SEARCH · Search PubMed
Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.
Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.
Injuries to the sternum and thoracic cage are relatively frequent in this age of motor-vehicle accidents, high-speed sports activities, and industrial injuries, yet non-union of a fracture of the sternum is exceptionally rare. Sternotomy is commonly performed in cardiothoracic surgery, and the sternum is usually divided vertically or transversely, but non-union of the sternal cut is rare. Fracture of the sternum in a child is especially rare.
A 39-year-old woman complained of anterior chest pain. A lateral chest X-ray film showed destruction of bone in the body of sternum. CT scan showed a soft tissue density within the sternum. Serum protein electropheresis revealed mild monoclonal gammopathy of IgG-kappa, but the urine contained no Bence-Jones protein. A biopsy specimen showed plasmacytoma with cytoplasmic Ig IgG-kappa. Bone scintigraphy and systemic bone roentgenography revealed only the lesion in the sternum. Sternal subtotal resectin was performed. The defect of the anterior chest wall was reconstructed with double folded marlex mesh and pedicles from the major pectoral muscle. Iliac bone marrow aspiration revealed no evidence of myeloma. There was no serum evidence of monoclonal gammopathy two months after the operation. Therefore, the final diagnosis was solitary plasmacytoma of the sternum. It is now 41 months since surgery, and there have been no signs of fecurrence. Long term follow up is necessary in this case.
Postnatal development and maturation of the human sternum are highly variable. Endochondral ossification centers (sternebrae) form within each cartilaginous segment of the sternum, with each center enveloped by a spherical growth plate. Within a cartilaginous center there may be either one or two ossification centers, those with two centers retaining and reflecting features of their bilateral embryonic origin. Malaligned bifid centers are clearly associated with rib articulation asymmetry as well. Expansion of individual ossification centers progresses within the peripheral cartilaginous domains of the sternum. With respect to the rostrocaudal axis, sternebrae form between the costosternal articulations. Consistent with the biology of endochondral transition, cartilage canals are evident throughout unossified regions of the hyaline matrix. Expanding ossification of adjacent sternebrae results in depletion of the common area of cartilage between the two sternebrae, and eventually in physiologic epiphysiodesis. Fusion of the mesosternebrae reciprocates the initial pattern of sternebral ossification site appearance, proceeding in a caudal-to-cranial direction. Union of adjacent sternebrae, initiated through a central osseous bridge, progresses through anterior, lateral, cephalocaudal, and posterior domains to achieve synostosis. Accessory and bifid centers of ossification within the same intercostal space coalesce prior to adjoining adjacent sternebrae. Manubriosternal fusion is rare due to the presence of a fibrocartilaginous joint restricting ossification. The xiphoid process remains connected to the most caudal mesosternum via a common zone of hyaline cartilage that ossifies by middle to late adulthood. A single pattern of development does not appear fundamental to successful growth of the sternum, as morphological variants were common.
CASE DESCRIPTION: A 5.5-month-old female domestic longhair cat was examined because of dorsal deviation of the caudal aspect of the sternum and progressively worsening dyspnea during play activities. CLINICAL FINDINGS: A diagnosis of pectus excavatum was made clinically and confirmed radiographically. The cardiac silhouette was shifted into the right hemithorax. The vertebral index (VI) and frontosagittal index (FSI), which are radiographic indices used to grade the extent of the deformity, were 5.2 and 3.0, respectively. Minimum thoracic height was 13 mm at this time. TREATMENT AND OUTCOME: The sternal malposition was corrected during surgery; for stabilization, an internal splint was provided by use of a plate that was applied to the ventral side of the sternum. Radiographic indices improved until day 85; at that time, an increase in the distance between plate and sternum was detected, and plate removal was advised. The radiographic indices improved again after plate removal. At 310 days after surgery, VI was 9.6, FSI was 1.6, and minimum thoracic height was 34 mm. No dyspnea was evident during physical examination. CLINICAL RELEVANCE: Results of treatment suggest that this technique may be useful as an alternative surgical option for cats with pectus excavatum that have a noncompliant sternum.
