Stress fracture of the manubrium sterni during parallel bar dips.

OBJECTIVE: Stress fractures are common in highly active people, such as athletes or those in the military. They occur frequently in the lower extremities but sternal stress fractures are rare injuries. METHODS: We present a case of a young male who reported no pain and a 'click' sound from the front of the chest while training with parallel bar dips with a grip that was wider than shoulder-width apart. RESULTS: In this case, radiological evaluation was the most helpful tool to diagnose manubrium sterni stress fracture. We advised him to rest but he started exercises immediately because he had to participate in a military camp after the injury. The patient was treated conservatively. The treatment consisted of activity modification and supplemental drugs. CONCLUSION: We report a case of manubrium stress fracture that developed in a young male military recruit.

Delayed presentation of manubriosternal dislocation after thoracolumbar spondylodesis in a polytrauma patient - a case report.

BACKGROUND: Manubriosternal dislocations are a rare entity and frequently associated with thoracic spine fractures and, in minority of cases, with cervical or thoracolumbar fractures. METHODS: Our case represents a 38-year-old male who fell from a height resulting in multiple fractures, amongst others of the first lumbar vertebra. At primary survey and computed tomography scan no manubriosternal injury was apparent. After posterior stabilization of the thoracolumbar vertebrae a manubriosternal dislocation was identified and stabilized using plate-and-screw fixation. RESULTS: Clinical findings of a manubriosternal dislocation are not always obvious, allowing them to be missed at initial assessment. CONCLUSIONS: Manubriosternal dislocations can be missed at the initial investigation, even on cross-sectional imaging, and only become visible after spine stabilization because of the tight relationship between sternum and vertebrae in the thoracic cage. There is no unanimity in literature for surgical treatment of manubriosternal dislocations, although plate fixation is generally considered a safe and effective treatment option.

Retrosternal hematoma in sternal fracture for prediction of concomitant injury on chest CT.

BACKGROUND: Isolated sternal fracture, a benign injury, has been increasing in the pan-scan era, although one-third of patients with sternal fracture still has trouble with concomitant injury. The differentiation of these two entities is important to optimize patient management. PURPOSE: To evaluate correlation between retrosternal hematoma and concomitant injury in patients with sternal fracture and to identify predicting factors for concomitant injury in sternal fracture. MATERIAL AND METHODS: A total of 139 patients (84 men; mean age = 54.9 ± 15.3 years) with traumatic sternal fracture were enrolled in this study. We reviewed medical charts and multiplanar computed tomography (CT) images to evaluate cause, location, and degree of sternal fracture, retrosternal hematoma, and concomitant injury. Univariate and multivariate analysis were used to identify variables that were associated with concomitant injury. RESULTS: Concomitant injury on chest CT was observed in 85 patients with sternal fracture. Of the patients, 98 (70.5%) were accompanied by retrosternal hematoma. Multivariate analysis revealed that retrosternal hematoma (odds ratio [OR] = 5.350; P < 0.001), manubrium fracture (OR = 6.848; P = 0.015), and motor vehicle accident (OR = 0.342; P = 0.015) were significantly associated with sternal fracture with concomitant injury. CONCLUSION: Manubrium fracture and retrosternal hematoma portend a high risk of concomitant injury and indicate the need for further clinical and radiologic work-up.

Missed manubriosternal dislocation in patient with thoracolumbar fracture, a case report.

BACKGROUND: Spine fractures combined with sternal injury are most commonly occur in the thoracic region. Lower cervical and thoracolumbar injuries have also been reported, especially for the patients with manubriosternal dislocation. The type of spine injury is easily recognized in initial presentation, but we may miss the sternal fracture and manubriosternal dislocation. CASE PRESENTATION: A 23-year-old male patient complained with chest, right ankle, and lumbar pain after a fall at ground level, with diagnosis of right distal tibial fracture, sternal fracture, calcaneus fracture, and L2 vertebral fracture. However, neurologically he was completely normal. He underwent the operation for his lower extremity and spine, but we missed his manubriosternal dislocation after discharged. After one month, he came to the clinic with complained of chest pain, the imaging exams showed anterior dislocation of manubriosternal joint. We chose conservative treatment for manubriosternal dislocation. He was followed up at monthly intervals and radiographs along with computerized tomography showed satisfactory in fracture healing of lumber and the sternal fracture. However, the manubriosternal dislocation was malunioned. The patient had appearance deformity of the manubriosternal joint. CONCLUSION: This case supports the concept of the existence and clinical relevance of the thoracic cage theory, the thoracolumbar vertebrae should also be included in the thoracic cage theory.

