JAAOS - 2026-04-21 - Journal Article
A Propensity-Matched Analysis of the Impact of Sternal Fractures on Outcomes in Concurrent Thoracic Spine Fractures: The Fourth Column of the Spine.
Carroll AH, Quinonez A, Perez-Albela A, Bellaire CP, Griffin D, Benn L, Ruijie Y, Yoon K, Japa JP, Ehioghae M, Mesfin A
Topics
Key Takeaway
Concurrent sternal and thoracic spine fractures carry a 4.38-fold increased odds of requiring spinal decompression/fusion and 3.0-fold increased odds of thoracic surgery compared to isolated thoracic spine fractures.
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Summary
This study asked whether concurrent sternal fractures worsen outcomes in thoracic spine fractures by querying the PearlDiver database and propensity-matching 4,513 combined sternal-thoracic fracture patients 1:1 to isolated thoracic fracture controls by age and Elixhauser comorbidity index. Combined injury patients had significantly higher rates of spinal cord injury, spinal decompression/fusion (OR 4.38), and thoracic surgery (OR 3.0), all P<0.0001. Hemodynamic, respiratory, cardiac, and renal complications were also significantly elevated at 90 days (P<0.001), supporting the sternum as a functional fourth stabilizing column of the thoracic spine.
Key Limitation
ICD-code-based identification precludes verification of fracture morphology, PLC integrity, or neurologic grade, making it impossible to determine whether the elevated surgical rate reflects true instability or coding-driven selection bias.
Original Abstract
BACKGROUND
The thoracic vertebrae, ribs, and sternum, provide structural and protective support for the upper body. The unique framework of the region suggests that fractures involving both the thoracic spine and sternum occur with notable spinal instability. Despite their clinical relevance, the short-term medical and surgical outcomes of combined sternal and thoracic spinal fractures remain poorly understood compared with thoracic fractures alone. This study aims to compare the 90-day complication rates and surgical intervention requirements in patients with concomitant sternal and thoracic vertebral fractures with those with isolated thoracic vertebral fractures.
METHODS
Patients presenting with acute sternal and thoracic spine fractures in the same admission were identified using the PearlDiver database. Patients with sternal and vertebral fractures were propensity matched in a 1:1 ratio with a control group by age and Elixhauser comorbidity index. Medical complications, rate of spinal cord injury, and rates of surgical intervention were assessed at 90 days.
RESULTS
A total of 9,026 patients were identified in this study with 4,513 patients presenting with sternal and thoracic spine fractures and 4,513 patients in the control group. Sternal and vertebral fracture coinjury was associated with higher rates of spinal cord injury (P < 0.0001), higher rates for spinal decompression/fusion (odds ratio = 4.38, P < 0.0001), and higher rates of thoracic surgery (odds ratio = 3.0, P < 0.0001). These patients were also statistically markedly more likely to develop hemodynamic, respiratory, cardiac, and renal complications (P < 0.001) at 90 days.
DISCUSSION
Patients with thoracic spine fractures who sustain simultaneous sternal fractures are markedly more likely to have concomitant spinal cord injury, require spinal stabilization or decompression, and develop medical complications. Our findings point toward the role of the sternum as a fourth column of stability in cases of thoracic spinal fractures, which mitigate complications, surgery, and neurologic injury in cases of trauma.