Twelve intractable funnel chests in young adults were treated with revascularization of the turnover sternum. The sternum and costal composite tissue were resected at the outskirt of the depressed area. Special attention was paid to the dissection of the vascular pedicle at both sides of the internal mammary vessels. The recipient vessels at one side were left long, so were the donor vessels at the other side. A segment of the rib at the exit of the recipient internal mammary vessels had to be removed to accommodate the vessels and to facilitate vascular anastomosis. Vascular anastomosis was accomplished with loupes (Keeler, sixfold magnification) in five patients because the direction of the vessels is vertically oriented. In four cases, artery and vein grafts were taken from the other side of the internal mammary vessels not bound for vascular anastomosis for length discrepancy of the vessels, while the remaining cases had direct vascular anastomosis without vascular grafting. Revascularization of the turnover sternum was performed successfully without vascular compromise. The patients all recovered well with much improved physical condition. Only one patient sustained spontaneous pneumothorax 1 month after the operation. Postoperative three-dimensional computed tomographic (CT) scan revealed increment of thoracic cage volume for 9-17%. Follow-up CT scan 2 years later revealed even more improved thoracic cage expansion.
The chest wall present diagnostic difficulties for both the clinician and the radiologist. Because of normal variations in anatomy and ossification, analysis of the sternal region can be particularly confusing. We reviewed the normal computed tomographic (CT) appearance of the sternum in 354 patients. Important normal sternal variants included cortical unsharpness along the posterior aspect of the manubrium , lateral surfaces of the body, and at the sternal fibrocartilaginous articulations; soft tissue prominence at the junction of the sternum and costochondral cartilage; and bony sclerosis at the transitions from manubrium to body and from body to xiphoid. In seven patients with clinically significant sternal abnormality, key CT features were abnormal soft tissue mass (7/7), destruction or irregularity of the cortical contour (7/7), and abnormal increased attenuation of bone (1/7). CT should be the radiologic study of choice in patients with suspected abnormality of the sternum and its articulations.
Because of the high tendency of breast cancer to develop metastatic deposits in the skeleton, space-occupying processes in the sternal region are mostly attributed to osseous metastases and not to parasternal lymph node involvement, even in case of solitary lesions, primary tumor localizations in the inner quadrants, positive axillary nodes and negative X-ray or bone scan findings. The sonographic examinations of 115 patients with breast cancer and clinical and/or scintigraphic suspicion of sternal metastasis, however, revealed the typical bone metastases of the sternum with a small soft tissue tumors in only 27.8 %, whereas 59.1 % of the cases showed parasternal recurrences; 5.2 % had both. Non-tumorous changes were seen in 6.1 %, equivocal results in 1.7 %. Solitary osseous metastasis of the sternum was rare; multiple skeletal lesions were found in the majority of this group in contrast to the patients in the parasternal relapse group, which moreover showed strong overrepresentation of the primary tumor localization in the inner quadrants. X-rays of the chest or the sternum were often false-negative and not reliable, the bone scans positive only in cases of secondary sternal invasion or skeletal metastases. Concerning reliability and cost, sonography was the imaging method of first choice for diagnosis, therapy planning and follow-up for space-occupying processes in the sternal region, with CT or MRI as adjuncts in cases of extended tumors invading the mediastinum.
BACKGROUND: Radiologic reports of "normal" chest are not uncommon when there clearly are irregularities of sternal ossification and maturation. Analysis of imaging studies of sternal deformities for growth disturbances is not common in the literature and is addressed in this manuscript. OBJECTIVE: To determine the influence of sternal growth on development of pectus deformities and correlate imaging studies with clinical aspects of different types of these deformities. MATERIAL AND METHODS: One hundred forty-one children and adolescents with pectus deformities were evaluated. Sternal growth was estimated through the development of radiographic indices that were available for 57 patients with pectus deformities and for 71 controls. Magnetic resonance imaging of the sternum was performed in two patients to correlate with radiographic information. RESULTS: Radiographic indices of the sternum suggested growth disturbances in three basic types of pectus carinatum deformities: superior, inferior and lateral, and in the localized type of pectus excavatum. CONCLUSION: Sternal growth seems to have an important influence on the development of carinatum superior; partial influence on carinatum inferior, carinatum lateral, and excavatum localized; and no influence on excavatum wide pectus deformities. The endochondral growth of the sternum and costal arches is an important concept that aids in the interpretation of imaging studies and the orthopedic approach to management of these deformities in children and adolescents.
