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Introduction: Sternal intraosseous (IO) access has advantages over humeral and tibial access for fluid resuscitation in military medical settings due to superior flow rates and pharmacokinetics. However, the morphology of the young adult manubrial cortical and medullary bone as it relates to IO catheter tips of currently available FDA-approved IO access devices is unclear., Materials and Methods: Computed tomography manubrium images of active duty service members (N = 93) aged 18 to 30 were assessed by radiologists, including manubrial height, width, and cortical thickness, as well as total thickness and medullary thickness at the thickest (superior) and thinnest (inferior) parts of the manubrium. Inference regarding medullary or cortical IO catheter tip placement rates were made for FAST1 (5.5 mm catheter depth) and TALON (4.5 mm catheter depth) sternal IO devices. Data were analyzed using ANOVA, non-parametric, and correlational statistics at P < 0.05., Results: As inferred from case-specific CT-derived manubrium dimensions and maximal catheter tip penetration depths, both FAST1 and TALON would be placed in the target medullary space on 100% of opportunities if properly applied in the superior manubrium and on 99% of opportunities if properly applied in the inferior manubrium. Age was not significantly related to IO-relevant manubrial dimensions., Conclusions: Present findings suggest that both FAST1 and TALON sternal IO catheter tips can be successfully placed into the target medullary bone with high accuracy in male military members aged 18 to 30 who require rapid resuscitation., (© The Association of Military Surgeons of the United States 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site–for further information please contact journals.permissions@oup.com.)

Rib graft is a common source of cartilage in rhinoplasty. Donor site choices for this resource were identified according to the authors who presented the introduction of this technique. However, the scientific basis of this valuable method lacks information, including the anatomical properties of costal cartilage. In this study, cartilage radioanatomy is examined and tested for if any estimators are present. A total of 148 thoracal CT scans of patients who applied to our facility were analyzed. Patients were divided per their sex and age of 35, and rib cartilage dimensions, including axial length between the sternal and costal ends of the cartilage (TotL), posteroanterior diameters at the sternal end (StDia), costal end (CosDia), the thickest part (MaxDia) as diametrical parameters and vertical height at the thickest part (h) were recorded. Length of the sternum (St), the axial length of the clavicle (ClavL), the distance of the sixth rib from the anterior axillary border (AntAx), and thorax circumferences at the level of both pectoralis major muscle origin (ThC) and nipples (BrC) were recorded. Statistical analyses were done for correlations. St, ClavL, ThC, and BrC were found to have the most correlated measurements in groups with the age of 35 and less of both genders, and the relations were lost in older groups. Thorax shape may change after the age of 35 years, but in younger patients, St in females and ClavL in males can be used as estimators of cartilage amount., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

The analysis of the sternoclavicular joint holds significant importance in forensic anthropology, especially through the evaluation of medial clavicular ossification stage, which, however, is helpful only in subjects younger than 30 years of age. Given this limitation, the aim of the present work was to examine, through micro-CT, the surface of sternoclavicular joints of deceased individuals across various age groups, aiming to identify age-related degenerative changes applicable to age estimation in adults over 30 years old. A total of 41 deceased subjects were categorized into three age groups (20-39 years; 40-59 years; ≥60 years) for the analysis. Degenerative morphological features on both clavicular and sternal articular surfaces, including topography, porosity, and presence of osteophytes, were evaluated using a composite scoring system based on a modified "Falys-Prangle method.", which assigns to each parameter specific score ranges: 1-3 for surface topography (smooth, slightly irregular, markedly irregular), 1-6 for porosity (absent, micro- and macroporosity for <50 % or >50 % of surface, surface breakdown), 1-3 for osteophytes (absent, present, not evaluable). The findings revealed a positive correlation between degenerative morphological features and age for both clavicular (rs = 0.719) and sternal articular surfaces (rs = 0.750). Additionally, the combined assessment of the clavicle and sternum, or the evaluation of the clavicle alone, exhibited better differentiation among the three age groups. The micro-CT evaluation of degenerative alterations affecting the sternoclavicular joint proves to be a reliable and efficient method for age estimation in adults., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