A novel method of open reduction and internal fixation of a displaced manubrial fracture using distal clavicle locking plates.

A 52-year-old man sustained a sternal fracture after a blunt traumatic chest injury. He was in severe pain in the intensive care unit, which resulted in difficulty breathing and increased analgesic requirement, and a decision was made to stabilize his manubrial fracture. Orthopaedic and thoracic surgeons jointly performed open reduction and internal fixation of the displaced manubrial fracture using 2 distal clavicle locking plates. This resulted in improvement in patient's pain and helped with his subsequent recovery and discharge from the hospital. This case report describes a new, safe and effective method of treating this uncommon injury.

["Manubriosternal Synchondrosis": A Rare Problem in Sports Medicine]. / "Synchrondritis manubriosternalis": Ein seltenes Problem in der Sportmedizin.

Non-traumatic, inflammatory and painful lesions of the manubriosternal joint are rare pathologies and, to our knowledge, have not been described in the literature of sports medicine. We report the case of a 30-year-old male strength athlete who developed chronic pain in the manubriosternal joint after exercise. Four-month abstinence from exercise combined with a conservative rehabilitation program performed after clinical and radiological tests did not bring any symptomatic relief. After a local ultrasound-guided single-shot sclerotherapy procedure performed in our clinic, the patient was free of symptoms and quickly regained his ability to exercise.

Manubrial stress fractures diagnosed on MRI: report of two cases and review of the literature.

In contrast to widely-reported sternal insufficiency fractures, stress fractures of the sternum from overuse are extremely rare. Of the 5 cases of sternal stress fracture published in the English-language medical literature, 3 were in the sternal body and only 2 were in the manubrium. We describe two cases of manubrial stress fracture related to golf and weightlifting, and present the first report of the MR findings of this injury. In each of these cases, the onset of pain was atraumatic, insidious, and associated with increased frequency of athletic activity. Imaging was obtained because of clinical diagnostic uncertainty. On MRI, each patient had a sagittally oriented stress fracture of the lateral manubrium adjacent to the first rib synchondrosis. Both patients had resolution of pain after a period of rest, with subsequent successful return to their respective activities. One patient had a follow-up MRI, which showed resolution of the manubrial marrow edema and fracture line. Based on the sternal anatomy and MR findings, we hypothesize that this rare injury might be caused by repetitive torque of the muscle forces on the first costal cartilage and manubrium, and propose that MRI might be an effective means of diagnosing manubrial stress fracture.

The oblique fracture of the manubrium sterni caused by a seatbelt--a rare injury? Treatment options based on the experiences gained in a level I trauma centre.

INTRODUCTION: Sternal fractures are rare with 3-8 % out of the total number of trauma cases mostly caused by direct impact to the anterior chest wall. Most cases described are due to motor vehicle crash either caused by direct impact to the steering wheel or by the seat belt. Fractures mainly occur to the sternal body. Only rarely are cases of manubrium fractures described in literature, for example, in relationship with a direct impact to the shoulder which caused an oblique fracture near to the sternoclavicular joint. Three patients with profoundly dislocated oblique manubrium fracture were admitted to our Level I Trauma Center in 2012 and 2013. Those patients suffered from instability of the upper sternum and the shoulder girdle. MATERIAL AND METHODS: Between January 2012 and October 2013, a total of 538 trauma patients were admitted to the emergency room and received whole body CT-scan. They were analysed retrospectively for sternal fractures. In cases of instability and dislocation, fracture stabilisation was performed by anterior plating through a medial approach using low profile titanium plates (MatrixRib®). RESULTS: Seventy-nine (14.7 %) patients showed sternal fracture, out of which 13 (2.4 %) patients showed a fracture of manubrium, ten caused by seatbelt. In three cases stabilization was performed. Follow up showed sufficient consolidation without complications. DISCUSSION: A total of 16.5 % of sternal fractures were localized at the manubrium, mostly caused by seat belt. Fractures without significant dislocation seemed to be stable and healed well under conservative treatment. Dislocation in this region leads to unstable shoulder girdle. Anterior plating provides sufficient stabilisation and allowed consolidation.

