Rigid anterior plating for open transverse sternal fracture traversing previous sternotomy: a case report

Traumatic sternal fractures account for 0.33-8% of blunt chest trauma admissions and are usually managed conservatively. However, displaced or unstable fractures may require surgical fixation. Fractures traversing a previous median sternotomy are exceptionally rare and present unique challenges due to retrosternal adhesions and the risk of injury to cardiac structures during posterior dissection. No prior reports have specifically described anterior-only rigid plate fixation for traumatic sternal fracture crossing a previous sternotomy in a patient with mechanical heart valves. We present such a case and discuss the surgical rationale and outcome.

A 64-year-old man with a history of mechanical mitral and aortic valve replacement 27 years previously presented after a motorcycle collision, sustaining an overlying parasternal skin laceration and a completely displaced, open transverse sternal fracture at the third intercostal space, crossing the previous sternotomy line. Intraoperative exploration confirmed direct communication between the parasternal laceration and the fracture site, establishing the diagnosis of a true open sternal fracture (Gustilo-Anderson type II). Associated injuries included multiple non-displaced right-sided rib fractures, pulmonary contusion, and bilateral hemothoraces. Given the fracture instability, wound contamination risk, and the need for anticoagulation, urgent surgical stabilization was performed. Two parallel one-third tubular titanium plates with monocortical locking screws were applied via anterior-only approach, deliberately avoiding retrosternal dissection to prevent injury to cardiac structures adherent to the posterior sternum. The postoperative course was uneventful. At 3-month follow-up, computed tomography confirmed correct alignment with a smooth posterior contour and no hardware protrusion into the mediastinum.

Anterior-only rigid plate fixation is a safe and effective strategy for traumatic sternal fractures crossing a previous sternotomy, avoiding the hazards of retrosternal dissection while providing adequate biomechanical stability. Preoperative review of prior cardiac surgical history is essential when planning sternal fracture fixation.