Sternal Research Articles

CPR related injuries of the chest wall: direct and indirect fractures

BackgroundRib and sternum fractures are common injuries associated with cardiopulmonary resuscitation (CPR). The fracture mechanism is either direct by application of force on sternum and anterior ribs or indirect by bending through compression of the thorax. The aim of this study was to determine morphologies of rib fractures after CPR and to reevaluate prior findings on fracture localisation, type and degree of dislocation.MethodsThe present study was based on all inpatients treated for chest wall fractures after non traumatic cardiac arrest at a Level 1 Trauma Centre from 2010 to 2016 who had received CT scans. Each fracture was analyzed for location, degree of dislocation and fracture type classified according to AO/OTA and CWIS. We also analysed Fracture Line orientation.ResultsWe enrolled 40 patients with a total of 423 rib fractures. We found most fractures anterolaterally between the 3rd to 6th rib symmetrically on both sides of the thorax. We found sternum fractures in 30% of the patients, 50% being located at the at the corpus sterni between rib 3 and 4. All patients with sternum fractures suffered from rib fractures and most had fractures of the cartilage or osteochondral junction. All cartilage fractures were straight, undisplaced type A fractures. Most indirect fractures occurred anterolaterally between 50 and 60° in the axial plane. More than 90% of those fractures were classified as type A, 70% showed a straight fracture line and 60% were undisplaced. There was no difference in degree of dislocation between straight and oblique fracture lines. We found 143 incomplete fractures.ConclusionWe confirmed prior findings regarding fracture patterns in CPR related injuries. We observed approximately 2–3 times as many straight-lined fractures as oblique ones following indirect trauma. One third of all fractures are incomplete, these highlights the special characteristics like high elasticity of ribs.

Utility of surface landmark technique in providing optimal intratracheal endotracheal tube placement during orotracheal intubation

Abstract Background and Aims: Optimal endotracheal tube (ETT) placement in patients with short tracheas by the existing techniques is challenging because of the fixed intratracheal ETT length of insertion. However, in the surface landmark technique (SLT), the individual’s tracheal length (distance between mid-thyroid and manubrium–sternum) was estimated and 3 cm was deducted from it to obtain the desired intratracheal ETT length of insertion. Being a new technique, its reliability in providing optimal placement is yet to be evaluated. Hence, to assess the utility and reliability of SLT in achieving optimal placement, this study was planned. Material and Methods: In this prospective study, 406 participants were equally randomized between SLT and intubation guide mark (IGM) groups for ETT placement. In both groups, ETT tip–carina distance (DTC) was measured to assess optimal placements. The placements were compared by paired t-test. The receiver operating characteristic (ROC) curve analysis was used to assess optimal ETT placement between techniques. Results: The mean DTC in the SLT (3.52 ± 0.68 cm) group was significantly higher than in the IGM (2.23 ± 1.01 cm) group, with P < 0.0001. Consequently, optimal placements were significantly higher in the SLT group (190 [95%]) compared to the IGM (121 [60.5%]) group (P < 0.0001). On ROC, at a cut-off value for DTC of 1.5 cm, the observed area under the curve to assess optimal ETT placements was significantly better in SLT (0.997, 95% confidence interval [CI] 0.997–1.000) compared to IGM (0.968, 95% CI 0.933–0.988), with P < 0.0001. Conclusion: Based on the measurement of an individual’s tracheal length, SLT is a reliable and useful technique to achieve optimal tube placement.

Open sternal fracture with bilateral dislocation of the sternoclavicular joints after a high-speed bicycle accident: a case report

BackgroundOnly a few cases of bilateral traumatic sternoclavicular dislocations have been reported in the literature. This injury is considered one of the rarest injuries of the human musculoskeletal system. Therefore, we present the first documented case of a cyclist with a third-degree open thoracic trauma (Gustilo–Anderson 3a) associated with a dislocated manubrium sterni fracture in the upper thoracic aperture, bilateral anterior dislocations of the sternoclavicular joints, rib fractures, and pleural ruptures.Case presentationThe patient, a 27-year-old Caucasian male, incurred this injury while participating in a professional cycling race at Nürburgring, Germany and received immediate interdisciplinary surgical treatment and has encountered no complications. We conducted a 1-year follow-up and present the clinical findings of this follow up. Additionally, we conducted a comprehensive review of the existing literature on this injury.ConclusionsImmediate interdisciplinary intervention, including surgical repair and meticulous postoperative care, facilitated successful patient recovery. This underscores the critical role of comprehensive trauma management in complex polytrauma cases. In conclusion, this case report highlights the rarity and complexity of a traumatic injury involving bilateral sternoclavicular dislocation, with this case being the first case reported with concomitant open thorax trauma. Our patient benefited greatly from immediate air-bound transportation to an interdisciplinary care provider, which houses both thoracic and trauma surgery departments.