This review delves into the forensic utility of the sternum in creating a biological profile, focusing on sex, stature, and age estimation. Emphasizing the sternum's significance in challenging scenarios, the study supports the combined length of the manubrium and sternal body as a crucial indicator in sex and stature estimation. However, it highlights the need for caution in applying findings across diverse populations and questions the reliability of Hyrtl's law. Age estimation, primarily based on morphological changes and ossification ages, is explored, with one study showing promise but requiring further validation. While acknowledging the sternum's advantages, the review underscores potential limitations and the absence of specific studies on ancestry estimation, leaving this aspect open for future research. In conclusion, the review provides a comprehensive overview of the sternum's forensic applications, urging continued research to enhance accuracy and applicability.

Background: The sternum exhibits unique anatomical variations with major clinical and forensic implications. This study is devoted to providing baseline epidemiological information about the sternal foramen and variant xiphoid morphology in Ethiopia. Two extremely interesting and unusual variations of the sternal foramen are also discussed. Methods: This observational study was carried out using dried adult human sternum obtained from skeletal remains samples brought for medicolegal examination over a period of 4 years. A total of 94 dried adult human sternums (66 males (70.2%) and 28 females (29.8%)) were obtained with an age range of 21 to 57 years and a mean age at death of 38.383 ± 11.3480 years. Dried human sternum specimens were morphologically examined, and morphometric parameters were recorded and photographed. Results: A sternal foramen was found in 18 specimens (19.1%); 17 were male and one was female. A single sternal foramen was observed in 83.3% (n=15/18) of the sternal bodies and 11.1% (n=2/18) of the xiphoid processes (both males). In addition, a double sternal foramen was observed in a single male specimen on the mesosternum and xiphoid process. The most common sternal foramen site was at the fifth costochondral junction level. The xiphoid process was present in 77 samples and ended as a single process in 83.1% (n=64/77) of samples. In 15.6% (n=12/77) of the samples, the xiphoid process was bifurcated and trifurcated in a single male (1.3%) specimen. Conclusions: The sternal foramen and variation in xiphoid morphology are common anatomical variations in Ethiopia. The findings of the current study highlight the necessity of strict precautionary measures during sternal procedures in this study population. In addition, such incidental findings during radiologic and autopsy procedures should be properly evaluated to avoid misdiagnosis and misinterpretation of such findings as traumatic or pathologic conditions., Competing Interests: No competing interests were disclosed., (Copyright: © 2023 Lema AS.)

Purpose: Sternal foramen is a perforation of the sternum that can be a source of misdiagnosis during radiographic imaging or life-threatening perforations during bone marrow sampling. The aim of this study was to conduct a meta-analysis on the prevalence, morphometrics, and location of foramen in the sternal body and xiphoid process, describe morphometric features of this phenomenon, and thus verify its clinical importance. Moreover, our secondary outcome was to compare effectiveness of various imaging methods in diagnosis of the sternal or xiphoid foramen., Methods: A comprehensive search was conducted on major scientific databases to identify studies containing relevant information. Data on foramen's prevalence, location, morphometrics, and accompanying findings were extracted and pooled into a meta-analysis using MetaXL 5.0., Results: Thirty-five studies (n = 16,666 subjects) were included. The overall pooled prevalence of a foramen in the sternal body and/or a xiphoid process was 8.9% (95% CI 6.5-11.7) and it equaled 6.5% (95% CI 5.6-7.6) for sternal body alone and 2.9% (95% CI 0.5-6.9) for the xiphoid process. The foramen was more prevalent in males than in females (12.2% vs. 6.8%). The prevalence of sternal foramen was higher in South American [13.9% (95% CI 11.2-16.9)] and African [13.6% (95% CI 9.7-18.0)] studies compared to North American [6.2% (95% CI 5.0-7.5)] and European populations [8.6% (95% CI 3.1-16.3)]. Mean transverse and vertical diameter of foramen equaled 4.7 mm (95% CI 3.8-5.5), and 5.6 mm (95% CI 4.2-6.9), respectively., Conclusion: Our analysis proves that the sternal foramina are structures of significant prevalence and size. Any physician should keep them in mind when performing punctures in this area., (© 2023. The Author(s).)