The aim of our study was to define the appearance of methyl methacrylate grafts replacing resected sternum and ribs on CT and MRI and how the sternal graft may mimic an abnormally sclerotic sternum on CT images. We reviewed the CT scans of nine patients who had undergone chest wall resection (eight with malignant and one with benign disease) and reconstruction with a composite of methyl methacrylate and Marlex mesh graft. One of them had an MRI study as well. The size, shape and CT attenuation were assessed on mediastinal and bone window settings. The sternal graft was seen on mediastinal and even better on bone windows as an abnormally wide, irregularly shaped structure, somewhat denser than the normal sternum. The chest wall prosthesis replacing resected ribs was seen as a continuous dense structure and of similar attenuation as that of the sternal graft. On MRI the prosthesis appeared as a well-defined structure with no signal. Reconstruction of the chest wall with methyl methacrylate appears on CT as a diffusely dense sclerotic bone lesion not unlike a malignant lesion. The possibility of a graft has to be included in the differential diagnosis in these cases.
PURPOSE: To study the clinical results of resternotomy in patients with dense and direct adhesion between the large vessels and the sternum, and define the morphologic features of the adhesion. METHODS: Between 2000 and 2003, 67 patients with a history of cardiac surgery underwent median resternotomy. We studied each patient's profile and the measurements taken from preoperative computed tomography scans. We then conducted multivariate logistic regression analysis to determine the predictive morphologic features of adhesion between the large vessels and the sternum in these 67 patients. RESULTS: Twenty (29.9%) of the 67 patients had direct adhesion between the large vessels and the sternum. Sternal re-entry was performed without injury to the large vessels in 18 (90%) but the aorta was injured in 2 (10%) patients, resulting in catastrophic hemodynamic disorder and operative death in one. Multivariate logistic regression analysis revealed that an extracardiac conduit and a high occupying rate of the aorta and pulmonary artery in the mediastinal space were significant morphologic factors. CONCLUSION: The morphologic features of large vessels to sternal dense adhesion as possible risk factors for injury to the large vessels are the presence of an extracardiac conduit and a large ascending aorta or pulmonary artery in relation to the mediastinal space.
Recent legislation has led to increasing numbers of car occupants wearing seat belts and presumably the number of injuries attributable to seat belts will also increase. The commonest such injury is a fracture of the sternum, and blunt myocardial damage is a logical sequel although often unsuspected and therefore unsought. Confirmation is difficult and ECG changes are usually absent or not specific. In three consecutive patients admitted with a fractured sternum we found raised blood levels of CK-MB (creatine kinase-myocardial band) and believe these indicate myocardial contusion. We therefore feel that an isolated fracture of the sternum should be considered a more serious injury than is initially apparent, as these patients are at risk of developing cardiac complications.
BACKGROUND: The internal thoracic artery (ITA) is the conduit of choice in coronary bypass grafting, due to the excellent long-term results achieved using it. However, increased incidence of sternal infections after pedicled ITA harvesting has revived interest in the morphology of sternal blood supply. Our aim was to discuss the topography of the sternal branches with emphasis on internal thoracic artery harvesting. METHODS: This study was conducted on 50 fresh specimens of the anterior thorax wall. Radio-opaque material was injected and angiograms of the ITA were performed. Subsequently, the specimens were preserved and a dry dissection of each ITA and its branches was carried out. RESULTS: In dry dissected specimens, four types of vessels were identified that have the potential to carry blood to the sternum after harvesting the ITA. In the first group, the artery to the sternum also supplies the intercostal space. In the second morphologic variant, the sternal branch gives off the perforating and anterior intercostal arteries. In the third group, we classified the common branch of the sternal and perforating arteries. In the fourth group, the sternal artery originated from the ITA as an independent branch. CONCLUSIONS: For sternal-intercostal, perforating-intercostal, and sternal-perforating branches to function as collaterals after ITA harvesting, the common trunk of origin must remain intact. Based on morphologic data, we recommend ligating the common trunk as close as possible to the ITA; in this way, collateral blood flow to the sternum remains intact.
