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In 1993, a 56 year old man was involved in a road traffic accident where his car was struck violently by another vehicle. Despite wearing a seatbelt he developed severe chest pain. At his local casualty department a chest radiograph confirmed a fractured sternum but was otherwise normal. An ECG showed T wave inversion in leads V1 to V6. Creatinine kinase concentrations were raised. A diagnosis of acute cardiac contusion was made and treated conservatively.
Some years later he developed signs of pericardial constriction. Contrast enhanced computed tomography (right) revealed a right pleural effusion in addition to a 6 cm soft tissue mass lying anteriorlywithin the pericardium just posterior to the sternum. This was surrounded by dense calcification and compressed the right ventricle. The contents of the mass can be seen to have a similar attenuation to blood in the ventricles and are denser than the pleural effusion.
The patient was referred for surgery where extensive plate calcification external to the right ventricular outflow tract was discovered and resected. The mass was found to contain old liquefied haematoma. Postoperative recovery was uneventful with the patient reporting a gradual improvement in exertional dyspnoea.
The low mortality and morbidity now associated with sternal fracture should not result in under investigation when there is clinical suspicion of associated, especially cardiac, injuries. Patients with a sternal fracture and ECG abnormalities should undergo diagnostic imaging other than just a plain chest radiograph, which is inadequate in assessing cardiac injury in this setting.