Poststernotomy fractures and pain management in open cardiac surgery

To assess whether (1) there is an increased incidence of sternal fractures associated with internal mammary artery (IMA) revascularization in open heart surgery and (2) there is a higher incidence of pain in postoperative patients with sternal fractures.

Two hundred eighty-eight consecutive adult patients who had undergone cardiac surgery underwent median sternotomy from 1989 to 1991. IMA revascularization was used in 94 patients. The remainder underwent conventional saphenous vein graft (SVG) revascularization or other open cardiac procedure. The sternum was checked for fracture at the time of chest-wall closure. Lung volumes, arterial blood gases, respiratory rate, and oxygen requirements were measured before and after pain relief by intravenous or epidural analgesia.

Of 288 consecutive median sternotomies, there were a total of 24 sternal fractures. IMA harvesting was associated with a significantly greater incidence of sternal fractures. In the 94 patients in whom IMA mobilization was used, there were 16 fractures; in the remaining 194 cases, there were 8 fractures (p < 0.007). Twenty-one of 24 patients were not seriously affected by their sternal fractures, whereas 3 patients suffered major respiratory compromise due to postoperative pain. Epidural analgesia was effective treatment for these three cases of severe sternal fracture pain and was not associated with any adverse consequences. All three patients had significant improvement in their respiratory condition after epidural analgesia was instituted. Respiratory rate decreased from 27 +/- 3 to 18 +/- 0.3 breaths/min (p < 0.001) and end maximum inspired volume increased from 700 +/- 1 mL to 1,525 +/- 275 mL.

The use of sternal retraction devices for IMA harvesting in coronary bypass procedures results in an increased incidence of sternal fractures when compared with conventional SVG bypass procedures. Although most sternal fractures are well tolerated, some patients with fractures can become a significant pain management problems. Epidural analgesia is a safe and effective treatment for severe pain associated with sternal fractures and provided improved postoperative pulmonary function.