Functional and Aesthetic Outcomes of Patients Underwent Modified Ravitch Technique for Repair of Pectus Excavatum.

Pectus excavatum is the most frequent congenital defect of the chest wall. Surgical treatment with modified Ravitch-type repair is recommended in patients with cosmetic dissatisfaction or considerable cardiopulmonary symptoms. We aimed to analyze the surgical, aesthetic, cardiopulmonary functions and patient satisfaction outcomes of modified Ravitch repair pre and postoperatively. This was a prospective analysis of 13 pectus excavatum patients undergoing repair by modified Ravitch using a permanent titanium plate fixed with a screw from September 2021 to August 2023. Patients were included to relieve pressure on the heart and lungs if complaining of exercise intolerance, cosmetic impairment, shortness of breathing, chest pain, or psychological disturbance with an age range from 10 years to 30 years old. While patients who had received conservative or surgical treatment previously or patients with scoliosis, Marfan syndrome or bronchial asthma were excluded. At the 6-month postoperative visit, a postoperative satisfaction survey was conducted. The means of the age of patients (16.4 ± 2.36 years); operative duration (120 minutes); blood loss (200± 15.47 mL) and Haller index was (3.8± 0.35) preoperatively compared with less than 3.0 (2.7± 0.08 postoperatively; hospital stay (7 days). The most frequent complications were seroma in one patient (7.69%), postoperative bleeding in one patient (7.69%) and skin infection in one patient (7.69%) of patients. No recorded infection of the sternal plate or required operative re-exploration for infection. All patients were subjectively satisfied with the excellent surgical results. Exercise intolerance despite increased exercise performance was observed following surgery, including less sensation of dyspnea. Modified Ravitch-type repair is a secure and reliable method for treating pectus excavatum with better relief of preoperative symptoms.

Syndrome Sinistre: Left Brachiocephalic Vein Compression and its Neurological Manifestations.

Embryologically, the left brachiocephalic vein (LBV) originates as an anastomotic channel between the right and left anterior cardinal veins. This positions the LBV between the manubrium sterni anteriorly and the innominate artery posteriorly. This pattern of adjacency of the aorta to the LBV is unique to mammals and results from a quirk of evolution. With age, the ascending aorta unfolds, elongates and dilates. Simultaneously, there is a change in the thoracic geometry that reduces the thoracic volume primarily from disc height loss and kyphosis. These transitions progressively compress the LBV. Normally, this compression is circumvented via collateral pathways and "Blood finds a way". However, traversing these circuitous pathways comes at a cost and can result in delayed transit times and venous congestion. While it is possible that compression of the LBV in the setting of adequate collateral channels may fail to provoke any pathologic sequelae, we propose a phenomenon in which such compression in the setting of inadequate collateral circulation may lead to a state of pathologic venous congestion. This anatomic anomaly and its associated clinical features, if identified, can offer a new avenue for treatment options for some of the hitherto unexplained neurologic disorders.