Manubriosternal dislocation with spinal fracture: A rare cause for delayed haemothorax.

Type 2 manubriosternal dislocations with concomitant spinal fracture are rare and may be associated with thoracic visceral injuries. The complication of delayed haemothorax has not been reported yet. We report a case of a young male who suffered manubriosternal dislocation with chance type thoracic spine fracture due to fall of a tree branch over his back. The haemothorax presented late on day three. The possible injury mechanism is discussed along with review of literature. We conclude that a lateral chest radiograph is indicated in spinal fracture patients complaining of midsternal pain. Computerized axial tomography scan of chest with contrast is indicated to rule out visceral injuries and a chest radiograph should be repeated before the patient is discharged to look for delayed haemothorax.

Traumatic subclavian arterial thrombosis presenting with cerebral infarct--a case report.

Subclavian artery thrombosis is a rare complication of sternoclavicular fractures. Also, cerebral infarcts caused by subclavian artery thrombosis, post trauma, is very unusual. We report the case of a 49 year-old female patient presenting with traumatic subclavian arterial thrombosis and cerebral infarction secondary to a fractured manubrium with posteriorly displaced right clavicle and retrograde thromboembolisation.

Thoracic injuries in professional rugby players: mechanisms of injury and imaging characteristics.

Professional rugby players are prone to traumatic thoracic injuries due to the use of minimal protective gear to cover the torso. In the 2007 Rugby World Cup, thoracic injuries occurred at a rate of 8.3 cases/1000 player-hours. CT and MRI play an important role in the diagnosis of these injuries. Vital internal organs, such as the heart, lungs, trachea, liver and large blood vessels lie within close proximity to the bony structures and what seems to be a simple rib fracture or clavicular dislocation can have potentially life-threatening complications that are not detected by conventional radiography. Cross-sectional imaging helps to determine the choice of treatment. Ultrasound offers a quick and dynamic imaging examination and allows high-resolution assessment of superficial tissues that complements conventional imaging. In this review article, we (1) presented data on incidence of thoracic injuries in professional rugby players; (2) described the anatomy of the joints comprising the thoracic cage and major muscles attached to the rib cage; (3) discussed indications and relevance for MRI and presented an optimised MRI protocol for assessment of suspected thoracic injury; and (4) illustrated various types of thoracic injuries seen in professional rugby players, including sternal contusion, retrosternal haematoma, manubriosternal disruption, sternoclavicular dislocation, rib fractures and injuries of the pectoralis major muscle.

Surgical management of traumatic isolated sternal fracture and manubriosternal dislocation.

BACKGROUND: The aim of this study was to evaluate the surgical procedures of osteosynthesis and the respective costs in isolated sternal fractures and manubriosternal dislocations. METHODS: Between January 2006 and July 2011, we treated 47 patients with an isolated fracture and 18 patients with a dislocation of the sternum surgically. In case of sternal fracture, the titanium plate was used in 30 (64%), steel plate in 12 (25%), and steel wire in 5 patients (11%). The stabilization after traumatic luxation was obtained with steel wire in 4 patients (22%) and titanium plate associated with demineralized bone matrix in 14 patients (78%). The quality adjusted life years (QALYs) was analyzed, as well as the incremental cost-effectiveness ratio based on QALYs. RESULTS: In the sternal fractures, titanium plate showed a decreased time of intervention (30 [2] minutes), length of stay (3 [1] days), and total cost (&OV0556;2,277.10) compared with steel plate (&OV0556;2,667.70) and steel wire (&OV0556;2,801.60) procedures, displaying an excellent difference in QALYs (0.825 and 1.615, respectively). In the sternal dislocation, steel wire technique highlighted a poor QALYs, although this approach was less expensive than titanium plate with demineralized bone matrix (&OV0556;3,553.60 vs. &OV0556;6,047.80). Incremental cost-effectiveness ratio revealed that the titanium plate costs were &OV0556;623.55 more than the steel wire per QALYs gained. CONCLUSION: The rigid titanium plate application ensured a safe and easy management of traumatic sternal lesions with a good prognosis of patients, justified by the improved QALYs compared with other methods. LEVEL OF EVIDENCE: Therapeutic study, level IV; economic analysis, level IV.