Anatomy of the first flying feathered dinosaurs, modern birds and crocodylians, proposes an ancestral flight system divided between shoulder and chest muscles, before the upstroke muscles migrated beneath the body. This ancestral flight system featured the dorsally positioned deltoids and supracoracoideus controlling the upstroke and the chest-bound pectoralis controlling the downstroke. Preserved soft anatomy is needed to contextualize the origin of the modern flight system, but this has remained elusive. Here we reveal the soft anatomy of the earliest theropod flyers preserved as residual skin chemistry covering the body and delimiting its margins. These data provide preserved soft anatomy that independently validate the ancestral theropod flight system. The heavily constructed shoulder and more weakly constructed chest in the early pygostylian Confuciusornis indicated by a preserved body profile, proposes the first upstroke-enhanced flight stroke. Slender ventral body profiles in the early-diverging birds Archaeopteryx and Anchiornis suggest habitual use of the pectoralis could not maintain the sternum through bone functional adaptations. Increased wing-assisted terrestrial locomotion potentially accelerated sternum loss through higher breathing requirements. Lower expected downstroke requirements in the early thermal soarer Sapeornis could have driven sternum loss through bone functional adaption, possibly encouraged by the higher breathing demands of a Confuciusornis -like upstroke. Both factors are supported by a slender ventral body profile. These data validate the ancestral shoulder/chest flight system and provide insights into novel upstroke-enhanced flight strokes and early sternum loss, filling important gaps in our understanding of the appearance of modern flight.

Sex determination is one of the first biological attribute to be assessed when unidentified remains surface. In material of forensic interest, being able to use every skeletal element available for identification purposes is of paramount importance. The osteometric method from the sternal rib end has been found to generate accurate sex estimates, but as various studies have proved, all osteometric methods should be population-specific, as one equation does not fit all. The aim of this study is to assess sexual dimorphism in a contemporary Greek population sample of 68 males and 43 females, with the use of discriminant function analysis. The superior-inferior height (SIH) and anterior-posterior breadth (APB) from the third to fifth sternal rib ends of both sides were taken from 3D models created with the use of a hand-held 3D scanner. The results demonstrated that SIH is more sexually dimorphic than APB (alpha value of .05) while the application of İşcan's (1985) formula on the contemporary Greek sample, provided results of low accuracy, ranging from 48.6-52.4%. The cross-validated discriminant functions equations for the current sample, produced results ranging between 74.0-82.9% indicating that population-specific formulas produce results of higher accuracy, that are vital in cases of forensic interest.

The sternum is a stabilizing element in the axial skeleton of most tetrapods, closely linked with the function of the pectoral girdle of the appendicular skeleton. Modern mammals have a distinctive sternum characterized by multiple ossified segments, the origins of which are poorly understood. Although the evolution of the pectoral girdle has been extensively studied in early members of the mammalian total group (Synapsida), only limited data exist for the sternum. Ancestrally, synapsids exhibit a single sternal element and previously the earliest report of a segmental sternum in non-mammalian synapsids was in the Middle Triassic cynodont Diademodon tetragonus. Here, we describe the well-preserved sternum of a gorgonopsian, a group of sabre-toothed synapsids from the Permian. It represents an ossified, multipartite element resembling the mammalian condition. This discovery pulls back the origin of the distinctive "mammalian" sternum to the base of Theriodontia, significantly extending the temporal range of this morphology. Through a review of sternal morphology across Synapsida, we reconstruct the evolutionary history of this structure. Furthermore, we explore its role in the evolution of mammalian posture, gait, and ventilation through progressive regionalization of the postcranium as well as the posteriorization of musculature associated with mammalian breathing., (© 2022. The Author(s).)