505. USE OF INDOCYANINE GREEN FOR ASSESSMENT OF GASTROPLASTY VASCULARIZATION AFTER MCKEOWN ESOPHAGECTOMY

Abstract Background Anastomotic leakage is one of the most feared complications of esophagogastric surgery, conferring significant morbidity and mortality in these patients. It is known that inadequate vascularization of the gastroplasty is a major risk factor for anastomotic dehiscence. The aim of this study is to evaluate and demonstrate the utility of intraoperative use of indocyanine green (ICG) in patients undergoing esophagectomy and reconstruction with gastroplasty to assess the relationship between its vascularization and the presence of anastomotic leakage in the postoperative period. Methods Prospective, longitudinal, observational, and analytical study of 36 consecutive cases in which intraoperative ICG was used for patients undergoing McKeown esophagectomy and reconstruction with gastroplasty and cervical anastomosis from June 2021 to December 2023. The distance traveled by the ICG in a proximal direction from the pylorus at 30 and 90 seconds after its intravenous infusion was measured. An automatic baseline point or point of maximum fluorescence was also recorded and compared both in net value and in percentage at 30, 60, 90, and 120 seconds after the infusion of ICG with the theoretical zone of anastomosis construction (zone reaching the sternal manubrium after extending the graft over the sternum). Statistical analysis was performed using SPSS version 24.0. Results The rate of leaks and necrosis of the graft was 19.4% and 2.8%, respectively. There is a significant relationship (p<0.05) between the rate of anastomotic dehiscence and the net value and percentage compared with the automatic baseline point of ICG at the anastomosis site and at the apex of the gastroplasty at 30, 60, 90, and 120 seconds. Using a ROC curve (figure 1) that analyzed the time it takes for ICG to reach the anastomosis, a cutoff point of 19.5 seconds was established, which gives ICG greater profitability as a diagnostic test with an AUC of 0.821 (0.642-1). The positive predictive value of this test is 0.36, and the negative predictive value is 1. Conclusion The use of indocyanine green appears to be a good method for identifying those anastomoses and gastroplasties that present a high risk of dehiscence and/or necrosis. The time it takes for ICG to reach the anastomosis, the speed at which it does so, as well as the quantitative value provided by the platform used, seem to be valid parameters for identifying high-risk cases. This would allow for the performance of additional measures to reduce the risk of dehiscence and/or necrosis. Randomized prospective studies with a larger sample size would be necessary.

Assessing the impact of corrosive acids on human bone integrity in forensic context.

Dissolving bodies is a contemporary method of disposing of human remains and has been practiced throughout the years. This research article discussed the impact of readily available corrosive chemicals, such as Hydrochloric acid (HCl), Sulfuric acid (H2SO4), and Expelz™ toilet cleaner, on human bone. Unfortunately, the existing literature on this subject is scarce, with only a few studies conducted on human bones. To address this gap, we conducted an experimental analysis using human sternum bone fragments. These samples were subjected to immersion in different acids, namely HCl and H2SO4, at two concentrations (10% and 37%), and Expelz™ toilet cleaner. This research aims to describe the impact of toilet cleaner, sulphuric acid, and hydrochloric acid on bone tissue deterioration at various time intervals. Further, the morphological alterations weight loss, and cytological analysis of bone tissue residue with various acid concentrations and immersion times (3.5, 9, 24, 36, 48, 60, and 72h) were analyzed. Among the chemicals examined, it is evident that 37% hydrochloric acid (HCl) and sulfuric acid (H2SO4), regardless of refreshment, exhibit the highest reactivity, resulting in the complete decomposition of hard tissue within a few hours. In contrast, the behaviour of 10% H2SO4 reveals a more intricate degradation process characterized by fluctuations in weight loss. These distinct reactivity profiles under different conditions are crucial in understanding the potential for rapid weight loss, signifying high reactivity and more gradual weight loss, indicating a faster decomposition rate. Notably, refreshment of the solution enhanced the reactivity of both HCl and H2SO4.

EASI monitoring in ventricular tachycardia, an alternative to conventional electrocardiography?

Abstract Background 12-lead electrocardiogram (ECG) is the gold standard for detecting ventricular arrhythmias. In cardiac critical care units (UCC), monitoring systems are used to detect transient events such as arrhythmias or ST-segment acute changes. The discomfort caused in the patient by the need for 10 electrodes to obtain the 12 leads continuously means that complete monitoring is not routine. The EASI monitoring system, based on vector electrocardiography, is an alternative that uses only 5 electrodes (4 thoracic and 1 ground) and theoretically allows obtaining a complete standard ECG. Objectives The main endpoint of this study was to evaluate the diagnostic accuracy of the EASI monitoring system in patients with ventricular tachycardia (VT), compared with conventional ECG. Methods Seven cases of patients admitted to the CCU due to episodes of VT are presented. The patients were monitored with the EASI system upon arrival, and the conventional ECG and the one derived from the EASI system were taken simultaneously for VT events for comparison. The 4 electrodes of the EASI system were placed, as recommended, on the sternal manubrium (S), lower sternum at the level of the 5th intercostal space (E), at the level of the 5th intercostal space, and on the right and left midclavicular lines (I and A). Results Analysing case by case, the axis of the tachycardia was similar in 5 patients, being able to assess the origin of the tachycardia in them. In 2 patients it was different. These cases of patients that differ, one episode has its origin in the right ventricular outflow tract (endocardial) and the other in the area of the left ventricular summit (epicardial). Two patients with different tachycardias and no cardiac characteristics in common. Figure 1. Conclusions EASI monitoring is a feasible alternative for monitoring patients in the CCU, which could give us reliable information (compared with standard ECG) with limitations in some cases in which the cardiac axis differs. For patients admitted for arrhythmic events, a better characterization of the differences would be interesting in order to optimize its use.