Pediatric primary malignancies of the sternum are rare. They represent less than 1% of all bone tumors. Primitive neuroectodermal tumor of the chest wall or Askin's tumor is more often seen in the ribs than in the sternum. Surgical treatment involves resection of the tumor followed by primary reconstruction. We report the case of a 16-year-old adolescent boy who was diagnosed to have primitive neuroectodermal tumor of the sternum and underwent resection with primary reconstruction of the anterior chest wall. We describe for the first time the use of a 2-mm Gore-Tex Dualmesh plus biomaterial (W.L. Gore and Associates, Flagstaff, Ariz) and locking mandibular multiperforated titanium plates with screws (Stryker-Leibinger, Freiburg, Germany) for primary sternal reconstruction in a child. Despite having a wide resection, he did not require postoperative ventilation and had an uncomplicated recovery. The reconstructed chest wall has a normal contour with normal pulmonary physiology.
Severe edematous heart after a cardiac operation is impossible to treat if there is compression of the heart due to the sternum. In these patients delayed sternal closure may be a useful procedure until the heart decreases in size. We devised a spool-like stent for the open sternum to maintain the optimal cardiac space for the severely edematous heart and to fix the chest wall to allow for management while the sternum is open.
INTRODUCTION: Among the extra-pulmonary localizations, isolated tuberculosis of the sternum is rare and difficult to diagnose. OBSERVATIONS: A 30 year-old man presented with tumefaction of the sternum that had developed over the past two months and a 52 year-old woman had developed a painful tumefaction of the sternum over the past 4 months. In both cases, the histopathological examination of a biopsy confirmed the diagnosis of tuberculosis. Anti-bacterial therapy permitted the favourable progression of the disease. DISCUSSION: Such diagnosis is rare. Contamination can occur through contiguity, which was not manifest in either of the two cases. Confrontation between the histological and/or bacteriological samples is required.
A 20-year-old man with a large, asymptomatic mediastinal mass was found to have desmoid-type fibromatosis (DF) by needle biopsy. The tumor arose from the internal periosteum of the sternum and mimicked an anterior mediastinal mass. A wide resection of the sternum, including portions of the clavicles and costal cartilages, and reconstruction with a Gore-Tex soft tissue patch were performed. Although extremely rare, desmoid tumor of the sternum should be considered in the differential diagnosis of anterior mediastinal tumors.
Therapeutic efficacy of bisphosphonates depends on how much drug is present in bone. Therefore, it is important to measure the amount of bone bisphosphonate in toxicological and pharmacological studies. We analyzed pamidronate content of bone samples from two previously published long-term dose studies. In the first study, mature beagle dogs were given oral pamidronate at doses of 0, 2.5, 12.5 and 25 mg/kg per day for 1 year. The dogs in the second study received the same dosages for 1 year followed by 1 year without drug. In both studies, the amount of pamidronate measured was dependent upon dose in bone samples of ilium, sternum, and vertebral body. After 1 year of treatment, vertebral bone had more pamidronate than sternum or iliac bone on a permilligram basis. After 2 years, there was significantly less pamidronate in the vertebral body, sternum, and ilium than there had been at 1 year. The fall in pamidronate content was largest in vertebral body and least in the ilium. The higher uptake of pamidronate by the vertebral body during the 1 year study, and its greater loss of pamidronate after a year without drug treatment, would reflect the higher turnover of trabecular bone in the vertebral body vs. cortical bone in the ilium. The percent difference in bone pamidronate content between the 1 and 2 year dogs varied with dose. The largest percent loss occurred in the intermediate-dose group. These data suggest that, after 1 year without the drug, bone turnover rates in dogs treated with the highest dose of pamidronate were lower than at the intermediate dose. Thus, the time required for bone turnover rates to return to pretreatment levels is probably dose-dependent.
BACKGROUND: Myocardial oedema, non-surgical bleeding and the use of mechanical assist devices following major heart surgery sometimes prevent primary closure of the sternum. METHOD: We describe a reusable sterile device for temporarily stenting the open sternum for safety. RESULTS: The sternal stent was used in 32 patients for a mean time of 2 days. We observed no mediastinitis and no wound-healing disorders. A secondary closure of the sternum was performed in 28 patients. CONCLUSION: We present a device for sternal stenting that is reusable, easy to apply and allows a good handling of the critically ill patient due to its extreme stability.