Morphometric analysis of variation in the sternum with sex and age

Age and sex‐related variations in sternum morphology may affect the thoracic injury tolerance. Male and female sternum size and shape variation was characterized for ages 0–100 from landmarks collected from 330 computed tomography scans. Homologous landmarks were analyzed using Procrustes superimposition to produce age and sex‐specific functions of 3D‐sternum morphology representing the combined size and shape variation and the isolated shape variation. Significant changes in the combined size and shape variation and isolated shape variation of the sternum were found to occur with age in both sexes. Sternal size increased from birth through age 30 and retained a similar size for ages 30–100. The manubrium expanded laterally from birth through age 30, becoming wider in relation to the sternal body. In infancy, the manubrium was 1.1–1.2 times the width of the sternal body and this width ratio increased to 1.6–1.8 for adults. The manubrium transformed from a circular shape in infancy to an oval shape in early childhood. The distal sternal body became wider in relation to the proximal sternal body from birth through age 30 and retained this characteristic throughout adulthood. The most dramatic changes in sternum morphology occur in childhood and young adulthood when the sternum is undergoing ossification. The lesser degree of ossification in the pediatric sternum may be partly responsible for the prevalence of thoracic organ injuries as opposed to thoracic skeletal injuries in pediatrics. Sternum fractures make up a larger portion of thoracic injury patterns in adults with fully ossified sternums. The lack of substantial size or shape changes in the sternum from age 30–100 suggests that the increased incidence of sternal fracture seen in the elderly may be due to cortical thickness or bone mineral density changes in the sternum as opposed to morphological changes. J. Morphol. 275:1284–1299, 2014. © 2014 Wiley Periodicals, Inc.     

由胸骨长度估算中国北方成年人身高的回归方程

调查了中国北方28具(男15、女13)汉族成年人尸体身高、胸骨全长、胸骨柄长和胸骨体长的均值,并计算了胸骨的长度与身高的相关系数。除男性胸骨全长高度相关外,其余皆为中度相关。由胸骨全长推算身高的回归方程式,较由胸骨柄长和胸骨体长推算身高的回归方程式,有较高的相关系数和较低的标准估计误差。由胸骨体长推算也较由胸骨柄长推算为佳。     

In-vivo analysis of sternal angle,sternal and sternocostal kinematics in supine humans during breathing

This paper aims at contributing to the understanding of the combination of in vivo sternum displacement, sternal angle variations and sternocostal joints (SCJ) kinematics of the seven first rib pairs over the inspiratory capacity (IC). Retrospective codified spiral-CT data obtained at total lung capacity (TLC), middle of inspiratory capacity (MIC) and at functional residual capacity (FRC) were used to compute kinematic parameters of the bones and joints of interest in a sample of 12 asymptomatic subjects. 3D models of rib, thoracic vertebra, manubrium and sternum were processed to determine anatomical landmarks (ALs) on each bone. These ALs were used to create local coordinate system and compute spatial transformation of ribs and manubrium relative to sternum, and sternum relative to thoracic vertebra. The rib angular displacements and associated orientation of rotation axes and joint pivot points (JPP), the sternal angle variations and the associated displacement of the sternum relative to vertebra were computed between each breathing pose at the three lung volumes. Results can be summarized as following: (1) sternum cephalic displacement ranged between 17.8 and 19.2 mm over the IC; (2) the sternal angle showed a mean variation of 4.4° ± 2.7° over the IC; (3) ranges of rib rotation relative to sternum decreased gradually with increasing rib level; (4) axes of rotation were similarly oriented at each SCJ; (5) JPP spatial displacements showed less variations at first SCJ compared to levels underneath; (6) linear relation was demonstrated between SCJ ROMs and sternum cephalic displacement over the IC.     

Sexing the human sternum

For differentiating a male from a female sternum, a metrical study of 400 adult North Indian sterna (312 males and 88 females) obtained from medicolegal postmortems was made. If the combined length of the manubrium and mesosternum was more than 140 mm. the sternum was male, and if less than 131 mm. it was female. No opinion could be given if the length was between 131 and 140 mm. By this measurement 72.12% male and 62.50% female sterna could be sexed with 100% accuracy. The length of the mesosternum alone could also determine the sex correctly in 50.32% male and 29.55% female specimens. The length of the manubrium, manubrium–corpus index, width of the first or third sternebra or their index, were not found to be useful in sexing a given sternum. By using multivariate analysis the probability of correctly identifying the sex of a sternum was over 85%.     

