Orthopedics

Letters 

Acute Traumatic Sternal Fracture in a Female College Hockey Player

Robert J. Douglas, BA, BAppSc(Dist), BM, BS, FRACGP

Abstract

To the Editor:

I read with interest the article “Acute traumatic sternal fracture in a female college hockey player” ( http://www.orthosuper-site.com/view.aspx?rid=67842) in the September 2010 issue of Orthopedics. The authors provided an excellent up-to-date summary of the investigation and management of a sport-related sternal fracture. However, I would like to bring 2 items to the attention of the Journal’s readers.

First, and most importantly, I must express my concern with the statement: “…a negative EKG sufficiently rules out any injury to the myocardium.”

While I agree with the broad implication of the statement, I would add the proviso, which is indicative of current Australian Emergency Medicine practice for the investigation and management of a similar sternal fracture (personal communication, Associate Professor R.J. Dunn, Director Clinical and Academic Emergency Medicine, Royal Adelaide Hospital, South Australia), that at least 1 repeat EKG is recommended1 and that consideration be given to further investigation and observation of the patient should they have a history of cardiac disease.2

Second, throughout the article, reference is made to a report of a nondisplaced sternal fracture in a rugby footballer.3 I would like to point out that the game of Australian rules football, of which the described patient was a participant, bears only a passing resemblance to rugby (in either of its guises) and can be differentiated from the more earth-bound varieties of football by the high mark, a good example of which is demonstrated in a recent article.4

Robert J. Douglas, BA, BAppSc(Dist), BM, BS, FRACGP
Adelaide, South Australia

Although differing information exists in the literature on EKG recommendations for isolated sternal fractures, our recommendation of outpatient management of the athlete with an isolated sternal fracture, chest radiograph that is negative for other injury, and normal initial EKG was made after reviewing the data found by Rashid et al,1 Sadaba et al,2 Velissaris et al,3 and Peek et al.4 We agree with the statement “that consideration be given to further investigation and observation of the patient should they have a history of cardiac disease,” and appreciate this being brought to the readers’ attention. Our athlete was young and otherwise healthy, and we implied this in stating that “this type of patient can be followed as an outpatient,” but we agree that this clarification should be made.

We appreciate Dr Douglas’ point regarding the difference between rugby and Australian rules football and thank him for correcting our error.

David C. Flanigan, MD
Kendra McCamey, MD
Columbus, OH

To the Editor:

I read with interest the article “Acute traumatic sternal fracture in a female college hockey player” ( http://www.orthosuper-site.com/view.aspx?rid=67842) in the September 2010 issue of Orthopedics. The authors provided an excellent up-to-date summary of the investigation and management of a sport-related sternal fracture. However, I would like to bring 2 items to the attention of the Journal’s readers.

First, and most importantly, I must express my concern with the statement: “…a negative EKG sufficiently rules out any injury to the myocardium.”

While I agree with the broad implication of the statement, I would add the proviso, which is indicative of current Australian Emergency Medicine practice for the investigation and management of a similar sternal fracture (personal communication, Associate Professor R.J. Dunn, Director Clinical and Academic Emergency Medicine, Royal Adelaide Hospital, South Australia), that at least 1 repeat EKG is recommended1 and that consideration be given to further investigation and observation of the patient should they have a history of cardiac disease.2

Second, throughout the article, reference is made to a report of a nondisplaced sternal fracture in a rugby footballer.3 I would like to point out that the game of Australian rules football, of which the described patient was a participant, bears only a passing resemblance to rugby (in either of its guises) and can be differentiated from the more earth-bound varieties of football by the high mark, a good example of which is demonstrated in a recent article.4

Robert J. Douglas, BA, BAppSc(Dist), BM, BS, FRACGP
Adelaide, South Australia

References

  1. Nagy KK, Krosner SM, Roberts RR, Joseph KT, Smith RF, Barrett J. Determining which patients require evaluation for blunt cardiac injury following blunt chest trauma. World J Surg. 2001; 25(1):108–111. doi:10.1007/s002680020372 [CrossRef]
  2. Velmahos GC, Karaiskakis M, Salim A, et al. Normal electrocardiography and serum troponin I levels preclude the presence of clinically significant blunt cardiac injury. J Trauma. 2003; 54(1):45–50. doi:10.1097/00005373-200301000-00006 [CrossRef]
  3. Douglas RJ. Sternal fracture in an Australian Rules footballer. Med J Aust. 2008; 188(8):493–494.
  4. Douglas RJ. Ooh–bet that hurt. Med J Aust. 2008; 189(9):524.

Reply:

Although differing information exists in the literature on EKG recommendations for isolated sternal fractures, our recommendation of outpatient management of the athlete with an isolated sternal fracture, chest radiograph that is negative for other injury, and normal initial EKG was made after reviewing the data found by Rashid et al,1 Sadaba et al,2 Velissaris et al,3 and Peek et al.4 We agree with the statement “that consideration be given to further investigation and observation of the patient should they have a history of cardiac disease,” and appreciate this being brought to the readers’ attention. Our athlete was young and otherwise healthy, and we implied this in stating that “this type of patient can be followed as an outpatient,” but we agree that this clarification should be made.

We appreciate Dr Douglas’ point regarding the difference between rugby and Australian rules football and thank him for correcting our error.

David C. Flanigan, MD
Kendra McCamey, MD
Columbus, OH

References

  1. Rashid MA, Ortenwall P, Wikström T. Cardiovascular injuries associated with sternal fractures. Eur J Surg. 2001; 167(4):243–248. doi:10.1080/110241501300091345 [CrossRef]
  2. Sadaba JR, Oswal D, Munsch CM. Management of isolated sternal fractures: determining the risk of blunt cardiac injury. Ann R Coll Surg Engl. 2000; 82(3):162–166.
  3. Velissaris T, Tang AT, Patel A, Khallifa K, Weeden DF. Traumatic sternal fracture: outcome following admission to a Thoracic Surgical Unit. Injury. 2003; 34(12):924–927. doi:10.1016/S0020-1383(02)00415-1 [CrossRef]
  4. Peek GJ, Firmin RK. Isolated sternal fracture: an audit of 10 years’ experience. Injury. 1995; 26(6):385–388. doi:10.1016/0020-1383(95)00051-A [CrossRef]

10.3928/01477447-20110427-02

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