Right transmanubrial approach to the cervicothoracic spine with venous reconstruction.

The transmanubrial approach first reported by Grunenwald in 1997 is well-known for superior sulcus lung malignancies involving the thoracic inlet. Because an anterior approach to levels below Th2 is difficult without removing the manubrium, we used the transmanubrial approach for anterior cervicothoracic corpectomy and fusion (C7-Th3) in a patient with bilateral lower extremity paralysis due to ossification of the posterior longitudinal ligament in the cervicothoracic spine. To ensure more working space in the deep surgical field, which was hindered by a prior cardiac operation with median sternotomy and a goiter protruding into the upper mediastinal region, the right brachiocephalic vein was temporarily divided and subsequently reconstructed using bovine pericardium.

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.

Analysis of sternal healing after median sternotomy in low risk patients at midterm follow-up: retrospective cohort study from two centres.

BACKGROUND: For low risk patients undergoing median sternotomies, no midterm follow-up studies involving sternal healing have been conducted. In this study we evaluated sternal healing in low risk patients by chest CT scan and the risk factors associated with poor healing were analyzed. METHODS: Patients who underwent sternal median incision heart surgery from September 2014 to March 2015 were recruited. The clinical information of these patients during hospitalization was collected, and the CT scan data were submitted to the two chief physicians of the Radiology Department for radiographical sternal healing score determination. Based on the method of wound closure, the patients were divided into sternum plate (Plates) and wire groups (Wires). RESULTS: Forty-four patients were recruited. The mean CT examination time was 17.27 ± 2.30 months postoperatively. Twenty-nine (65.9%) patients met the criteria for radiographic sternal healing. Three segments, including the aortopulmonary window, the main pulmonary artery, and the aortic root, had healed less in comparison to the manubrium segment. Compared to patients in whom 6-7 metal wires were used for sternal closure, healing of the lower sternum was worse in patients in whom five wires were used, but the difference in healing was not statistically significant. Univariate analysis of sternal healing showed that patient age was a risk factor for sternal non-healing. When the patient age was > 45 years, the predicted risk of radiographic sternal non-union was 1.833 (95% CI: 1.343-2.503). CONCLUSIONS: At the mid-term follow-up, 65.9% of patients undergoing median sternotomies demonstrated radiographic sternal healing. Age, but not closure device, was a risk factor for sternal non-healing in low risk patients. Use of more wires had a positive impact on sternal healing. TRIAL REGISTRATION: researchregistry4918, registered 28 May 2019, retrospectively registered.

Custom-made Prosthesis for Reconstruction after Radical Resection for Chondrosarcoma of Manubrium.

The clinical incidence of tumors in the manubrium is not high. Regardless of whether the tumor is primary or metastatic, the tumor should be completely removed as long as the patient is able to tolerate the surgery. This procedure can lead to sternal defects. Deciding on the method of defect reconstruction is a critical problem that clinicians face. In this , to reduce the limitations of the patient's upper body movement after surgery due to the inflexibility in the connections of the sternal prosthesis, we created a prosthesis using a computer-assisted design method and a 3-D technique, to completely preserve the agility of the sternum and maximize the patient's post-operational movement. The method used in the present study takes into consideration the individual's chest anatomy, sternum stress, and many other biological characteristics. Care is taken to measure the sternum size accurately, to provide personalized treatment, to accomplish precise results, and to reduce potential future damage. The patient's shoulder function was improved following the procedure.

Forensic age estimation by morphometric analysis of the manubrium from 3D MR images.

Forensic age estimation research based on skeletal structures focuses on patterns of growth and development using different bones. In this work, our aim was to study growth-related evolution of the manubrium in living adolescents and young adults using magnetic resonance imaging (MRI), which is an image acquisition modality that does not involve ionizing radiation. In a first step, individual manubrium and subject features were correlated with age, which confirmed a statistically significant change of manubrium volume (Mvol:p<0.01, R2¯=0.50) and surface area (Msur:p<0.01, R2¯=0.53) for the studied age range. Additionally, shapes of the manubria were for the first time investigated using principal component analysis. The decomposition of the data in principal components allowed to analyse the contribution of each component to total shape variation. With 13 principal components, ∼96% of shape variation could be described (Mshp:p<0.01, R2¯=0.60). Multiple linear regression analysis modelled the relationship between the statistically best correlated variables and age. Models including manubrium shape, volume or surface area divided by the height of the subject (Y∼MshpMsur/Sh:p<0.01, R2¯=0.71; Y∼MshpMvol/Sh:p<0.01, R2¯=0.72) presented a standard error of estimate of two years. In order to estimate the accuracy of these two manubrium-based age estimation models, cross validation experiments predicting age on held-out test sets were performed. Median absolute difference of predicted and known chronological age was 1.18 years for the best performing model (Y∼MshpMsur/Sh:p<0.01, Rp2=0.67). In conclusion, despite limitations in determining legal majority age, manubrium morphometry analysis presented statistically significant results for skeletal age estimation, which indicates that this bone structure may be considered as a new candidate in multi-factorial MRI-based age estimation.

