100% of individuals had injury located at the sternum.The age of the patients at the time of diagnosis ranged from 9 years to 70 years with a mean age of 40.5 years and a median age of 40 years.Most of F I G U R E 2 CT 3-D reconstruction of fully displaced sternomanubrial fracture from blunt chest trauma.

F I G U R E 3
Intraoperative images with reduction of sternomanubrial joint with plating.
Reported cases of sternal plating.
T A B L E 1 Patient characteristics, symptoms, and treatments.
T A B L E 2