Anatomical Variation of Sternal Angle and Body: a Cross sectional study

Background: The sternum is one of the important skeletal components ofthoracic case that frequently has congenital defects, and researchers routinely use variances to ascertain an individual's age and sex. Additionally, it helps the physician with biopsy procedures as well as therapy. The objective of this study was to evaluate the morphological characteristics of sternal body and sternal angle in both sexes. Method: This cross-sectional stuywas carried out at the Department of Anatomy, Sylhet MAG Osmani Medical College. For this purpose, 100 dried ossified sternums of unknown sex had been collected. The sample was collected in compliance with the inclusion and exclusion criteria. Discriminant function analysis was used to determine the sex of each sternum (DFA). Study variables were the maximum length of sternal body, maximum breadth of sternal body, thickness of the sternal body and sternal angle. Variables were measured using a vernier caliper and documented in a pre-designed data sheet. Result: The mean length of the body of sternum was 93.84±23.31 mm in male and 82.84±14.8 mm in female. The mean width of the body of the sternum was 35.3±10.83 mm in male and 29.22±9.65 mm in female. The thickness of the body of the sternum is 19.86±9.91 mm in males and 16.12±7.39 mm in females. Analysis revealed that length of body sternum, width of body of sternum and thickness of body of sternum were higher in male than female which was statistically significant (p<0.05).The mean angle of sternum was 148.29±8.240 degrees in males and 149.32±9.690degrees in females, respectively. The difference was statistically not significant (p<0.05). Conclusion: In females, the maximum sternal length, maximum sternal breadth, and maximum sternal thickness were all significantly lower.

Optimal Chest Compression Point During Pediatric Resuscitation: Implications for Pediatric Resuscitation Practice by CT Scans.

Current European guidelines for pediatric cardiopulmonary resuscitation (CPR) recommend the lower half of the sternum as the chest compression point (CP). In this study, we have used thoracic CT scans to evaluate recommended and optimal CP in relation to cardiac anatomy and structure. Analysis of routinely acquired thoracic CT scans acquired from 2000 to 2020. Single-center pediatric department in a German University Hospital. Imaging data were obtained from 290 patients of 3-16 years old. None. We measured and analyzed 14 thoracic metrics in each thoracic CT scan. In 44 of 290 (15.2%) scans, the recommended CP did not match the level of the cardiac ventricles. Anatomically, the optimal CP was one rib or one vertebral body lower than the recommended CP, that is, the optimal CP was more caudal to the level of the body of the sternum in 67 of 290 (23.1%) scans. The recommended compression depth appeared reasonable in children younger than 12 years old. At 12 years old or older, the maximum compression depth of 6 cm is less than or equal to one-third of the thoracic depth. In this study of thoracic CT scans in children 3-16 years old, we have found that optimal CP for CPR appears to be more caudal than the recommended CP. Therefore, it seems reasonable to prefer to use the lower part of the sternum for CPR chest compressions. At 12 years old or older, a compression depth similar to that used in adults-6 cm limit-may be chosen.

Practice Patterns in Sternal Closure and Evaluation of Adoption of a Novel Sternal Closure Device.