Can standard anterior Smith-Robinson supramanubrial approach be utilized for approach down to T2 or T3?

PURPOSE: The aim of this study was to determine a plain radiographic criterion for determining the feasibility of using the standard anterior Smith-Robinson supramanubrial approach for anterior surgery down to T2 or T3. METHODS: The surgical database (2002-2014) was searched to identify patients with anterior cervical surgery to T2 or T3. A method to determine whether a standard anterior Smith-Robinson approach can be used to operate on the upper thoracic levels was evaluated. The surgeon chose the surgical approach preoperatively using a lateral radiograph by determining if a line from the intended skin incision to the lower instrumented level (LIV) passed above the top of the manubrium. If so, a standard Smith-Robinson approach was selected. Another spine surgeon then analyzed all patients who had anterior thoracic fusion to T2 or below. The lateral radiographs were retrospectively reviewed. RESULTS: A total of 44 patients who underwent anterior surgery down to T2 or T3 vertebrae were identified. T2 was the LIV in 39 patients. T3 was the LIV in five patients. No surgery was abandoned or converted to a difference approach after making the standard Smith-Robinson approach. To increase visualization, T1 corpectomy was necessary in 4 of 39 patients when T2 was the LIV. T2 corpectomy was necessary in 2 of 5 patients when T3 was the LIV. CONCLUSION: If a line from the intended skin incision to the LIV passes over the top of the manubrium, a standard Smith-Robinson approach without sternotomy can be successfully used.

["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.

Complete sternal cleft associated with right clavicular, manubrial, and thyroid hypoplasia, pectus deformity, and spinal anomalies.

Sternal cleft anomalies are rare. Associated anomalies include pentalogy of Cantrell and posterior fossa abnormalities, hemangiomas, arteriopathy, cardiac anomalies, eye abnormalities, and sternal defects syndrome. There is only a single report of complete sternal cleft, pectus excavatum, and right clavicular hypoplasia in an adult. Thyroid hemiagenesis is also very rare. To our knowledge, this is the first case of complete sternal cleft, pectus deformity, and right clavicular hypoplasia in a child and the first case with right thyroid hemiagenesis.

Relevance of discrete traits in forensic anthropology: From the first cervical vertebra to the pelvic girdle.

In forensic anthropology, identification begins by determining the sex, age, ancestry and stature of the individuals. Asymptomatic variations present on the skeleton, known as discrete traits, can be useful to identify individuals, or at least contribute to complete their biological profile. We decided to focus our work on the upper part of the skeleton, from the first vertebra to the pelvic girdle, and we chose to present 8 discrete traits (spina bifida occulta, butterfly vertebra, supraclavicular nerve foramen, coracoclavicular joint, os acromiale, suprascapular foramen, manubrium foramen and pubic spine), because they show a frequency lower than 10%. We examined 502 anonymous CT scans from polytraumatized individuals, aged 15 to 65 years, in order to detect the selected discrete traits. Age and sex were known for each subject. Thin sections in the axial, coronal and sagittal planes and 3D volume rendering images were created and examined for the visualization of the selected discrete traits. Supraclavicular foramina were found only in males and only on the left clavicle. Coracoclavicular joints were observed only in males. The majority of individuals with a suprascapular foramen were older than 50 years of age. Pubic spines were observed mostly in females. Other traits did not present significant association with sex, age and laterality. No association between traits was highlighted. Better knowledge of human skeletal variations will help anthropologists come closer to a positive identification, especially if these variations are rare, therefore making them more discriminant.

[Treatment Strategies for Septic Arthritis of the Sternoclavicular Joint]. / Behandlungsstrategie der septischen Arthritiden des Sternoklavikulargelenks.

