Accessory Sutures Research Articles

Assessing the frequency and variability of accessory zygomatic sutures in dry skulls: clinical insights and potential implications.

This study aimed to determine the presence and incidence of accessory sutures and bipartite zygomatic bone types, and their effects on population affinity and clinical significance. We examined 120 dry skulls and 50 zygomatic bones to evaluate the presence, frequency, and location of accessory zygomatic sutures as well as subtypes of bipartite zygomatic bones. Morphometric analysis included measuring the total width and length of the zygomatic bone with accessory sutures (ASs), the total length of the AS, and the shortest distance between the AS and various anatomical landmarks. Bipartite zygomatic bone was observed in 14 of 120 dry skulls (11.6%) and 1 of 50 zygomatic bones (2%), indicating an overall incidence of 16 occurrences (8.82%). The ASs were predominantly located posterolaterally in 11 cases (six males, five females), anteromedially in two cases (one male, one female), superiorly in one case (male), and superolaterally in one case (male). Significant differences were noted in the distribution of the ASs (p < 0.001). Notably, a vertical inferior bipartite zygomatic type, which has not been reported in the literature, was identified. Correlations were observed between the various anatomical landmarks. Among females, the length of AS was significantly different (p = 0.038). Significant differences were also noted in the shortest distance between the AS and the zygomaticofacial foramen (ZFF) based on the body side (p = 0.034). Our study suggests that the bipartite zygomatic bone is not a common occurrence, indicating its significance as a morphological variation present in certain individuals. The type VII bipartite zygomatic bone exhibited the highest incidence rate, suggesting potential ethnic-specific differences in the prevalence of certain subtypes. The consistent pattern of suture distribution, along with the asymmetry and variability in suture patterns, emphasizes its potential clinical relevance.

Skull Fracture or Accessory Sutures: How Do We Tell the Difference?

Skull Fracture or Accessory Sutures: How Do We Tell the Difference?

Imaging Findings in Pediatric Accessory Cranial Sutures using 3D CT Reconstruction: Fracture or Rudimentary Suture.

Objective:Although accessory sutures are considered to be relatively rare, the consequences of a missed diagnosis are profound. Distinguishing between accessory sutures and cranial fractures can be difficult, especially in cases of suspected non-accidental trauma. High-resolution imaging is the best way to discern between two- and three-dimensional computerized tomography (3D CT) is considered the preferred method for evaluation. The goal of this study was to determine the impact of 3D CT scans in distinguishing between accessory sutures and cranial fractures in suspected child abuse cases in a rural community and the importance of early detection in such cases, as well as call attention to the consequences of initial misinterpretation. Materials and methods:The researchers conducted a retrospective chart review of all pediatric patients diagnosed with cranial fractures (265 in total) at University Medical Center between May 30, 2016, and May 30, 2021. Initial computed tomography (CT) scans and subsequent 3D CT scans were evaluated for each patient that fit the inclusion criteria, 13 in total. Patients were then categorized into two groups based on the final diagnosis on the radiology report: accessory cranial suture or cranial fracture. Once these patients were identified, the etiology and structural components of each were evaluated, and the key differences were highlighted. Results:Our results showed that, of the 11 cases of suspected non-accidental trauma, six were finally diagnosed with accessory sutures with the use of 3D CT scans, and of those six, four were diagnosed with cranial fractures from the initial CT scan report due to a similar presentation and asymmetric nature. Conclusion:Discerning between fracture and accessory suture is essential in evaluating pediatric patients presenting with signs ofcranial fracture due to the increased risk of misinterpretation that can lead to severe legal consequences considering that cranial suture variants may mimic intentional injury and be mistaken for child abuse, causing significant distress for patients and their families.