Clinical morphology of the sternum]

The length, width and thickness of the sternum were measured in 74 adult specimens with the aim of optimizing the dimensions of staples used after sternotomy. This article describes the experimental procedure and presents the results. Sex differences were confined mainly to the length, with males measuring 16.5 cm, and females 15 cm. Width and thickness maxima (7.4 cm and 1.7 cm, respectively) are measured at the proximal and distal ends of the manubrium, while the width and thickness of the corpus (2.7-3.5 cm and 1.0-1.4 cm, respectively) show relatively minor differences.     

Configuration and localization of the nipple-areola complex in men.

The causes of bilateral absence of the nipple-areola complex in men are seldom congenital, but attributable rather to destruction as a result of trauma, or after mastectomy in female-to-male transsexuals and in male breast cancer, or after the correction of extreme bilateral gynecomastia. Such a bilateral loss becomes a major reconstructive challenge with respect to the configuration and localization of a new nipple-areola complex. Because there is very little information available in the literature, we carried out a cross-sectional study on the configuration and localization of the nipple-areola complex in men.A total of 100 healthy men aged 20 to 36 years were examined under standardized conditions. The first part of the study dealt with the configuration of the nipple-areola complex (dimensions, round or oval shape). The second part concentrated on the localization of the complex on the thoracic wall with respect to anatomic landmarks and in correlation to various parameters such as weight and height of the body, circumference of the thorax, length of sternum, and position in the intercostal space.Of the 100 subjects examined, 91 had oval and seven had a round nipple-areola complex. An asymmetry between the right and the left side was found in two cases. The mean ratio of the horizontal/vertical diameter of an oval nipple-areola complex was 27:20 mm and the mean diameter for a round nipple-areola complex was 23 mm. The center of the nipple-areola complex was in the fourth intercostal space in 75 percent and in the fifth intercostal space in 23 percent of the subjects. To localize the nipple-areola complex on the thoracic wall de novo, at least two reproducible measurements proved to be necessary, composed of a horizontal line (distance from the midsternal line to the nipple = A) and a vertical line (distance from the sternal notch to the intersection of line A, = B). The closest correlation for the horizontal distance A was given by the circumference of the thorax: A = 2.4 cm + [0.09 x circumference of thorax (cm)], (r = 0.68). The best correlation to calculate the vertical distance B was found using the distance A and the length of the sternum: B = 1.2 cm + [0.28 x length of sternum (cm)] + [0.1 x circumference of thorax (cm)], (R = 0.50).In cases of bilateral absence, we recommend creating an oval nipple-areola complex in men. The appropriate localization can be calculated by means of two simple equations derived from the circumference of the thorax and the length of the sternum.     

Real mineral density of the sternum

Mineral density of the sternum is insufficiently known. The aim of this research was to investigate mineralisation of the sternum and collect normative data on mineral density of the standard male and female sternum in elderly people (average age of female samples was 64 and male's was 62 years). The research was conducted on 93 cadaveric sternums, 56 male and 37 female samples. To determine regional mineral density of the sternum each sample was cut into six bony segments (Figure 1). Mineral density of every segment was determined using the method of ashing. Male sternums were on average denser than female ones in all segments. Average mineral density of the manubrium in women was 0.169 g/cm3 and 0.220 g/cm3 in men. Average mineral density of the body of the sternum also showed existence of sex difference; it was 0.160 g/cm3 in women and 0.227 g/cm3 in men. Both male and female sternums showed identical mineral density distribution. Mineral density of the manubrium and the body was roughly equal, while the analysis of longitudinal segments showed that the central part of both the manubrium and the body of the sternum was denser than lateral parts. Complex determination of the real mineral density for defined segments of the sternum and analysis of the obtained results were used to create the map of mineral density of the sternum in men and women (Figure 2). Maximum density values were four times greater than minimum density values for analysed samples. These data showed that osteoporosis also occurs on the sternum. Loss of structure and lower mineral density decrease the sternum quality and increase the risk of sternal dehiscence after median sternotomy.     

Respiratory muscle activity measured with a noninvasive EMG technique: technical aspects and reproducibility.

