Brachial plexus injury following median sternotomy. Part II

Brachial plexus injury may be a consequence of median sternotomy. In a previous study, we documented that median sternotomy can cause first rib fractures and that the first rib fractures may be associated with brachial plexus injury. In the current study, two groups of patients were compared for the incidence of brachial plexus injury and first rib fracture. In Group A, an Ankeney retractor was used with the crossbar placed caudal to the incision: in Group C, a Cooley sternal retractor was used with the crossbar placed cephalad to the incision. The major effective difference between these two retractors was the more caudal placement of the retractor blades with the Cooley retractor than with the Ankeney retractor. Our previous study showed that first rib fractures were caused by high placement of the sternal retractor and that they could be avoided by placing the retractor at a lower position. In the present study, 33% in Group A and 14% in Group C sustained first rib fractures (p = 0.024). Signs of brachial plexus injury occurred in 18% of Group A and 12% of Group C (p = 0.52). We found no correlation between the presence of rib fracture and the presence of neurologic symptoms, but all patients who had both neurologic symptoms and a rib fracture had the symptoms only on the same side as the rib fracture. We also found that standard chest x-ray films identified only 15% of the rib fractures seen on special first rib views. The study demonstrates that the incidence of first rib fractures following median sternotomy is reduced when the sternal retractor is placed at a lower position and that the incidence of brachial plexus injury may also thereby be reduced.