Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Fracture, Sternum (Closed)


Medical Codes

ICD-9-CM:
807.2 - Fracture, Sternum, Closed

Related Terms

  • Fractured Sternum
  • Sternal Fracture

Overview

A closed fracture of the sternum is a break of the breastbone that occurs without an associated skin injury. The upper and middle thirds of the sternum are the portions most commonly fractured.

The majority of sternum fractures are caused by blunt trauma to the chest. Sternum fractures may occur from compression of the rib cage such as during cardiopulmonary resuscitation. Most sternum fractures are merely a crack, but occasionally violent trauma pushes (displaces) the sternum into the chest cavity. Sternum fractures can also be caused by repeated stress or can occur spontaneously because of bone weakness (stress fracture). Stress fractures of the sternum are uncommon.

Most sternum fractures are caused by motor vehicle accidents (deceleration injuries). The use of seatbelts has led to an increase in the number of sternum fractures, but the severity of other injuries associated with motor vehicle accidents has decreased. Sternum fractures occur more frequently in women than in men, probably due to positioning of the safety belt while driving. Sternum fractures may also be caused by falls, assaults, and direct impact sports.

Incidence and Prevalence: In the US, 60% to 90% of sternum fractures are caused by a motor vehicle accident (Slabinski). About 3% of individuals who sustain blunt trauma to the chest develop sternum fractures (Fisher). Among adult individuals receiving cardiopulmonary resuscitation (CPR), 20% experience sternum fractures (Hoke).

Source: Medical Disability Advisor



Diagnosis

History: Physical examination begins with careful observation for any associated injuries. The chest and ribcage are inspected for any evidence of bruising (ecchymoses), swelling (edema), and asymmetry, which may suggest rib or sternal fracture. The presence of a new or increased hunchback (kyphosis) may suggest sternal fracture.

The physician can usually reproduce pain when the individual’s sternum is felt with the hands (palpated). Palpation does not usually detect sternal displacement or a grating sensation (crepitation) unless the injuries are severe. Approximately 15% to 20% of those with a sternal fracture present with breathing difficulty (dyspnea) (Slabinski). A thorough exam includes listening to the heart and lungs with a stethoscope (auscultation). The presence of irregular heart rhythms or murmurs may suggest cardiac injuries.

Physical exam: The significant majority of those with a sternal fracture present with pain and tenderness when the sternum is felt with the hands (palpated). Palpation may detect sternal displacement and/or a grating sensation (crepitation). Approximately 50% of those with a sternal fracture present with breathing difficulty (dyspnea). The individual may have bruising or swelling (edema) over the sternum. Individuals with an insufficiency fracture usually display an exaggerated hunchback (kyphosis). A thorough exam includes listening to the heart and lungs with a stethoscope and observation and palpation for other chest injuries.

Tests: Chest x-rays usually include posteroanterior, lateral, and sternal views. CT scanning or ultrasonography may be performed, especially if the injuries are more extensive. Electrocardiogram (ECG), cardiac monitoring, pulse oximetry, and blood tests for cardiac enzymes (creatine phosphokinase–MB) may be performed on individuals who sustained a significant blunt force injury.

Source: Medical Disability Advisor



Treatment

A minor sternal fracture is treated with analgesics (nonsteroidal anti-inflammatory drugs and opiates) and activity restrictions for several weeks. Adequate pain relief helps promote sufficient chest expansion during breathing and can help prevent pneumonia. Intercostal nerve blocks may be used for pain control. Stress fractures of the sternum receive the same treatment as a minor sternal fracture.

Treatment of a displaced sternum may require making a small cut (incision) into the chest so that a hook can be used to pull the sternum into the proper position. More severe sternal fractures may require surgical fixation. This may speed the healing process for painful, unstable fractures.

Source: Medical Disability Advisor



Prognosis

Most sternum fractures will heal on their own, but adherence to the treatment recommendations can prevent delays in the recovery process. Although sternum fractures take several weeks to heal and pain may take 6 to 12 weeks to resolve, a complete recovery can be expected. The prognosis is excellent for sternum fractures in the absence of other significant injuries.

Source: Medical Disability Advisor



Differential Diagnosis

Source: Medical Disability Advisor



Specialists

  • Critical Care Surgeon
  • Emergency Medicine Physician
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical Therapist
  • Sports Medicine Physician
  • Thoracic Surgeon

Source: Medical Disability Advisor



Rehabilitation

Before rehabilitation for a fractured sternum can begin, the individual must be assessed for possible involvement of the thoracic spine, and other vital structures in and adjacent to the chest (Collins). The severity of the injury and stability of the sternum and thoracic spine must be assessed, including the integrity of the spinal cord. In the absence of thoracic involvement, physical therapy is indicated in those individuals with a compromised respiratory system, advanced age, or functional limitations associated with postural muscles.

