Sternal precautions are post-operative guidelines designed to protect the breastbone following open-heart surgery, such as coronary artery bypass grafting or valve replacement. These instructions are mandatory for patients who have undergone a median sternotomy, which involves cutting through the sternum to access the heart. Adhering to these temporary restrictions is a fundamental requirement for a successful recovery and helps ensure the surgical incision and underlying bone heal correctly.
The Purpose of Sternal Precautions
During a median sternotomy, the surgeon divides the breastbone vertically down the center to access the heart. After the procedure, the two halves of the sternum are realigned and secured back together, typically using specialized stainless-steel wires. These wires hold the bone fragments in place while the natural healing process takes over.
Like any fractured bone, the sternum requires time and stability to fuse back together, a process that usually takes about six to eight weeks. Sternal precautions minimize any force, strain, or leverage that could pull on the wires or the healing bone fragments. The primary goal is to prevent sternal dehiscence, the separation of the breastbone halves, which can lead to instability, prolonged pain, and an increased risk of deep wound infection.
Specific Activities to Strictly Avoid
The most immediate precaution involves strict limitations on using the arms for physical effort. Patients must avoid lifting anything heavier than 5 to 10 pounds, roughly the weight of a gallon of milk. This weight restriction applies to all objects, including groceries, pets, and small children, and must be followed for the full duration of the recovery period.
Any movement that involves pushing or pulling with the arms is prohibited, as these actions create significant leverage against the sternum. Patients must not use their arms to push themselves up from a chair or out of bed, or to pull open heavy doors. Specific ranges of motion must also be avoided to prevent undue stress on the chest musculature. Reaching both arms overhead or reaching too far behind the back simultaneously can place tension on the healing sternum. Driving is restricted for several weeks, not only due to the arm movements required for steering but also because the impact of an airbag poses a severe risk to the unprotected breastbone.
Techniques for Safe Daily Movement
While restrictions are placed on arm use, maintaining mobility is important, and specific techniques allow for safe movement.
Getting Out of Bed (Log Roll)
To get out of bed, patients are taught to use the “Log Roll” technique, where the body moves as a single unit without twisting the trunk. This involves rolling onto the side, swinging the legs off the bed, and using the core and leg muscles to push the torso up to a sitting position, keeping the elbows tucked close to the body.
Coughing and Standing
When coughing or sneezing, which generates immense internal pressure, the chest must be splinted to absorb the force. Patients are instructed to firmly hug a small pillow against the sternal incision to provide external support and stabilize the bone. When transitioning from a sitting to a standing position, patients should slide their hips to the edge of the chair, lean forward, and use the strength of their legs to stand up without pushing off the armrests.
Daily Activities
Daily activities like showering and dressing require modification to keep the arms close to the body. Patients can wear shirts that button or zip up the front to avoid overhead dressing, and they should keep their elbows near their sides when washing or combing their hair. The general guideline for all load-bearing movements is “Keep Your Move in the Tube,” which means keeping the hands and elbows within the imaginary cylinder extending from the shoulders to the waist. This simple visualization helps ensure that stress is not placed on the healing sternum.
Recovery Timeline and Recognizing Complications
Sternal precautions are maintained for six to eight weeks following open-heart surgery, the time required for the breastbone to achieve initial bone fusion. The exact duration of the restrictions is determined by the surgeon and can vary based on individual healing factors. Once the bone is stable, the surgeon will provide instructions for a gradual return to normal activities and exercise.
Patients and caregivers must be vigilant for warning signs that indicate the sternum may not be healing properly or that an infection is developing. A mechanical sign is a new clicking, popping, or grinding sensation in the chest, which suggests the bone fragments are rubbing against each other, known as sternal instability. Signs of infection include persistent fever, new or worsening pain at the incision site, or excessive redness, warmth, or drainage from the wound. If a patient experiences any of these symptoms, or if new shortness of breath develops, they must contact their surgical team immediately. Prompt reporting allows for timely intervention to address potential complications like sternal dehiscence or deep sternal wound infection.