Background: Occipital artery (OA)-posterior inferior cerebellar artery (PICA) bypass is a challenging procedure and is not frequently performed owing to the difficulty of OA harvest. To facilitate harvest, the intersection between the sternocleidomastoid and splenius capitis (the OA triangle) is used as the anatomical landmark to identify the OA segment that carries the highest risk of damage. This clinical study aimed to demonstrate efficacy and safety of OA harvest using this landmark., Methods: The study included 18 patients who underwent OA harvest using the OA triangle as a landmark for treatment of vertebral artery and PICA aneurysms. Patients were retrospectively evaluated for safety and patency of OA after harvest and OA-PICA bypass., Results: Of 18 patients with ruptured and unruptured vertebral artery and PICA aneurysms, 13 (72.2%) underwent OA-PICA bypass and 5 (27.8%) did not undergo bypass. The OA was completely harvested without damage in all patients. After harvest, the OA was patent in 17 patients (94.4%) and was occluded in 1 patient owing to vasospasm; this patient then underwent recanalization resulting in good patency of the OA-PICA bypass. The patency rate of the OA-PICA bypass was 100%., Conclusions: The OA triangle, which is the anatomical landmark of the proximal end of the transitional segment of the OA, facilitated OA harvest using the distal-to-proximal harvest technique with safety and good patency. To the best of our knowledge, this is the first study of OA harvest in clinical cases., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Abstract: There is a paucity of osteometric standards for sex estimation from unknown skeletal remains in Jordan and the sexual dimorphism of the sternum has not yet been investigated. The aim of this study was to evaluate the sexual dimorphism in sternal measurements using 3D multidetector computed tomography (MDCT), and to assess their reliability for sex estimation in a Jordanian population. A total of 600 MDCT scans (300 males and 300 females) were used and a total of 8 sternal measurements were studied (manubrium length, sternal body length, combined length of manubrium and body, corpus sterni width at 1st and 3rd sternebrae, sternal index and area). Sexual dimorphism was evaluated by means of discriminant function analyses. Significant sexual dimorphism was found mainly in middle-aged and older adults. Including all subjects, multivariate, and stepwise functions gave an overall accuracy of 83.0% and 84.0%, respectively. Additionally, multivariate and stepwise analyses were conducted separately for each age group. The accuracy of sex estimation in multivariate analysis (all variables) varied from 63.2% in the young, and 83.7% in the middle adults to 84.9% for older adults. In stepwise analysis, the highest accuracy rates were provided by only sternal area in young adults (81.6%), and sternal area combined with sternal body length in middle-aged and older adults (84.2% and 85.3%, respectively). The best sex discriminator using univariate analysis (single variable) was sternal area followed by sternal body length (84.0% and 80.8% respectively). Notably, univariate analyses for most variables gave relatively higher classification accuracies in females but were poor at predicting males in the sample (sex bias ranged between -6.4% and -20%). Our data suggest that dimorphism in the human sternum increases with advancing age and separate discriminant functions are needed for each age group in Jordanians. In addition, multivariate and stepwise analyses using sternum gave higher classification accuracies with comparatively lower sex biases compared to univariate analyses., Competing Interests: The authors have no conflicts of interests to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Forensic age estimation is a crucial aspect of the human identification process. Sternebral fusion is one of the skeletal indicators of age that has not been thoroughly researched for the purpose of age estimation. The present study was conducted with the aim of assessing the utility of each of the sternebral fusion in age estimation, and to ascertain if these fusion stages can help in identifying whether an individual has attained the medicolegally significant ages of 16 and 18 years. Thoracic CT images of 148 study participants (74 females, 74 males) were analysed to evaluate the fusion of sternebrae 1-2, sternebrae 2-3, and sternebrae 3-4. The fusion scores for these were found to be statistically significant (P < 0.001) with sternebrae 1-2 fusion showing the highest coefficient of correlation at R = 0.900. Linear regression models were generated using each of the sternebral fusions separately and together for estimation of age. The standard error of estimate for the regression models ranged from 1.51 to 2.86 years. Box and Whisker plots were constructed to see the fusion score wise age distribution of the study population, and it was observed that sternebral fusion has the ability to indicate whether an individual has attained the age of 16 and 18 years. Our study concludes that sternebral fusion can act as an accurate method of forensic age estimation of juveniles and young adults., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: The origin of powered avian flight was a locomotor innovation that expanded the ecological potential of maniraptoran dinosaurs, leading to remarkable variation in modern birds (Neornithes). The avian sternum is the anchor for the major flight muscles and, despite varying widely in morphology, has not been extensively studied from evolutionary or functional perspectives. We quantify sternal variation across a broad phylogenetic scope of birds using 3D geometric morphometrics methods. Using this comprehensive dataset, we apply phylogenetically informed regression approaches to test hypotheses of sternum size allometry and the correlation of sternal shape with both size and locomotory capabilities, including flightlessness and the highly varying flight and swimming styles of Neornithes., Results: We find evidence for isometry of sternal size relative to body mass and document significant allometry of sternal shape alongside important correlations with locomotory capability, reflecting the effects of both body shape and musculoskeletal variation. Among these, we show that a large sternum with a deep or cranially projected sternal keel is necessary for powered flight in modern birds, that deeper sternal keels are correlated with slower but stronger flight, robust caudal sternal borders are associated with faster flapping styles, and that narrower sterna are associated with running abilities. Correlations between shape and locomotion are significant but show weak explanatory power, indicating that although sternal shape is broadly associated with locomotory ecology, other unexplored factors are also important., Conclusions: These results display the ecological importance of the avian sternum for flight and locomotion by providing a novel understanding of sternum form and function in Neornithes. Our study lays the groundwork for estimating the locomotory abilities of paravian dinosaurs, the ancestors to Neornithes, by highlighting the importance of this critical element for avian flight, and will be useful for future work on the origin of flight along the dinosaur-bird lineage., (© 2021. The Author(s).)