The technique for sternal closure has remained largely unchanged owing to the efficacy, simplicity, and low cost of stainless-steel sternal wires. Despite their ubiquity, several other closure devices designed to address the complications associated with sternal wires such as sternal bleeding and dehiscence have become popular. We have developed a novel sternal closure device that reduces sternal bleeding and dehiscence. This study quantifies the use of currently available sternal closure devices and determines predicted uptake of the novel device. An electronic survey, designed to determine practice patterns for sternal closure, was distributed to 70 US cardiac surgeons. The survey included a discrete choice section in which surgeons evaluated relative value of device attributes including cost, ease of emergent sternal reentry, and dehiscence risk. There were 70 surgeons from 30 states who completed the survey. The most frequent means of sternal closure was straight sternal wires (35.8%), followed by straight sternal wires plus figure-of-8 sternal wires (18.1%), double wires (10.9%), plates (10.2%), and other (25%). The relative utilization shifted from sternal wires to sternal plates as the risk for dehiscence increased. The adoption of the novel closure device was estimated at 34.6%. The standard stainless-steel sternal wire remains the most common means of sternal reapproximation, but its utilization is lower in patients at high risk for sternal dehiscence. Based on this survey, there is acceptance in the community for a novel sternal closure device designed to address the limitations of traditional sternal closure methods.

Assessing the reliability and accuracy of sex estimation models utilizing sternal morphometry derived from computed tomography in the Ghanaian population

Sex estimation models are specific to populations and cannot be generalized due to genetic and environmental variabilities. This retrospective cross-sectional study, conducted between January and September 2023 at the Tamale Teaching Hospital, included 119 (50.9 %) females and 115 (49.1 %) males aged 23–82 years. Measurements, including manubrium length (M), manubrium width (MW), sternal body length (B), combined manubrium and sternal body lengths (CL), corpus sterni width at first sternebrae (CSWS1), and corpus sterni width at third sternebrae (CSWS3), were obtained from Computerized Tomographic (CT) images of the sternum using DICOM Viewer, accurate to 0.1 cm. Subsequently, sternal area (SA) and sternal index (SI) were calculated. Univariable and stepwise multivariable discriminant function analysis (DFA) and logistic regression (LR) models were developed using a training sample (70 %), and cross-validation was performed on a holdout sample (30 %). Results showed that the linear measurements, excluding M, and sternal area were higher in males than females (P<0.001), while the sternal index was <50 % in males but >50 % in females (P<0.001). Univariable sex estimation accuracies, in cross-validation, ranged from 43.7 % to 92.9 % in DFA and 50.0–92.9 % in LR. For multivariable models, the accuracy ranges were 92.9–94.3 % in DFA and 91.6–93.0 % in LR. The sternal body length was the most accurate at 90.1 % in DFA and 90.2 % in LR, with lower sex bias (male-female) in LR than in DFA (-0.1 vs. 8.7). The sternum proves valuable for sex estimation, with sternal body length as the most accurate linear measurement. However, multivariable models, particularly LR, demonstrate higher accuracy compared to DFA.

Defining the imaging diagnostic criteria for adult chronic non-bacterial osteitis.

Osteitis of the sternocostoclavicular (SCC) region, referred to as sternocostoclavicular hyperostosis (SCCH), is the clinical expression of chronic non-bacterial osteitis (CNO) in adults with this rare chronic auto-inflammatory disorder of the axial skeleton. The diagnosis is based on distinctive computerized tomography (CT) features of sclerosis and hyperostosis of the SCC region, and local increases in osteoid formation visualized by high radiopharmacon uptake on skeletal scintigraphy but clear radiologic diagnostic criteria are lacking. In a cross-sectional study, CT scans and whole-body skeletal scintigraphy images obtained in 169 patients seen at the Center for Bone Quality of the Leiden University Medical Center between 2008 and 2018 with a suspected diagnosis of CNO of the SCC region were re-evaluated by 2 skeletal radiologists and 2 nuclear physicians. The diagnosis was confirmed in 118 (70%) predominantly female patients (n= 103, 89.2%); median age at first symptoms 45years (range 20-73). The diagnosis was excluded in the remaining 51 "non-CNO" patients. Increased radiopharmacon uptake at the SCC region was observed in 82% CNO patients, with the manubrium sterni having the highest predictive ability to discriminate on both imaging modalities. The prevalence of sclerosis of the clavicles, manubrium and first ribs was significantly higher in CNO patients (P< 0.001). Hyperostosis was not observed in non-CNO patients. 46 CNO versus only 2 non-CNO patients had costoclavicular ligament calcification. Our findings identify CT scan features of sclerosis and hyperostosis of manubrium sterni, medial end of clavicles and first ribs, and calcification of costoclavicular ligaments, associated with increased tracer uptake on skeletal scintigraphy at the SCC region, specifically manubrium sterni, as well-defined imaging diagnostic criteria for adult CNO. Pitfalls encountered in the diagnosis of CNO are highlighted. These defined imaging diagnostic criteria for adult CNO should facilitate the diagnosis of this rare auto-inflammatory bone disease across the spectrum of its early to late stages.