A new method is being developed to investigate airway obstruction in young children by means of noninvasive electromyography (EMG) of diaphragmatic and intercostal muscles. The purpose of this study was to evaluate the reproducibility of the EMG measurements. Eleven adults, 39 school children (20 healthy, 19 asthmatic), and 16 preschool children were studied during tidal breathing on separate occasions: two for adults with a time interval of 3 wk and three for children with time intervals of 1 and 24 h. Single electrodes were placed on the second intercostal space left and right of the sternum and at the height of the frontal and the dorsal diaphragm. Bipolar electrode pairs were placed on the rectus abdominis muscle. A newly designed digital physiological amplifier without any analog filtering was used to measure the EMG signals. Except for the average dorsal diaphragm EMG derivation in healthy school children on the second occasion, a significant correlation between the mean peak-to-peak inspiratory activity of average diaphragmatic and intercostal EMG was found in the different age groups on the different measurement occasions (P < 0.05). To assess the repeatability, we described the agreement between the repeated measurements within the same subjects. No significant differences were found between the measurements on the separate occasions. Our observations indicate that the EMG signals derived from the diaphragm and intercostal muscles are, in different age groups with and without asthma, reproducible during tidal breathing.     

Internal mammary vessels as a model for power Doppler imaging of recipient vessels in microsurgery.

The aim of this interdisciplinary study was to evaluate power Doppler imaging as a method of collecting reliable preoperative data concerning the diameters and topography of exemplary internal mammary vessels as recipient vessels in reconstructive microsurgery. Thirteen female patients (range, 37 to 58 years; mean, 45.6 years) were examined preoperatively with power Doppler imaging from the first to the fifth intercostal space parasternally and bilaterally. These data are compared with measurements obtained intraoperatively in each individual. Mean velocity in the artery in the second intercostal space on the right side is 47.11 cm/sec (range, 15 to 90 cm/sec) and on the left side is 42.25 cm/sec (range, 18 to 95 cm/sec). Mean velocity in the vein in the second intercostal space on the right side is 17.80 cm/sec (range, 10 to 30 cm/sec) and on the left side is 13.06 cm/sec (range, 5.3 to 32 cm/sec). The topographic results are in close agreement with intraoperative measurements and previous anatomical studies. Sonographic preoperative data of arteries (mean, 1.88 mm) show slightly smaller diameters than intraoperative measurements (mean, 2.08 mm), whereas veins show slightly larger diameters in sonography (mean, 2.33 mm) than intraoperatively (mean, 2.12 mm). Mean sonographic diameter of artery ranges from 2.14 mm (second intercostal space) to 1.46 mm (fifth intercostal space), of the vein from 2.76 (second intercostal space) to 1.25 mm (fifth intercostal space). In one case, a vein was not detectable. This noninvasive method leads to confirmation of the preoperative choice of the optimal recipient vessels for free tissue transfer and does not harm the patient.     

Relationship between parasternal intercostal length and rib cage displacement in dogs

The relationship between parasternal intercostal length and rib cage cross-sectional area was examined in nine supine dogs during passive inflation and during quiet breathing before and after phrenicotomy. Parasternal intercostal length (PSL) was measured with a sonomicrometry technique, and rib cage cross-sectional area (Arc) was measured with a Respitrace coil placed around the middle rib cage. During active inspiration as well as during passive inflation, PSL decreased as Arc increased. However, the relationship between PSL and Arc during active inspiration, whether in the intact or phrenicotomized animal, was almost invariably different from that during passive inflation, so that the same increase in Arc was associated with a greater decrease in PSL in the former than in the latter instance. This difference between passive inflation and active inspiration is probably due to the active contraction of the parasternals during inspiration and the consequent caudal displacement of the sternum. In upright humans, the sternum moves cephalad and not caudad during inspiration, so the relationship between PSL and Arc during active breathing might be similar to that during passive inflation.     

Dacron fabric-enveloped hydroxyapatite prosthesis for sternal tumor defect: an autopsy report

A 38-year-old housewife with solitary plasmacytoma of the manubrium who underwent a subtotal sternectomy treated by resection of the lesion is reported. This was followed by replacement with a Dacron fabric-enveloped hydroxyapatite prosthesis. The Dacron fabric was sutured to the surrounding tissues, and then the clavicle was passed through the cylindrical-shaped Dacron fabric to form a sternoclavicular joint capsule. The patient returned to her daily life 3 months after the operation. She had no trouble in her daily living, without any dislocation of the sternoclavicular joints or any displacement of the artificial sternum. The autopsy examination about 1 year after the operation showed that the Dacron fabric enveloping the artificial sternum became stronger with time. The sternoclavicular joint also was stably fixed, and the Dacron fabric fulfilled its function as an artificial articular capsule and biologic fixation of the surrounding supporting tissues.     