Parallel plating for a sternomanubrial dislocation.

Sternomanubrial dislocations are rare injuries. Although few cases of this injury have been reported in the literature, the etiology has varied widely: trampoline injury, seizures, falls from height, sporting injuries, gradual deformities from spine fractures, and motor vehicle collisions. This injury has been classified into 2 types: in type I, the sternal body is displaced posteriorly to the manubrium, and in the more common type II, the sternal body is displaced anteriorly. The sternomanubrial joint is an amphiarthroidal joint that bears hyaline cartilage on both surfaces connected by a fibrocartilage meniscus. It serves a protective role to vital thoracic structures and is an anterior stabilizing strut to the thorax, assisting the thoracic spine in upright stability. It is important to not ignore type I dislocations because posterior sternum displacement is a harbinger of injury to the pulmonary tree, heart, and esophagus. Chronic instability at this joint can lead to dyspnea and dysphasia due to sternum displacement. In the right scenario, type II injuries are occasionally treated conservatively with palliative treatment until the sternum heals with malformation. This article describes the case of a 20-year-old man who was treated surgically for symptomatic type II sternomanubrial dislocation with dual anterior locked plating. Locked plating gives the benefit of unicortical fixation, with the screws and plate acting as a unit to resist motion. Screw pullout and failure is less common, and the construct is more resistant for this application. The patient returned to full participation in activities of daily living and military duty 4 months postoperatively.

Biomechanical impact response of the human chin and manubrium.

Chin-to-chest impact commonly occurs in frontal crash simulations with restrained anthropomorphic test devices (ATDs) in non-airbag situations. This study investigated the biofidelity of this contact by evaluating the impact response of both the chin and manubrium of adult post-mortem human subjects (PMHSs). The adult PMHS data were scaled to a 10-year-old (YO) human size and then compared with the Hybrid III 10YO child (HIII-10C) ATD response with the same test configurations. For both the chin and manubrium, the responses of the scaled PMHS had different characteristics than the HIII-10C ATD responses. Elevated energy impact tests to the PMHS mandible provided a mean injury tolerance value for chin impact force. Chin contact forces in the HIII-10C ATD were calculated in previously conducted HYGE sled crash simulation tests, and these contact forces were strongly correlated with the Head Injury Criterion (HIC(36 ms)). The mean injurious force from the PMHS tests corresponded to a HIC(36 ms) value that would predict an elevated injury risk if it is assumed that fractures of the chin and skull are similarly correlated with HIC(36 ms). Given the rarity of same occupant-induced chin injury in booster-seated occupants in real crash data and the disparity in chin and manubrium stiffnesses between scaled PMHS and HIII-10C ATD, the data from this study can be made use of to improve biofidelity of chin-to-manubrium contact in ATDs.

[A man with thoracic pain]. / Een man met aanhoudende thoracale pijn.

A 46-year-old man had pain between the shoulders and at the sternum. Two and a half months earlier he had fallen when cycling. It appeared the pain was caused by fractures of thoracic vertebrae V and VI and a dislocation of the manubrium and body of the sternum.

Osteosynthesis of traumatic manubriosternal dislocations and sternal fractures with a 3.5/4.0 mm fixed-angle plate (LCP).