Radiographic and computed tomographic evaluation of tracheal diameter and length in kittens.

To measure the tracheal diameter and length in kittens using radiography and CT and to evaluate the concordance between measurements obtained with these 2 modalities. 15 kittens with an estimated age of 12 weeks and mean body weight of 1.49 kg. Radiographic and CT images were retrospectively evaluated to measure tracheal lengths and diameters. Tracheal diameters were measured at 5 different sites (A [at the level of the C2-3 intervertebral disk space], B [at the level of the C4-5 intervertebral disk space], C [at the cranial end of the manubrium sterni], D [at the level of the second rib], and E [1 cm cranial to the carina]) along the trachea. The cross-sectional area and transverse and vertical diameter ratios were calculated for each measurement site. The cross-sectional area was largest at site A and decreased from site C to site E. Based on the vertical diameter ratio, the tracheal shape was most circular at sites A and E, whereas from sites B to D, it was elliptical. The vertical diameters of the trachea on radiography and CT did not differ statistically significantly. However, the tracheal length measured on radiography was approximately 6 mm longer than that measured on CT (P < .05). Using the first rib as an anatomical reference, the placement of a cuffed endotracheal tube is recommended in kittens. In emergency situations, regression equations based on body weight may be helpful in predicting tracheal diameters.

Description of a new species of the Petrolisthesgalathinus complex from the Caribbean Sea, and resurrection of Petrolisthesoccidentalis from the East Pacific (Crustacea, Anomura, Porcellanidae).

The Petrolisthesgalathinus complex currently consists of six American species distributed in the West Atlantic, including the amphi-American P.galathinus. All species in the complex are similar in their adult morphology but differ in colour, size, larval morphology, and shape of the adult sternal plate. The West Atlantic species have different geographic ranges, which overlap in the southern Caribbean. Previously published molecular data support the monophyly of the complex, and the reciprocal monophyly of each described species and further clades corresponding to different colour morphs. Here, the morph P.caribensis "Blue" is described as Petrolisthescoeruleussp. nov., and Petrolisthesoccidentalis is formally resurrected for the Pacific individuals of P.galathinus. By adding these two species to the P.galathinus complex, this now consists of eight species. Colour illustrations of all species and colour morphs are provided and their geographic distributions and ecological ranges are discussed and updated.

Mediastinal Tuberculosis with Sternal Encroachment - A Rare Presentation of Tuberculosis

Introduction Extra-pulmonary tuberculosis constitutes 15-20% of the total tuberculosis (TB) caseload in immunocompetent patients. Affliction of the skeletal system is rare with still rarer presentation of sternal tuberculosis. Sternum is one of the least common bones of the body to get infected (1) Sternal TB is predominantly seen in middle-aged adults although no age is immune and it has also been reported in an infant. It can arise primarily due to a hematogenous route or direct extension from the hilar lymph nodes and/or could be due to lymphatic disseminatio(2) . Sternal tuberculosis has also been reported after BCG vaccination in the pediatric age group (3-5) Here we present an unusual case of tuberculosis of the sternum, which presented with swelling and pain in the chest in a 9 year old boy. Keywords: Sternal tuberculosis, Manubrium sterni, Skeletal Tuberculosis, Pediatric sternal tuberculosis, Mediastinal Koch’s

Presence of manubrium-sternum joint does not assure sufficient elevation of sternum in Nuss procedure for pectus excavatum patients.

