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The Clinical Picture

Dancing sternal wires: A radiologic sign of sternal dehiscence

Mohamed M. Gad, MD and Amit Gupta, MD
Cleveland Clinic Journal of Medicine February 2019, 86 (2) 87-88; DOI: https://doi.org/10.3949/ccjm.86a.18091
Mohamed M. Gad
Research Fellow, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic
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Amit Gupta
Clinical Assistant Professor, Department of Radiology, Division of Cardiothoracic Imaging, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
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A 52-year-old man underwent coronary artery bypass grafting, which was complicated by cardiac tamponade requiring repeat sternotomy with mediastinal washout (Figure 1). On postoperative day 4, plain imaging revealed a midline sternal lucency and a slight leftward deviation of the second-from-the-lowest sternal wire (Figure 2), subtle signs suggesting sternal dehiscence. Those signs were missed initially, as no clinical signs of dehiscence were evident.

Figure 1
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Figure 1

Radiography immediately after surgery showed cardiac tamponade, which led to repeat sternotomy with mediastinal washout.

Figure 2
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Figure 2

On postoperative day 4, midline sternal lucency and a slight leftward deviation of the second- from-the-lowest sternal wire (arrow)—early signs of dehiscence—resulted in mild loss of alignment.

The next day, routine radiography showed widely separated sternal wires (Figure 3), indicating significant progression of sternal dehiscence. The patient subsequently underwent open reduction and internal fixation of the sternum.

Figure 3
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Figure 3

On postoperative day 5, the widely separated sternal wires indicated advanced sternal dehiscence.

STERNAL DEHISCENCE

Sternal dehiscence is a rare but serious complication of sternotomy.1 In most cases of dehiscence, the sternal wires malfunction, leading to separation of sternal fragments. Lack of proper alignment of the sternum impairs bone healing, and the loose fragments of bone and wire pose a danger of puncturing the heart, making sternal dehiscence a surgical emergency.2

Physical examination may reveal tenderness to palpation, but findings that are more characteristic are an audible click and rocking of the sternum with coughing or forced chest movements.3

Plain chest radiography can clearly show early signs of sternal dehiscence; however, physicians rarely scrutinize the films for wire placement. Subtle signs include loss of sternal alignment with shifting of the segments and central sternal lucency. Gross signs start to appear when 2 or more wires are displaced; these signs are dramatic and rarely missed.

Loss of alignment and central sternal lucency are the earliest radiographic signs of dehiscence. Awareness of early subtle signs can lead to prompt diagnosis and treatment to prevent progression to gross sternal dehiscence.

  • Copyright © 2019 The Cleveland Clinic Foundation. All Rights Reserved.

REFERENCES

  1. ↵
    1. Olbrecht VA,
    2. Barreiro CJ,
    3. Bonde PN,
    4. et al
    . Clinical outcomes of noninfectious sternal dehiscence after median sternotomy. Ann Thorac Surg 2006; 82(3):902–907. doi:10.1016/j.athoracsur.2006.04.058
    OpenUrlCrossRefPubMed
  2. ↵
    1. Efthymiou CA,
    2. Kay PH,
    3. Nair UR
    . Repair of spontaneous right ventricular rupture following sternal dehiscence. A novel technique. Interact Cardiovasc Thorac Surg 2010; 10(1):12–13. doi:10.1510/icvts.2009.217810
    OpenUrlCrossRefPubMed
  3. ↵
    1. Santarpino G,
    2. Pfeiffer S,
    3. Concistré G,
    4. Fischlein T
    . Sternal wound dehiscence from intense coughing in a cardiac surgery patient: could it be prevented? G Chir 2013; 34(4):112–113. pmid:23660161
    OpenUrlPubMed
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Cleveland Clinic Journal of Medicine: 86 (2)
Cleveland Clinic Journal of Medicine
Vol. 86, Issue 2
1 Feb 2019
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Dancing sternal wires: A radiologic sign of sternal dehiscence
Mohamed M. Gad, Amit Gupta
Cleveland Clinic Journal of Medicine Feb 2019, 86 (2) 87-88; DOI: 10.3949/ccjm.86a.18091

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Dancing sternal wires: A radiologic sign of sternal dehiscence
Mohamed M. Gad, Amit Gupta
Cleveland Clinic Journal of Medicine Feb 2019, 86 (2) 87-88; DOI: 10.3949/ccjm.86a.18091
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