Intercostal muscle action inferred from finite-element analysis

The external and internal intercostal muscles are important respiratory muscles in humans, but their mechanical actions have been controversial. We used finite-element analysis based on anatomic and mechanical measurements in dogs to assess the action of the intercostal and other rib cage muscles in a model of an isolated canine rib cage. When intercostal muscle forces of either the internal or the external layer were applied in a single interspace, they pulled the adjacent ribs together, consistent with published observations in dogs. However, when the forces were applied in all interspaces, the external layer caused an inspiratory motion and the internal layer caused an expiratory motion, consistent with conventional understanding of intercostal muscle actions. Parasternal intercostal, levator costae, and transversus thoracis (triangularis sterni) muscle actions were also simulated. These muscles caused expected movements of the ribs and sternum. We conclude that the actions of intercostal muscles depend on the spatial extent of their activation. Their actions in a single interspace and in multiple interspaces can be observed and explained with three-dimensional finite-element models.     

Transitional forms of the cervical and first ribs]

The upper ribs possessing the signs of both cervical and first ribs (such as the size, conjunction with the sternum, dilatation of the superior intercostal spaces, double width and others) are the intermediate forms. Small dimension fluorography of 400.000 humans with roentgenographical control has revealed 468 persons with transitional forms of cervical and first ribs (0,12%), i. e. one case per 800 humans at an average. Transitional forms of cervical and first ribs can be grouped as follows: asymmetry of clavicles, asymmetry of the upper ribs, close position of the upper ribs, double width of the first ribs, conjunction of the cervical and first ribs at the vertebrum.     

Mechanics of the parasternal intercostals during occluded breaths in dogs

The electrical activity and the respiratory changes in length of the third parasternal intercostal muscle were measured during single-breath airway occlusion in 12 anesthetized, spontaneously breathing dogs in the supine posture. During occluded breaths in the intact animal, the parasternal intercostal was electrically active and shortened while pleural pressure fell. In contrast, after section of the third intercostal nerve at the chondrocostal junction and abolition of parasternal electrical activity, the muscle always lengthened. This inspiratory muscle lengthening must be related to the fall in pleural pressure; it was, however, approximately 50% less than the amount of muscle lengthening produced, for the same fall in pleural pressure, by isolated stimulation of the phrenic nerves. These results indicate that 1) the parasternal inspiratory shortening that occurs during occluded breaths in the dog results primarily from the muscle inspiratory contraction per se, and 2) other muscles of the rib cage, however, contribute to this parasternal shortening by acting on the ribs or the sternum. The present studies also demonstrate the important fact that the parasternal inspiratory contraction in the dog is really agonistic in nature.     

Pleural space thickness in situ by light microscopy in five mammalian species

The thickness of the pleural space was measured by a focusing method using a light microscope (X157, 2.5-micron depth of focus). In anesthetized animals, thin transparent parietal pleural windows were made by dissection of intercostal muscle. Multiple postmortem measurements were made of the combined thickness of the pleural space and the window by focusing in sequence on the lung surface and on 1- to 2-micron tantulum particles sprayed on the window. The window thickness was measured after creating a pneumothorax and retracting the lungs. In supine rabbits the pleural space measured at various heights on the costal surface was of uniform thickness (16 micron) except for a thicker region (62 micron) located within 3 mm of the most dependent part of the lung. The thicker region reverted to the uniform thickness after it was placed in a nondependent position by inverting the animal from the supine to prone position, indicating fluid drainage by gravity. In the prone position near midchest, pleural space thickness (t) averaged 6.9 micron in the mouse, 10.2 in the rat, 17.2 in the rabbit, 18.3 in the cat, and 23.6 in the dog. Animals of larger body mass (M, kg) had a wider pleural space: t = 13.1 X M0.20. There was no contact between the two pleurae, indicating that fluid lubrication facilitates sliding between the lung and chest wall. Based on the t vs. M relationship and estimates of the viscous flow of pleural liquid, pleural fluid exchange rate would be proportional to body mass and the work of sliding as a fraction of the work of breathing would be smaller in larger animals.     