The Morphometric analysis of accessory sutural bones with an emphasis on association with parietal emissary foramina

Background: The sutural bones and fontanelle of the skull display unique morphological characters. Sutural bones are also called supernumerary bones or ossicles or Wormian bones (WB). These are irregular and develop from the independent ossification centers present along the cranial sutures. They appear on periosteal and endosteal surfaces of the skull with variations in size, number, shape, and location. In the present study, we aimed to determine the morphological characteristics of sutural bones and emphasize the significance of the same. One interesting entity of skull near the posterior fontanelle is the presence of Inca bones. Methods: The present study was done on 128 dry human skulls by a convenient sampling method. The skulls were collected from the Department of Anatomy and significant characteristic features of Inca and Wormian bones like shape, number, size and location were recorded. Results: Of the 128 dry skulls examined Wormian bones were seen in 13.2 % of skulls and Inca bones in 5.4 % of skulls. Incorporation of Wormian bones in lambdoid suture was noted in 12.5 % in sagittal suture in 0.7 % skulls respectively. The Wormian bones were found frequently on the left side (n=12) as compared to the right side (n=5). The morphometry of the accessory bones showed quadrilateral as the most common shape (n=9, 37.5 %) followed by triangular (n=4, 16.6 %). Radiological examination of all 24 skulls with accessory bones showed a zigzag pattern of accessory suture lines. Conclusions: The presence of Wormian and Inca bones can be easily confused with fractures of the related bony regions. The surgeons need to be aware of this fact in order to make a proper and accurate diagnosis. The knowledge regarding these bones is highly beneficial to the clinician, radiologist, and neurosurgeon.

Utility of three-dimensional and reformatted head computed tomography images in the evaluation of pediatric abusive head trauma.

Skull fractures are common in the pediatric population following head trauma and are estimated to occur post head trauma in 11% of children younger than 2years. A skull fracture indicates potential underlying intracranial injury and might also help explain the mechanism of injury. Multiple primary and accessory sutures complicate the identification of non-depressed fractures in children younger than 2years. Detection of linear skull fractures can be difficult on two-dimensional (2-D) CT and can be missed, particularly when the fracture is along the plane of image reconstruction. Knowledge of primary and accessory sutures as well as normal anatomical variants is of paramount importance in identifying pediatric skull fractures with a greater degree of confidence. Acute fractures appear as lucent cortical defects that do not have sclerotic borders, in contrast to sutures, which might demonstrate sclerotic margins. Three-dimensional (3-D) CT has increased sensitivity and specificity for detecting skull fractures and is essential in the evaluation of pediatric head CTs for distinguishing subtle fractures from sutural variants, especially in the setting of trauma. In this review, we present our experience of the use of 3-D reformats in head CT and its implications on the interpretation, especially in the setting of accidental or abusive head trauma.

Accessory Cranial Suture Leading to Abnormal Head Shape

Accessory cranial sutures have been described in the literature and are most commonly associated with the parietal bone. These sutures are typically identified incidentally and there have been no reported cases of accessory cranial sutures leading to abnormal head shape.The authors present the case of a 3-month-old patient with multiple congenital anomalies and an accessory parietal suture leading to abnormal head shape. The patient was successfully treated with cranial orthotic therapy. To our knowledge, this is the first reported case of an accessory cranial suture leading to abnormal head shape.

Skull fractures in abusive head trauma: a single centre experience and review of the literature.

The authors provide a comprehensive framework with which to approach paediatric calvarial injury sustained as a result of suspected abusive head trauma (AHT). This is achieved through the presentation of a case series set in the context of the unique morphology of the infant skull and the possible diagnostic pitfalls which may arise due to the presence of variant anatomy or other mimicking conditions. A retrospective analysis of sixty-three patients referred to our institution with suspected AHT was carried out. Seventeen patients with skull fractures were identified and their fractures were described in terms of anatomical location, type and course. Our data was then interpreted in the light of known anatomical fracture mimics and the available literature on the subject. Forty-two skull fractures were identified and described in our cohort, most of which were simple linear fractures of the parietal bones (33%). There were also a substantial number of complex stellate fractures, namely of the parietal (29%) and occipital (10%) bones. Eleven fracture mimics including accessory sutures and wormian bones were also identified in this cohort. Our study supports and builds on the existing literature, thereby offering a more complete view of the spectrum of calvarial damage sustained as a result of AHT in the context of its diagnostic pitfalls.

Developmental changes in the occipital cranial sutures of children less than 2years of age.

