title: Flexible intramedullary nailing of a displaced transverse sternal fracture associated with a flexion-compression injury of the thoracic spine.
abstract: METHODS
  A case report.
  
  
  OBJECTIVE
  To report the successful surgical management of a patient with a displaced sternal fracture associated with flexion-compression injury to the thoracic spine by flexible intramedullary nailing of the sternum, thereby emphasizing the existence and clinical relevance of the concept of the fourth column of the thoracic spine.
  
  
  BACKGROUND
  Displaced sternal fractures resulting from indirect trauma are often associated with unstable injuries to the thoracic spine that require stabilization of the spine to prevent increasing kyphosis. The theory of the sternal-rib-complex as a possible fourth column giving structural support to the thoracic spine has been proposed. However, such a model has rarely been described, and the role of surgical stabilization of an unstable fourth column is unknown.
  
  
  METHODS
  A 58-year-old man with Forestier syndrome presented with a severely displaced sternal fracture associated with an unstable injury to the thoracic spine at T4-T8 after a fall at ground level. The patient complained of sternal pain and respiratory distress. However, neurologically he was completely normal. His pain and respiratory distress improved, so he refused spinal stabilization, and was discharged 20 days after the injury.
  
  
  RESULTS
  Eight weeks after the injury the patient complained of persistent sternal pain and symptoms of sternal instability. A computed tomogram (CT) showed increasing displacement of the sternal fracture and increasing kyphosis of the thoracic spine. To relieve the sternal pain and prevent further displacement the patient now agreed to stabilization of the sternal fracture by minimal invasive flexible intramedullary nailing. Postoperative CT showed an almost anatomically-reduced sternum and even a slight correction of the thoracic kyphosis. After removal of the implants 5 months later the patient was free of pain, and was able to resume normal physical activity and return to his work as a farmer. Thirty months after sternal stabilization surgery, CT showed complete healing of the sternal fracture and a continuing reduction of the thoracic kyphosis.
  
  
  CONCLUSIONS
  This case supports the concept of the existence and clinical relevance of the fourth column of the thoracic spine, and its role in giving added spinal stability.
authors.affiliation: Department of Surgery, University of Munich, Germany. Markus.Regauer@med.uni-muenchen.de
authors.forename: Markus
authors.initials: M
authors.lastname: Regauer
authors.forename: Stefan
authors.initials: S
authors.lastname: Huber-Wagner
authors.forename: Timothy
authors.initials: T
authors.lastname: Oedekoven
authors.forename: Wolf
authors.initials: W
authors.lastname: Mutschler
authors.forename: Ekkehard
authors.initials: E
authors.lastname: Euler
mesh_terms: D000058:Accidental Falls; D005594:Fracture Fixation, Intramedullary / Q000379:methods; D050815:Fractures, Compression / Q000000981:diagnostic imaging / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011859:Radiography; D016103:Spinal Fractures / Q000000981:diagnostic imaging / Q000601:surgery*; D013249:Sternum / Q000000981:diagnostic imaging / Q000293:injuries* / Q000601:surgery*; D013904:Thoracic Vertebrae / Q000000981:diagnostic imaging / Q000601:surgery*