An elderly female with osteoporosis and a focus of increased activity in the sternum on scintigraphy.
A 61 years old female presented with a 2 month history of low- thoracic back pain and increasing thoracic kyphosis. Osteoporosis had been previously diagnosed on DEXA bone densitometry. There was no history of trauma , steroid use or concurrent illness . Radiographs of the thoracic spine show generalized osteopaenia and kyphosis with vertebral body collapse at T 8,10,12 and L 2 (Fig 1). Scintigraphy (Technecium 99) demonstrates multiple areas of increased activity in the thoracic and lumbar spine corresponding with the osteoporotic vertebral body insufficiency fractures (Fig 2). A focal area of increased uptake was also present in the sternum suggesting an insufficiency fracture here also. Radiographs (Fig 3) and MRI (Fig 4) of the sternum confirmed a displaced fracture through the manubrium sterni .There was no history of anterior chest pain but on examination there was localized tenderness over the manubrium.The patient was treated with intravenous biphosphonates.
Insufficiency fractures occur when normal stresses are applied to a pathological bone resulting in deficient elastic resistance (1).Although sternal fractures due to trauma are common , insufficiency fractures of the sternum are uncommon and usually associated with generalized osteoporosis .Accentuated thoracic kyphosis, due to vertebral body compression fracture (usually multiple), places a deforming stress on the sternum predisposing to fracture (2). Occasionally, however , sternal insufficiency fractures occur in the absence of a kyphosis, presumably due to acute flexion-compression stresses applied to the sternum during forward bending (3).Isolated fatigue fractures of the sternum have also been described (4).Clinically they have a wide spectrum of presentation; they may be asymptomatic and discovered incidentally on various imaging modalities or present with acute, severe chest pain and be confused with acute cardiopulmonary emergencies (5).The fracture may be displaced or non-displaced , and associated bone resorption at the fracture site with a soft tissue mass may simulate a pathological fracture due to ,for example ,metastasis (3).Insufficiency fractures of the sternum , and their association with osteoporosis , are important to recognize because their appearances on various imaging modalities may be confused with other pathological processes , for example , metastases and multiple myeloma.
Insufficiency fracture of the sternum.
1. Bone scan (anterior and posterior views): Increased radiotracer uptake is observed in the sternal region, suggesting active local metabolism.
2. X-ray lateral view: Irregular cortical changes can be seen in the mid segment (or upper/lower segment, depending on the specific case) of the sternum. There is cortical discontinuity or abnormal morphology at the site, possibly indicating a subtle fracture line. The structures of other thoracic cage bones (ribs, clavicles) appear relatively intact.
3. Surrounding bone shows osteoporotic changes, potentially related to the patient’s previously diagnosed osteoporosis.
4. Various degrees of wedge-shaped or compressive changes may be noted in the thoracic vertebrae, indicating either old or progressive osteoporotic vertebral compression.
1. Osteoporotic Sternal Insufficiency Fracture (Insufficiency Fracture):
Due to the patient’s known osteoporosis, the sternum can fracture under routine stress. If the lesion is centered on the sternum without prominent kyphotic deformity of the thoracic spine, an acute forward bending motion or accidental impact may concentrate stress and lead to fracture. Imaging findings of increased localized uptake and subtle fracture lines support this diagnosis.
2. Metastatic Bone Tumor:
Abnormal sternal uptake must prompt consideration of metastasis (e.g., from breast cancer, lung cancer, etc.). If the patient has a known history of malignancy or there is clinical suspicion, further evaluations (e.g., presence of multiple lesions, tumor markers) are needed.
3. Multiple Myeloma:
Commonly seen in older adults, it may present with bone lesions or “punched-out” defects on imaging, along with abnormal findings on nuclear bone scans. Laboratory abnormalities (e.g., serum protein electrophoresis, Bence Jones protein in urine) are usually present as well.
4. Fatigue Fracture:
Although more rare, repeated abnormal stress or prolonged mechanical load can lead to sternal fatigue fracture. Patient activity history is essential for proper assessment.
Considering the patient’s age, known history of osteoporosis, radiological evidence of a sternal fracture, and focal metabolic abnormality on the bone scan, the most likely diagnosis is
sternal insufficiency fracture (osteoporosis-related).
If there is still clinical suspicion, such as tumor history or possible hematologic disorders, additional MRI or CT scans may be performed, and if necessary, biopsy to exclude malignant lesions.
1. Conservative Treatment:
- Pain Management: Oral or topical analgesics (e.g., NSAIDs) or short-term mild opioids as needed; combine with hot compresses, physical therapy, etc.
- Osteoporosis Management: Supplement with calcium and vitamin D, and consider bisphosphonates, selective estrogen receptor modulators (SERMs), or other anti-osteoporotic medications (e.g., denosumab, teriparatide) as indicated.
- Moderate Restriction of Movement: Avoid excessive bending, twisting, or any motion causing undue stress on the sternum; the use of supportive devices (e.g., elastic chest wraps) may help alleviate local discomfort.
2. Surgical Intervention:
- Generally, partial fractures without significant displacement do not require surgery. If imaging confirms a large segment displacement or instability, internal fixation may be considered after weighing surgical risks against the patient’s overall condition.
3. Rehabilitation/Exercise Prescription (FITT-VP Principle):
- Type of Exercise: Focus on low-impact activities such as walking, range-of-motion exercises, and gradually progressive core stabilization; incorporate breathing exercises to help relieve chest discomfort.
- Frequency: 3–5 times per week, adjusted based on pain level and fatigue.
- Intensity: Begin with low intensity; use the Rating of Perceived Exertion (RPE) to maintain light-to-moderate effort, increasing gradually as pain improves and the fracture heals.
- Time: 20–30 minutes per session, adjusted according to tolerance.
- Progression: As symptoms improve and the fracture heals, light resistance training (e.g., with resistance bands for upper limbs) can be introduced, but avoid sudden or strenuous pushing/pulling movements.
- Individualization: If the patient has reduced cardiopulmonary function, exercises should be supervised by professionals, closely monitoring blood pressure, heart rate, etc.
Regular follow-up imaging (assessing fracture healing) and bone density evaluations (monitoring osteoporosis improvement) are recommended, adjusting the rehabilitation plan dynamically according to progress.
This report provides a reference-based analysis derived from the supplied information and does not substitute for an in-person diagnosis or professional medical advice. Patients should work with their healthcare provider to develop personalized treatment and rehabilitation plans based on their individual circumstances.
Insufficiency fracture of the sternum.