The occipital bone is located on the boundary between the membranous and cartilage bones and contains a wide variety of accessory sutures. In this study, we describe the age distribution of pediatric patients who are less than 2years of age with occipital cranial sutures using a three-dimensional computed tomography (3D-CT). A total of 167 consecutive patients who are less than 2years of age and underwent computed tomography for head trauma were included in this study. Based on the results of this study, various types of sutures were observed among the pediatric participants. In particular, superior median fissures, mendosal sutures, other interparietal segment's accessory sutures, and interparietal sutures were noted in 21%, 35%, 9%, and 6% of the participants, respectively. Additionally, Wormian bones within the lambdoid suture were noted in 32% of the patients. The median age of children with superior median fissure and mendosal suture was 0month. Meanwhile, superior median fissure was not observed among children older than 5months of age. In this population, 13 patients (8%) were found to have skull fracture. Knowledge of the normal cranial anatomy and developmental patterns of cranial sutures is crucial in the evaluation of questionable fractures in the occipital region. A combination of 3D-CT and axial bone window imaging is useful in differentiating normal structures from pathological changes in the cranium.

Biomechanical Comparison of Graft Preparation Techniques for All-Inside Anterior Cruciate Ligament Reconstruction

Background:All-inside anterior cruciate ligament reconstruction (ACLR) is an emerging technique used to treat ACL injuries. The all-inside technique uses a 4-stranded graft made from a single tendon that is looped on itself. The 4 strands of the graft must be secured to each other to become a closed-loop structure. Various suture configurations exist to secure the graft to adjustable loop devices, and there is a lack of data to support one technique over another. In addition to the primary sutures used to fasten the graft together, accessory sutures can be tied over the button as secondary fixation.Purpose:To evaluate biomechanical properties of 4-stranded grafts prepared in 5 different configurations.Study Design:Controlled laboratory study.Methods:Porcine flexor tendons (N = 25) were prepared in 5 different configurations (n = 5 tendons per group): simple-interrupted sutures (unsecured fixation), side-to-side fixation with and without secondary fixation, and end-to-end fixation with and without secondary fixation. The grafts were put through the same mechanical testing protocol (cyclic loading, pull to failure) to measure average load at graft failure, average displacement at failure, average stiffness, and average elongation rate. Differences between graft preparation techniques were investigated using 1-way analyses of variance (ANOVAs) with post hoc t tests (P < .05).Results:Significant 1-way ANOVAs for each biomechanical property were found. Unsecured fixation was the weakest graft preparation with the lowest stiffness (167 ± 12 N/mm), lowest ultimate failure load (637 ± 99 N), and highest elongation rate (0.0033 ± 0.0007 mm/s). End-to-end fixation without secondary fixation showed the highest ultimate failure load (846 ± 26 N), highest stiffness (212 ± 10 N/mm), and lowest rate of elongation (0.0025 ± 0.0001 mm/s). End-to-end fixation, both with and without secondary fixation, as well as side-to-side fixation with secondary fixation showed significantly higher ultimate failure loads than grafts with unsecured fixation. End-to-end fixation performed better than side-to-side fixation; however, for most variables, the difference was not statistically significant. Secondary fixation did not provide significant improvement.Conclusion:The all-inside ACL graft with simple-interrupted sutures is biomechanically inferior to a graft that has its free ends secured to the adjustable tibial loop. Adding secondary fixation to the tibial button does not significantly change the biomechanical properties. Further clinical studies are required to determine whether these findings translate into differences in clinical outcome.Clinical Relevance:All-inside ACLR is gaining popularity in hamstring ACL reconstructive techniques. These results provide surgeons with guidance on the best graft preparation method when using a single quadrupled hamstring tendon graft.

An Aberrant Line on CT Head: The Mendosal Suture.

A knowledge of variant anatomy is important in clinical practice. The skull bones have several normal anatomical variations, especially in the occipital bone. Accessory sutures have been described in newborns and young children.In this study, we discussed radiological findings of an accessory occipital suture in a 14-year-old child who had presented with mastoiditis and brain abscess. We further describe this “mendosal suture,” and its pathophysiology and clinical implications. It is important to bear this entity in mind to avoid misdiagnosing this as a fracture. The use of CT scans and 3D CT using volume rendering technique (VRT) helps in detection and correct diagnosis.