The goal of rehabilitation is to decrease pain, prevent respiratory complications, and restore function. Local application of heat or cold may provide temporary relief of discomfort (Salter), in conjunction with pharmacological treatment. The therapist will instruct patients in deep-breathing exercises to promote full lung expansion, relieve muscle spasm, and mobilize lung secretions. Shoulder and trunk gentle stretching exercises may relieve discomfort, promote chest expansion and functional shoulder mobility, and improve posture when the fracture is stable.

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistFracture, Sternum (Closed)
Physical TherapistUp to 6 visits within 4 weeks
The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Source: Medical Disability Advisor



Comorbid Conditions

Source: Medical Disability Advisor



Complications

Injuries associated with sternal fracture include cardiac contusion (a bruise to the heart), hemothorax (blood in the chest cavity), aortic injury, pulmonary contusion (a bruise to the lungs), pneumothorax, rib fracture, and spinal injuries. However, less than 10% of sternum fractures are associated with spinal fractures, and less than 20% are associated with rib fractures (Perron).

Complications arising from a sternal fracture include osteomyelitis (infection in the bone), abscess, infection in the mediastinum, collapse of all or part of a lung, pneumonia, and nonunion of the fracture.

Source: Medical Disability Advisor



Factors Influencing Duration

The severity of the fracture, presence of complications, and effectiveness of pain management can influence the length of disability. Duration may be longer for individuals whose duties involve heavy and very heavy work.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Overhead lifting, pushing, pulling, and lifting objects that weigh more than 5 pounds should be avoided until the fracture has healed. After the fracture has healed, there should be a gradual return to normal activities. A temporary reassignment of duties may be necessary. Pain medication can affect mental alertness, as well as the ability to operate machinery or drive a motor vehicle.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Did individual present with findings consistent with a sternal fracture (pain, bruising, swelling in the sternum or chest wall)?
  • Was fracture confirmed on x-ray?
  • Were CT scan of the chest, 12-lead ECG, cardiac isoenzymes, and pulse oximetry done to rule out other associated injuries or other conditions?
  • Would individual benefit from consultation with a specialist (orthopedic surgeon, cardiologist, pulmonologist, trauma surgeon, cardiovascular surgeon)?

Regarding treatment:

  • Was treatment appropriate for the type of fracture and associated injuries?
  • Is pain being adequately controlled with analgesics? If not, has an intercostal nerve block been considered?
  • Did individual suffer any associated injuries that may influence length of disability?
  • If so, are associated injuries being addressed in the treatment and rehabilitation plan?
  • Is individual participating in physical therapy?

Regarding prognosis:

  • Has adequate time elapsed for recovery?
  • Does individual have any comorbid conditions, such as cardiac disease, osteoporosis, chronic obstructive pulmonary disease, or bleeding disorders that may affect the ability to recover?
  • What was the expected outcome?
  • Have appropriate work accommodations been made to allow individual to return to work safely?

Source: Medical Disability Advisor



References

Cited

Collins, J. "Chest Wall Trauma." Journal of Thoracic Imaging 15 2 (2000): 112-119. National Center for Biotechnology Information. National Library of Medicine. 2 Mar. 2009 <PMID: 10798630>.

Fisher, David A., and David Gazzaniga. "Sternum, Fractures." eMedicine. Eds. Leon Lenchik, et al. 22 Dec. 2008. Medscape. 29 Oct. 2004 <http://emedicine.medscape.com/article/396211-overview>.

Hoke, R. S., and D. Chamberlain. "Skeletal Chest Injuries Secondary to Cardiopulmonary Resuscitation." Resuscitation 63 3 (2004): 327-328. National Center for Biotechnology Information. National Library of Medicine. 2 Mar. 2009 <PMID: 15582769>.

Perron, A. D. "Chest Pain in Athletes." Clinics in Sports Medicine 22 1 (2003): 37-50. National Center for Biotechnology Information. 1 Jan. 2003. National Library of Medicine. 2 Mar. 2009 <PMD: 12613085>.

Salter, Robert, ed. Textbook of Disorders and Injuries of the Musculoskeletal System. 3rd ed. Philadelphia: Lippincott, Williams & Wilkins, 1999.

Slabinski, Mark, et al. "Sternal Fracutres." eMedicine. Eds. Michelle Ervin, et al. 23 Aug. 2007. Medscape. 2 Mar. 2009 <http://emedicine.medscape.com/article/826169-overview>.

Source: Medical Disability Advisor