Ultrasound-guided percutaneous cryoneurolysis for management of acute sternal fracture pain

Abstract

Background: Establishing adequate analgesia for rib and sternal fractures remains a challenge due to the prolonged nature of the associated pain. Historically, cryoneurolysis has demonstrated beneficial in treating chronic pain, and the recent development of hand-held devices has allowed its functionality to expand into the management of acute pain.

Case: We present a polytrauma patient with sternal and multiple rib fractures that underwent ultrasound-guided intercostal cryoneurolysis at bedside, resulting in significant analgesia lasting several weeks and improving mobilization. This is the first report of the utilization of cryoneurolysis to treat acute sternal fracture pain.

Conclusion: The most common sternal fracture pattern is transverse which only requires treatment of four intercostal nerves, making cryoneurolysis feasible in trauma centers. This portable, minimally invasive, and low risk technique has the added benefits of reducing opioid requirements, decreasing length of hospital stay, and improving mobility in polytrauma patients.

Keywords: Acute pain; Cryoneurolysis; Intercostal nerve; Persistent pain; Sternal fracture; Trauma.

Fig. 1

Ultrasound image of sternal fracture. Fracture sonography demonstrating a mid-body sternal fracture. The orientation indicator is cranial. The fracture site appears as a contour defect in the cortical bone of the sternal body. The upper body of the sternum is displaced posteriorly.

Fig. 2

CT chest of sternal fracture. CT imaging demonstrating our patient's transverse sternal body fracture with anterior-posterior displacement.

Fig. 3

Ultrasound image of superficial parasternal intercostal catheter. The orientation indicator is caudal. The ultrasound probe is held over the 4th parasternal cartilage in a sagittal orientation. The catheter is visualized in-plane going through the subcutaneous tissue, pectoralis major muscle, 4th costal cartilage with the tip lying between the pectoralis major muscle and the intercostal muscles.

Fig. 4

Ultrasound image of intercostal cryoneurolysis. The orientation marker is caudal. The shadow created by the probe needle can be seen in-plane approaching the caudal end of the 4th rib, which is seen in the center of the ultrasound.