A new anatomic trait for identifying the mendosal suture in young children: the mendosal-lambdoidal angle.

Radiologic diagnosis of skull fractures in young children is difficult due to numerous accessory sutures. This is especially true around the occipital bone because it has more than one ossification center. Normal anatomic variants, such as the mendosal suture, may be misinterpreted as a skull fracture. We investigated the anatomic traits of the mendosal suture in young children. We retrospectively evaluated 52 children, aged between 1month and 4years, who had undergone head computed tomography with three-dimensional reconstructions. We evaluated the presence or absence of the mendosal suture. If present, then we measured the length of the suture and the angle between the lambdoidal and mendosal suture lines. The presence of the mendosal suture was bilateral in 12 children and unilateral in 5 children. The mendosal suture had a mean length of 13.9±3.4mm on the right side and 11.2±4mm on the left side. The angle between the mendosal and lambdoidal sutures had a mean value of 54.2°±11° for the right side and 53.6°±13.9° for the left side. The 95% confidence interval for the mean value of the angle had a lower and upper bounds of 48° and 60° on the right side and 46° and 61° on the left side, respectively. The angle between mendosal and lambdoidal suture lines may help radiologists to identify the mendosal suture.

Acute Posterior Fossa Epidural Hematoma in a Newborn Infant With Menkes Disease

Epidural hematoma (EDH) in newborn infants is rare compared with other types of intracranial hemorrhages. Furthermore, posterior fossa EDH is extremely rare. We present a case of posterior fossa EDH in an infant with Menkes disease with accessory bones in the occiput. A male infant with a condition diagnosed with Menkes disease by prenatal testing was born at 39 weeks via vacuum extraction. The patient presented with a mild tremor at 2 days after delivery. A brain computed tomography (CT) scan showed an acute EDH in the posterior fossa, extending into the occipitoparietal area. Three-dimensional CT and bone window CT scan revealed several accessory bones, diastasis of 1 accessory suture, a communicated fracture, and a linear fracture in the occipital bone. Furthermore, a bone fragment from a communicated fracture displaced toward the inside. The patient was treated conservatively for EDH because of his good general condition. The hematoma gradually resolved, and his tremor did not recur. We suggest the following mechanism of posterior fossa EDH development in our patient: (1) external force was applied to the occiput inside the birth canal during delivery, resulting in diastasis; (2) a communicated fracture occurred, and a bone fragment displaced toward the inside (linear fracture was caused indirectly by the force); (3) a transverse sinus was injured by the fragment; and (4) EDH developed in both the posterior fossa and supratentorial region. Copper deficiency can also cause fragility of connective tissues, vessels, and bones.

Skull fracture vs. accessory sutures: how can we tell the difference?

Plain film radiography remains the most cost effective method in evaluating skull fractures and can easily differentiate major sutures and common vascular grooves from fractures. However, in children this can be complicated due to the presence of numerous synchondroses and unusual accessory sutures. Plain film evaluation is especially challenging not only because of various artifacts that can degrade the study but also the inability to visualize intracranial processes, such as contusions and hemorrhage, that can substantiate a calvarial finding. Minimal soft tissue swelling can be difficult to see even with oblique views. Superimposition of normal suture lines like the metopic suture can mimic a fracture if one is not careful to obtain additional views [1]. During the past decade, the increasing use of spiral and multidetector CT have lead to the ability of workstations to generate three-dimensional (3D) reconstructions of the skull. Therefore if cranial CT is deemed clinically necessary in trauma patients, questionable fractures can be confidently differentiated from unusual accessory sutures using these additional workstation capabilities.

