An 86-year-old female who lived alone at home arrived in the ED of our hospital and complained of chest pain that worsened with inspiration. She stated that the pain had started after a fall at home. Her medical records revealed a history of mild Alzheimer’s disease and hypertension. A photocopy of a recent ambulance report was found, according to which paramedics had responded to a chest pain call at her apartment the previous day. A rib fracture had been suspected and the patient was advised to seek medical attention in primary health care, but she arrived in the hospital ED instead.
The patient was in no apparent pain or distress. She was able to walk unassisted, although the overall impression suggested frailty. Respiration rate was 17/min, oxygen saturation 97% on room air, pulse 58/min, and blood pressure 156/72 mmHg. Troponin T concentration was within normal limits, and hemoglobin level (13.7 g/dL) was normal. An electrocardiogram (ECG) showed sinus rhythm with a prolonged PR interval (.218 s) and a bifascicular block, which were also present on her previous ECGs and appeared unchanged.
A physical examination revealed local pain in the sternum, but there were no external signs of trauma to the patient’s head, neck, or upper body. The rib cage was stable and nontender. Lung sounds were normal on auscultation. A systolic grade 2 murmur was noted. The cervical, thoracic, and lumbar spine were stable and nontender. No focal neurological deficits were noted.
The patient underwent imaging (Fig. 1), and the initial radiology report of the chest x-ray (CXR) came back as normal. The CXR was reviewed in the ED. On the lateral view (A), a cortical breach in the body of the sternum was noted. There were no signs of newly displaced rib fractures, pneumothorax, or hemothorax. A computed tomography scan of the chest (B) confirmed the diagnosis of an isolated SF. No traumatic damage to major vessels or the heart could be discerned, but the ascending aorta was dilated (45 mm). Cortical thinning and loss of bony trabeculae were present, suggestive of osteopenia.
Upon further questioning, the patient gave a more precise description of the fall. She recalled how she fell forward, trapping her right fist between the floor and her chest. We believe this was an accurate account of the incident, despite the patient’s problems with short-term memory. The MOI is unusual but plausible. The patient denied having had episodes of syncope or transient loss of consciousness, and she did not use alcohol or any drugs that could have contributed to the fall.
Conservative treatment was started for isolated SF. The exact cause of the fall remained obscure, but frailty was interpreted as a risk factor for recurrent falls and fractures in the future. The patient’s relatives were informed, and the patient was discharged with prescriptions for acetaminophen and a vitamin D and calcium supplement. Written instructions were given to book a follow-up appointment with a primary care physician who could perform an osteoporosis workup and a comprehensive geriatric evaluation with the aim of preventing future falls. A cardiology referral was made due to the conduction abnormalities on the ECG, the systolic murmur, and the dilated ascending aorta.