To the Editor: A 20-year-old sub-elite Australian Rules football player presented with pain and tenderness in the lower third of the sternum. He had been involved in a moderate body collision with an opposing player about 3 weeks before presentation, and had continued to train and play despite sternal discomfort. He described no other symptoms.

On examination, there was no obvious sternal deformity. There was mild to moderate tenderness over the lower third of the sternum, and minimal sternal discomfort on lateral chest compression. Chest auscultation was clear. Plain chest and sternal x-rays were normal.

A technetium-99m HDP bone scan showed increased tracer uptake in the lower sternum, consistent with an undisplaced oblique sternal fracture (Box).

Management of the player’s injury and his fitness to train and play were discussed informally with medical and paramedical practitioners. Their opinions ranged from an immediate return to competition to 12 weeks of complete rest. After discussions within the player’s club, he was placed on a training regimen that avoided all upper body clashes and stresses, and he was rested from match play. He was regularly reassessed for symptoms and made an uneventful return to full competition 6 weeks after his initial injury. He remained asymptomatic and competitive for the remainder of the season and at 1-year review.

The usual cause of sternal fracture is blunt anterior chest trauma, with about 90% of sternal fractures caused by trauma resulting from the forces associated with motor vehicle accidents.1 Sternal fracture is rarely encountered in Australian Rules football and such a case has not previously been described in the literature. The Australian Football League Injury Report database revealed only four cases of sternal fracture over the period 1992–2006, accounting for a total of 18 missed games (range, 1–11 games) (John Orchard, Conjoint Senior Lecturer, Sports Medicine Program, University of New South Wales, personal communication, May 2007).

Patients suspected of suffering a sternal fracture should be investigated with appropriate chest x-rays. If these are inconclusive, it is now suggested the patient should be further investigated with sternal ultrasound, which has recently been demonstrated to be superior to bone scan in identifying sternal fractures,2 and without the associated radiation exposure. Patients with an acute suspected sternal fracture should also undergo electrocardiography. If the electrocardiogram is normal and there is no evidence of intrathoracic injury on radiological investigation, the patient can safely be discharged.3

Chest pain is the predominant persisting symptom after sternal fracture.4 Conservative management with rest, analgesia and/or anti-inflammatories, and, if required, appropriate padding and taping5 should result in full recovery and an uneventful return to competition.

Bone delay views from dynamic localised technetium-99m HDP bone scan

There is a band of low to moderate tracer uptake running in a slightly oblique line across the lower sternum (arrow), suggesting a sternal fracture.