Great Mediastinal Vein Reconstruction Using Autologous Superficial Femoral Vein Superficial Femoral Vein Graft

Great mediastinal veins may be reconstructed using autologous, synthetic, or allograft conduits. Autologous conduits have been found superior to other conduit options. The superficial femoral vein (SFV) offers excellent early patency, minimal lower limb morbidity, and ease of harvest without accessory suture lines. Although rarely used, the SFV provides an acceptable alternative for conduit in large vein reconstructions. Two recent cases using SFV for great mediastinal vein reconstruction were reviewed and operative technique of vein harvest detailed. This is the first report of successful reconstruction of a left superior vena cava using SFV conduit. Both superior vena cava (SVC) reconstructions reported were perfectly patent at intermediate term follow-up (20 and 14 months) as determined by computed tomography angiogram or magnetic resonance imaging. Successful and durable reconstruction of the SVC or a persistent left subclavian vein is possible with minimal morbidity using the SFV.

The mendosal suture of the occipital bone: occurrence in Indian population, embryology and clinical significance

The occipital bone is ontogenetically and functionally unique when compared to the other bones of the skull in humans and other mammalian cousins. The occipital bone develops from six ossification centers; any defect in the ossification process will give rise to mendosal suture (accessory suture) and conditions like posterior plagiocephaly. There is a paucity of literature regarding the mendosal suture and further more, its report in Indian population is not known. The present study was conducted to find out the occurrence of mendosal suture in the Indian dry skulls. Fifteen specimens (3%) were found to have these sutures out of five hundred (500) skulls examined. Nine (3.1%) samples are of male skulls out of two hundred ninety (290) and six (2.85%) samples are that of female skulls out of two hundred ten (210). The mendosal suture ran close to the superior nuchal line in all specimens and traveled medially from the lambdoidal suture. The length of the sutures ranged from 0.8 cm to 2.6 cm (1.88 cm) on the right side and 1.4 cm to 2.9 cm (1.94 cm) on the left side respectively in male skulls; and 0.7 cm to 2.8 cm (1.55 cm) on the right side and 1 cm to 2.4 cm (1.42 cm) on the left side, respectively, in female skulls. The origin of mendosal suture from the lambdoidal suture was 5.7 cm to -6.3 cm (5.98 cm) from the tip of the mastoid process on the right side and 5.6 to -6.3 cm (6 cm) on the left side, respectively, in male skulls; and 5.4 cm to -5.8 cm (5.58 cm) on the right side and 5.4 cm to -5.6 cm on the left side respectively in female skulls. The occurrence and clinical significance of the present study is discussed.

A reappraisal of the dinoflagellate cyst genus Montanarocysta

The dinocyst genus Montanarocysta Corradini is emended, based on re-examination of the holotype, the paratype and well-preserved specimens of the type species, Montanarocysta aemiliana Corradini. This re-examination shows that M. aemiliana has a sexiform gonyaulacacean tabulation incompletely delineated by processes and septa, a large untabulated ventral area, an apical archeopyle type (tA)a with well-developed precingular accessory sutures, and a simple adnate operculum attached to the sulcal as and precingular plates 1ʺ and 6ʺ. Maghrebinia chleuh Below and Maghrebinia mirabilis (Below) Masure are here transferred to Montanarocysta, since they have closely similar morphology to M. aemiliana. Previously Atopodinium Drugg has been considered as taxonomic senior synonym of Maghrebinia Below and Bejuia Stover Williams, and the species in these two genera have been transferred to Atopodinium. From the present analyses, Atopodinium is separated from Montanarocysta on the ornamentation: Atopodinium has a more subdued ornamentation, consisting of ridges, folds, grana and gemmae; whereas Montanarocysta is characterised by processes and septa. Maghrebinia is herein retained as separate genus, which has a ceratocoryacean tabulation and contains the single species Maghrebinia perforata Below.

A review of the Jurassic dinocyst generaCtenidodiniumDeflandre 1938 andDichadogonyaulaxSarjeant 1966

Abstract The historical development of the study of the Jurassic dinocyst (dinoflagellate cyst) genera Ctenidodinium Deflandre 1938 and Dichadogonyaulax Sarjeant 1966 is outlined, and various aspects of their paratabulation and archaeopyle structure are discussed. The gonyaulacoid paratabulation is topologically constant, with the exception of the insertion of two small anterior intercalary paraplates and/or several pre‐apical paraplates in some species. This is true despite geometric changes to individual paraplates, particularly on the ventral area of the hypocyst and on the hypo‐cyst in general. The mode of excystment consists of a principal archaeopyle suture which runs along a line immediately anterior to the paracingulum, the operculum (the complete epicyst) remaining attached at the parasulcus, with no accessory archaeopyle sutures occurring. The generic concepts of Ctenidodinium and Dichadogonyaulax are emended, and two new genera, Bradleyella gen. nov. and Korystocysta gen. nov. are proposed. Eac...