The manubrium and body of the sternum are connected by the manubrium-sternum joint (MSJ). In performing the Nuss procedure for pectus excavatum patients, the body of the sternum is elevated as the operator flips correction bars upside down. Theoretically, the presence of the MSJ should allow elevation of the sternum body. However, does the MSJ secure sufficient elevation of the sternum? This study aims to elucidate this clinical question. Seventy-four adult pectus excavatum patients with moderate to serious deformity (with Haller Index being equal to or greater than 5) were included in the study. The MSJ was open in all patients. For 29 patients, the sternum was elevated by only bar flipping (Non-Separation Group); for 45 patients, the sternum was horizontally separated after bar flipping (Separation Group). Whether or not additional elevation for Separation Group patients results from the division was observed, and the degree of the additional elevation was evaluated. Furthermore, 74 patients subjectively evaluated postoperative pain and gave scores with a Visual Analog Scale ranging from 0 (no pain) to 10 (intolerable pain). The VAS scores were compared between the two groups. In the Separation Group, the sternums of all patients achieved additional elevation from sternum separation. The pain scores were lower for the Separation Group than for the Non-Separation Group. Even when the MSJ is present, horizontal separation enhances the elevation of the sternum. Furthermore, horizontal separation of the sternum reduces postoperative pain.

Sternal Tuberculosis: About Two Senegalese Cases

Tuberculosis (TB) remains a major public health problem in resource-limited countries where it is endemic. Sternal TB is a rare entity. It accounts for less than 1% of tuberculous osteomyelitis.&#x0D; We report two cases of sternal TB occurring in two young Senegalese aged 21 and 23, who presented with inflammatory sternal swelling in the context of evening raise of temperature and weight loss. In both cases, Mycobacterium tuberculosis was detected in the pus specimen using the Genexpert® MTB/RIF test (Cepheid, California). In one case, a chest CT scan revealed lysis of the sternal manubrium. The patient's condition improved with anti-tuberculosis treatment and surgery.&#x0D; These cases, particularly in areas where tuberculosis is endemic, highlight the importance of considering tuberculosis as a possible cause of sternal tumefaction.

A new pterosaur from the early stage of the Jehol biota in China, with a study on the relative thickness of bone walls

The Huajiying Formation (135.4–128.7 Ma) of the northern Hebei represents the early stage of the Early Cretaceous Jehol Biota in China, yielding many kinds of vertebrates. The only known pterosaur specimen was incomplete and assigned to the Ornithocheiroidea. Here we report a more complete pterosaur specimen, assigned to the Ctenochasmatidae. A new taxon is established on two autapomorphies: a large pneumatic foramen present on the ventral surface of the proximal end of the first wing phalanx; and coracoid lacking an expansion at its contact with the scapula, as well as the following combination of characteristics: subsquare sternal plate; coracoid having an extremely concave articulation with a posterior expansion; humerus without a tubercle on the proximal margin between the deltopectoral crest and the head; humerus slightly longer than the wing metacarpal; and the first and third wing phalanges equal in length. The relative thicknesses of bone walls are investigated among pterosaurs in three ways. The overall distribution of R/t ratios shows that most non-pterodactyloids, archaeopterodactyloids, and dsungaripterids have smaller R/t ratios than other groups. Relatively thick bone walls are not unique for the Dsungaripteridae as previously thought, and the humerus and radius of dsungaripterids have thinner walls than other bones. The feature of small R/t ratios is plesiomorphic and the thin-walled humerus and radius of dsungaripterids were evolved to meet the need of the flight, not for frequent take-off and landing as previously thought.

MANUBRIAL INDEX–A RELIABLE GUIDE IN DETERMINING THE SEX OF THE STERNUM

Objective: Sexing an unknown skeleton is a very important and difficult process that anatomists and jurists have to fulfill. Sex can be predicted by the sternum with 90% accuracy. It is crucial to predicting age in the middle age range and sternum is particularly useful for it. In the study conducted for sexing the sternum, different measurements were compared and it was found that manubrium alone is a good tool for gender differentiation of the sternum. Methods: Study was conducted on 100 Sternums of known age and sex which were collected from the postmortem room of the forensic department after taking due consent from the attendants of the deceased. Different measurements of manubrium were taken and contrasted for gender differentiation. ANOVA was used to evaluate the statistical significance. Results: It was found that among morphometric criteria of prosternum manubrial index was found to be accurate and reliable along with clear-cut demarcation in length and width of the manubrium sterni of two sex. Conclusion: It was concluded by this study that the manubrial index is a trustworthy tool for sexing sternum and manubrial width could be fairly reliable criterion for determining sex of the sternum.