INTRODUCTION: We present a case series of three patients with manubriosternal dislocation and/or sternal fractures. METHOD: We describe our experiences of invasive surgical treatment with 3.5/4.0 mm fixed-angle plate (Locking compression plate, LCP) in this group of patients. Recommended nonoperative treatment options, e.g. correction tape or plaster bandage, symptomatic pain treatment, application of ice, and several weeks without sports are associated with a not inconsiderable rate of subluxations or reluxations with an increased risk of pseudarthrosis and chronic pain syndrome. RESULTS: Due to a small number of cases and the lack of controlled studies, a standardized operative procedure could, therefore, so far not been established. CONCLUSION: Our positive experiences with the operative treatment using 3.5/4.0 mm fixed-angle plate (LCP) may help to establish the operative procedure of first choice in this group of patients.

Alternativas quirúrgicas en el tratamiento de los tumores: de la pared torácica / Surgical alternative for the treatment of thoracic wall tumor

Los tumores de la pared torácica son neoplasias poco frecuentes, y de difícil tratamiento. Cuatro pacientes con neoplasias de la pared torácica fueron intervenidos en el Hospital Universitario de Maracaibo entre los años 2005 a 2008, con los diagnósticos de: plasmocitoma en dos pacientes y condrosarcoma en dos pacientes. Entre las intervenciones quirúrgicas realizadas destacan: resección de tumor de la pared torácica e interposición de malla en tres pacientes y resección de tumor esternal con interposición de malla y metacrilato en un paciente. La evolución posoperatoria fue satisfactoria en tres pacientes, un paciente en quien se interpuso malla y metacrilato se produjo el desplazamiento de la malla a un año de la intervención. Es importante en los pacientes con tumores de la pared torácica una adecuada planificación preoperatoria de la intervención para disminuir la morbilidad y mortalidad posoperatoria, y lograr mejores resultados quirúrgicos y funcionales.

The chest wall tumors are neoplasm with a low frequency and they are of difficult in the treatment. Four patients with chest wall neoplasm were operated in the Universitary Hospital from Maracaibo between 2005 at 2008 with the diagnoses of plasmacytoma in two patients and chondrosarcoma in two patients. The surgical procedures for us performed were: Chest wall tumor resection and mesh interposition in three patients and sternum tumor resection with interposition of mesh with methyl methacrylate in one patient. The postoperatory evolution was satisfactory in three patients and the patient with the reconstruction using mesh and methyl methacrylate had the displacement of the mesh after of a year of the surgical procedure. It is very important in the patients with chest wall tumors an adequate preoperatory evaluation with the objective of reduces the mortality and morbidity postoperatory and obtains better surgical and functional results.

Manubriosternal subluxation/dislocation can lead to manubriosternal septic arthritis in patients with kyphoscoliosis.

Locally deranged joint anatomy can predispose to septic arthritis which can be managed by surgical debridement. We present a case of manubriosternal subluxation/dislocation caused by kyphoscoliosis leading to manubriosternal septic arthritis.

Manubriosternal joint dislocation: an unusual risk of trampolining.

BACKGROUND: Manubriosternal joint (MSJ) dislocation is a rare but potentially serious injury that can be associated with concurrent injuries to ribs, lungs, or myocardium. Two distinct types of MSJ dislocation have been described in the literature: type I, involving posterior dislocation of the sternum due solely to direct trauma; and type II, involving the sternum being pushed anteriorly as a result of indirect trauma. Until now, the relationship between the nature of the forces acting on the sternum and the type of MSJ dislocation that results has been absolute, whereby indirect forces never cause a type I dislocation, and direct forces never result in a type II dislocation. OBJECTIVES: To describe a case demonstrating that type I MSJ dislocation can occur without direct trauma. CASE REPORT: A 14-year-old boy developed sternal pain accompanied by an audible crack while executing a maneuver on a trampoline that required hyperflexion of the thorax. A lateral chest radiograph demonstrated a type I manubriosternal dislocation normally associated with direct trauma, as opposed to the more typical type II dislocation pattern one would expect to find in a hyperflexion injury. CONCLUSION: MSJ dislocations are classified into two groups, depending on the position of the sternum in relation to the manubrium. Each type of dislocation has been ascribed to either direct forces (for type I dislocation) or indirect forces (for type II dislocation). This case highlights that it is possible to have a type I dislocation in the absence of any direct sternal trauma.