Internal fixation of the sternum in median sternotomy dehiscence.

Sternal dehiscence may be defined as separation of the bony sternum and manubrium following median sternotomy. It may occur at any time postoperatively and has various etiologies. Restoration of sternal integrity in sternal dehiscence is a challenging problem, particularly when associated with deep-seated infection. This report reviews a single-stage technique that virtually eliminates the infected sternotomy wound and provides anatomic reduction and stabilization of the sternum. Complete debridement of infected and/or nonviable soft tissue, bone, and cartilage is followed by pulse irrigation. Parallel stainless steel mandibular reconstruction plates are then placed on each side of the remaining sternum and wired together. One or more transmanubrial compression plates may be added. Bilateral pectoralis major musculocutaneous flap advancement and primary skin closure is performed over two to three closed suction drains. From January of 1994 to July of 1996, this technique was used by the same surgeon in 26 male and 4 female patients aged 43 to 78 years (mean = 61). Indications for the operation were sternal dehiscence with infection (osteomyelitis and/or mediastinitis) in 14 patients and sternal dehiscence without infection in 16 patients. All patients survived to discharge with mean time on the ventilator, intensive care unit length of stay, and postoperative length of stay of 0.7, 2, and 8 days, respectively. Choice and duration of antibiotics were based on culture results and operative findings. Subsequent hardware removal was necessary in one patient for hardware loosening and three patients for late periplate infection. A closed wound was eventually achieved in all 30 patients, and sternal stability was restored in 29 patients. In the management of sternal dehiscence, the described technique of internal fixation can provide anatomic sternal reduction and stabilization, elimination of infection, and wound closure in a single-stage operation. Successful outcomes were achieved despite the presence of severe infection.     

Identifying a reliable blubber measurement site to assess body condition in a marine mammal with topographically variable blubber,the Pacific walrus

Pacific walruses may be unable to meet caloric requirements in the changing Arctic ecosystem, which could affect body condition and have population‐level consequences. Body condition has historically been monitored by measuring blubber thickness over the xiphoid process (sternum). This may be an unreliable condition index because blubber at other sites along the body may be preferentially targeted to balance energetic demands. Animals in aquaria provided an opportunity for controlled study of how blubber topography is altered by caloric intake. Morphology, body mass, blubber thickness (21 sites), and caloric intake of five mature, nonpregnant, nonlactating female walruses were measured monthly (12 month minimum). Body condition (mass × standard length^?1) was described by a model that included caloric intake and a seasonal effect, and scaled positively with estimates of total blubber mass. Blubber thicknesses (1.91–10.69 cm) varied topographically and were similar to values reported for free‐ranging female walruses. Body condition was most closely related to blubber thickness measured dorsomedially in the region of the anterior insertion of the pectoral flippers (shoulders); sternum blubber thickness was a relatively poor indicator of condition. This study demonstrates the importance of validating condition metrics before using them to monitor free‐ranging populations.     

Effect of diaphragmatic contraction on the action of the canine parasternal intercostals.

The inspiratory intercostal muscles enhance the force generated by the diaphragm during lung expansion. However, whether the diaphragm also alters the force developed by the inspiratory intercostals is unknown. Two experiments were performed in dogs to answer the question. In the first experiment, external, cranially oriented forces were applied to the different rib pairs to assess the effect of diaphragmatic contraction on the coupling between the ribs and the lung. The fall in airway opening pressure (deltaPa(O)) produced by a given force on the ribs was invariably greater during phrenic nerve stimulation than with the diaphragm relaxed. The cranial rib displacement (Xr), however, was 40-50% smaller, thus indicating that the increase in deltaPa(O) was exclusively the result of the increase in diaphragmatic elastance. In the second experiment, the parasternal intercostal muscle in the fourth interspace was selectively activated, and the effects of diaphragmatic contraction on the deltaPa(O) and Xr caused by parasternal activation were compared with those observed during the application of external loads on the ribs. Stimulating the phrenic nerves increased the deltaPa(O) and reduced the Xr produced by the parasternal intercostal, and the magnitudes of the changes were identical to those observed during external rib loading. It is concluded, therefore, that the diaphragm has no significant synergistic or antagonistic effect on the force developed by the parasternal intercostals during breathing. This lack of effect is probably related to the constraint imposed on intercostal muscle length by the ribs and sternum.