Spontaneous fracture of sternum secondary to forceful coughing: A case report.

Dear Editor,

Spontaneous sternal fracture (SSF) secondary to incessant forceful coughing is one of the rarest etiologies of a fractured sternum. This condition is commonly missed because it may be attributed to benign musculoskeletal pain. The sternum overlies major intrathoracic and mediastinal structures, and it is essential to assess for and properly manage the injury associated with sternal fractures. The symptoms in a patient with a SSF create a greater diagnostic challenge unless the diagnosis is considered carefully because the symptoms often resemble other grave conditions. These fractures tend to occur in the elderly population, especially postmenopausal women. Our patient, to our knowledge, is the first case report of a male who presents with a SSF secondary to forceful coughing.

A 75-year-old male with previous medical history of hypertension, congestive heart failure, and atrial fibrillation presented to the emergency room with sudden onset of chest pain. The patient stated that he has been coughing incessantly for two days. He had a severe bout of coughing that day followed by severe chest pain, described as substernal, nonradiating, and constricting in nature. It was aggravated by movement without specific alleviating factors. He denied any trauma or using corticosteroids in the past. He had no history of previous tobacco abuse or illicit drug use, but did admit to occasional alcohol use socially. His medications included carvedilol, ramipril, and coumadin. He appeared to be in respiratory distress. He was tachycardic and tachypneic. He also had localized tenderness at the midsternal area. Rest of the physical exam was unremarkable. Computed tomography (CT) scan of the chest revealed a congenital chondrosternal depression with fracture of the sternum [Figures 1 and 2]. He was hospitalized for 2 days and received analgesic therapy. His condition improved rapidly, and he was discharged in a stable condition.

Figure 1

Computed tomography scan of the chest revealed a congenital chondrosternal depression of the sternum

Figure 2

Computed tomography scan of the chest revealed a transverse fracture of the sternum at themanubrial position

Sternal fractures rarely occur spontaneously.[123] Generally, patients are discharged relatively quickly because they have minor injury, and hence the published data is biased toward severe cases.[4] Risk factors associated with SSF include advanced age, congenital chest wall deformity, chronic use of corticosteroids, and previous sternal trauma. In up to 30% of individuals, the sternomanubrial and sternoxiphoid centers may not be fused and that increases the risk of SSF with minor strain. Patients with advanced age may develop such fracture even with minor strain due to the loss of elasticity of costal cartilages and decreased density of the bony thorax.[2]

Common symptoms of SSF are pleuritic chest pain and dyspnea similar to acute coronary syndrome or pulmonary embolism.[23] Bony crepitus or deformity is generally only present if the fracture is extensive and has displaced the broken fragments of sternum.

Initial imaging should include a posteroanterior and lateral chest radiograph with a sternal view because it may increase visualization of the affected area since it modifies the angle and focus of exposure.[5] In 2006, a study by Jin et al. found that bedside ultrasonography may be more effective in the diagnosis of sternal fractures than radiography and significantly shortens the time to diagnosis.[3] CT scan is also useful for the diagnosis of SSF.

Management of sternal fracture includes basic trauma care with supplemental oxygen, cardiac monitoring, and analgesics. Occasionally, sternal fractures result in the development of mediastinal hematoma with active bleeding from the adjacent internal mammary artery. This may require angioembolization or open ligation in the setting of hemodynamic instability.[6] Taping or splinting of sternal fracture is contraindicated because this restricts normal chest expansion during respiration and can lead to atelectasis. Surgical fixation of fractures is reserved for painful unstable fractures where it has been shown to lead to more rapid recoveries.[456]