Book reviewsAtlas of the Battered Child Syndrome. By CameronJ. M. and RayL. J., pp. ix+90, illus. in colour, 1975, £8·50.

This book achieves its stated aim to help in distinguishing accidental injury from the injuries found in the battered child on clinical and X-ray examination. While the early part of the book does not give great prominence to the important role played by radiologists, notably John Caffey, in the description and identification of this condition, this is more than compensated by the excellent section on radiographic findings and differential diagnosis, which accounts for just over half the total subject- matter in the book. The fact that skull injuries on their own are usually not enough to confirm a suspicion of battering is noted, and also the appearances of some of the accessory sutures which may be confused with vault fractures are described.

Transapical sutures in dinoflagellate cysts

Abstract Several lacustrine species of Pleistocene and Recent peridiniacean cysts form archeopyles by means of a single transapical suture, with or without accessory sutures. Previously published records of closely similar structures in marine Cretaceous peridiniacean cysts are documented and reinterpreted, and a further type is described from the Albian of Oklahoma. These bipesioid cysts appear to represent a lineage that diverged from the marine peridiniacean stock in the Early Cretaceous and invaded freshwater environments during the Tertiary, completely abandoning marine environments by the Quaternary.

The midline occipital fissure: diagnosis of fracture versus anatomic variants.

ROENTGEN DIAGNOSIS of skull fracture in the child is complicated by the numerous accessory sutures which may be present. Previous authors (2–4) have documented many normal variations simulating fracture about the foramen magnum, an area unusually rich in accessory sutures and ossicles. Recently, several cases have come to my attention in which a midline occipital fissure extending to the foramen magnum was seen on roentgenograms taken for head trauma. Because of lack of information in the literature on the differentiation of fracture versus suture in these patients, the present study was initiated. A brief review of the pertinent embryology of the occipital bone (1, 3) shows that six ossification centers are present (Fig. 1). The interparietal bone is of membranous origin with the remainder preformed in cartilage. Augier (1) established that the supraoccipital bone forms from a single center, which is arranged around the dorsal surface of the original foramen magnum, the occipital fissure. The occipital fissure closes in a complicated fashion, with descent of a median process (Kerkring's process) and apposition of the lateral margins of the fissure. Anomalous sutures are found in the infant corresponding to this area, but they should extend no further dorsally than the original occipital fissure (1 to 2 em). The embryological evidence would not predict a fissure extending the entire length of the supraoccipital bone. In evaluation of approximately 900 skull roentgenograms, several midline occipital fissures were encountered, but in none of these was there any serious difficulty of ascertaining their nontraumatic nature. Several patients, one of whom is illustrated, exhibited a tripartite defect of the posterior lip of the foramen magnum (Fig. 2). This could be explained embryologically by failure of appositional growth of the lateral borders of the occipital fissure combined with lack of fusion of the innominate sutures (between the supraoccipital and exoccipitals) bilaterally. One case of a “keyhole” foramen magnum was seen (Fig. 3). This unusual variation was noted in an infant with oxycephaly and could be considered due to lack of downward migration of the Kerkring process. Examination of the skull in a cretin revealed the persistence of Kerkring process (Fig. 4). No cases of a midline occipital fissure (median cerebellar suture) resembling fracture were seen. One patient with cleidocranial dysostosis did show a midline fissure of the interparietal bone associated with deficient ossification elsewhere (Fig. 5). During this same period 2 patients with midline occipital fracture were encountered, and search of previous material revealed an additional case (Figs. 6–8). All 3 showed midline fissures extending from the foramen magnum dorsally beyond the superior margin of the supraoccipital bone.