Septic arthritis of the sternoclavicular joint (SCJ) is a relatively rare disease. Due to serious complications including mediastinitis and generalised sepsis early diagnosis and rapid onset of treatment are mandatory. The disease often affects immunocompromised patients, diabetics, or patients with other infectious diseases. The therapeutic options range from administration of antibiotics to extended surgery including reconstructive procedures. Apart from rare situations where conservative treatment with antibiotics is sufficient, joint resection followed by plastic surgical procedures are required. We present a retrospective analysis with data from two hospitals. From January 2008 to December 2012 23 patients with radiographically confirmed septic arthritis of various aetiology were included. Fourteen (60.8 %) male, nine (39.2 %) female patients with an average age of 60.3 ± 14.2 years (range: 23-88 years) with septic arthritis of the SCJ were treated. Seven (30.4 %) patients suffered from Diabetes mellitus, nine (39.1 %) had underlying diseases with a compromised immune system. In 14 (60.8 %) out of 23 patients a bacterial focus was detected. Only six (26 %) patients suffered from confined septic arthritis of the SCG, in 17 (73,9 %) patients osteomyelitis of the adjacent sternum, and the clavicle was present. In addition, 15 (65.2 %) patients already suffered from mediastinitis at the time of diagnosis, eight (35 %) patients even from septicaemia. In conclusion, septic arthritis requires an active surgical treatment. Limited incision of the joint and debridement alone is only successful at early stages of the disease. The treatment concept has to include the local joint and bone resection as well as complications like mediastinitis. After successful treatment of the infection, the defect of the chest wall requires secondary reconstructive surgery using a pedicled pectoralis muscle flap.

Tuberculosis of the manubriosternal joint and concurrent asymptomatic active pulmonary tuberculosis in a patient presenting with a chest wall mass.

A 62-year-old woman presented to our hospital with an anterior chest wall swelling. Computed tomography (CT) and magnetic resonance imaging showed findings consistent with an infectious arthritis of the manubriosternal joint, and CT images also demonstrated multiple centrilobular nodules in both lungs, suggesting an infectious bronchiolitis. A CT-guided fine needle aspiration of a presternal mass yielded growth of Mycobacterium tuberculosis. Bronchoalveolar lavage confirmed an active pulmonary tuberculosis. Septic arthritis of the manubriosternal joint is exceedingly rare.

Relationship of the Medial Clavicular Head to the Manubrium in Normal and Symptomatic Degenerated Sternoclavicular Joints.

BACKGROUND: Clavicular prominence is common in patients with symptomatic degenerative sternoclavicular arthritis. It is unclear if this is caused by enlargement or subluxation of the clavicle. The aim of this report is to describe a reproducible measurement technique to evaluate the relationship of the medial clavicular head to the manubrium. METHODS: One hundred normal sternoclavicular joints, twenty-five sternoclavicular joints with symptomatic degenerative arthritis, and twenty-five non-symptomatic sternoclavicular joints on the contralateral side were studied with three-dimensional (3D) reconstruction with use of computer modeling. The greatest width (anterior-posterior distance) and height (superior-inferior distance) of the clavicle in the sagittal plane were measured, and the positions of the anterior and superior borders of the medial clavicle and their distances to the frontal and axial planes, respectively, were evaluated. The ratio of the anterior-posterior distance to the anterior-frontal plane distance was measured to evaluate the anterior-posterior position of the clavicle and the ratio of the superior-inferior distance to the superior-axial plane distance was measured to evaluate its superoinferior position. If the ratio was not in the 95% normal range, the clavicle was defined as subluxated. The reproducibility of this technique was evaluated on the basis of the interobserver and intraobserver reliability. RESULTS: This technique showed good interobserver and intraobserver reliability. The mean anterior-posterior and superior-inferior distances were significantly larger in association with symptomatic sternoclavicular arthritis than in the normal sternoclavicular joints (p < 0001). The clavicle was subluxated anteriorly in twenty-two of the twenty-five cases of symptomatic sternoclavicular arthritis, but it was not subluxated superiorly. CONCLUSIONS: The medial clavicular head in patients with degenerative sternoclavicular arthritis is significantly larger than it is in the normal population, and it is usually subluxated anteriorly.

"Hidden" bone metastasis from thyroid carcinoma: a clinical note.

The (131)I-iodide ((131)I) whole-body scan, for thyroid carcinoma is at times difficult to interpret. In a diagnostic whole body (131)I scan of a patient with follicular carcinoma, a posterior skull lesion was partially hidden by overlapping facial structures. On lateral head view, the abnormality was clearly evident. SPECT/CT and MRI showed the lesion originated in the occipital bone and had enlarged into the posterior fossa. The mass was surgically removed and the patient received (131)I therapy for residual tissue. The study demonstrates a pitfall in the reading of two dimensional radioiodine images which can be overcome by SPECT or lateral imaging.