Sex estimation is critical during forensic and anthropological investigations, and various techniques are used based on the presence of complete or fragmented human remains. This study evaluated sexual dimorphism in Sudanese sterna using multidetector computed tomography. This information was used to develop models for estimating sex, and to compare the accuracies of models based on discriminant function analysis (DFA) and binary logistic regression (BLR). The study included 126 Sudanese men and 144 Sudanese women who underwent computed tomography scans to create three-dimensional reconstructions. Six linear dimensions were measured on the manubrium and mesosternum. Men had larger mean values for most parameters, and nine parameters exhibited highly significant sexual dimorphism. The leave-one-out cross-validated sex estimation accuracies were 60.4-88.9% for DFA-based models and 60.4-89.3% for BLR-based models. The BLR-based models had noticeably better performances, with six parameters having sex estimation accuracies of >80% (vs. three parameters for DFA). The best BLR-based models incorporated the lengths and widths of the manubrium and mesosternum (accuracy: 89.3%, sex bias: 2.2%) and the combined manubrium and mesosternum lengths (accuracy: 85.6%, sex bias: 2.7%). Thus, computed tomography may be useful for measuring sternal dimensions and estimating sex among Sudanese subjects.

Background: Current guidelines for maternal cardiopulmonary resuscitation recommend the hands be placed on the lower half of the sternum for compressions. We sought to evaluate the effect of the gravid uterus and left uterine displacement on the position of the left ventricle (LV) using transthoracic echocardiography., Methods: We enrolled 20 women in the third trimester of a singleton pregnancy. Transthoracic echocardiography images in the supine and left lateral position, using a 30° wedge, were acquired. Parasternal long and short axis views of the LV were obtained at the lower half of the sternum and at the ideal imaging window (best image of mid-LV at 90° transducer orientation) The primary aim was to evaluate the distance between the distal end of the xiphoid and the location of the best imaging window of the LV., Results: The cohort included women without prior anatomical cardiac disease. The LV was best visualized 5.8 (±2) cm cranial to the distal end of the xiphoid in the supine position and 6.1 (±2) cm in the lateral position (P=0.6), using the left parasternal border as a reference. No lateral cardiac displacement was evidenced in either position., Conclusions: This pilot study used transthoracic echocardiography to document the position of the LV during the third trimester of pregnancy. The LV was located approximately 6 cm cranial to the distal tip of the xiphoid process. Further validation is required before recommending changes in hand placement during maternal cardiopulmonary resuscitation., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Some researchers have reported that applying compression closer to the maximum diameter of the left ventricle (Point&#95;max.LV) is associated with worse clinical outcomes, challenging its traditional position as optimum compression point (Point&#95;optimum). By locating the mid-sternum (the actual compression site) in terms of Point&#95;max.LV and its right ventricular equivalent (Point&#95;max.RV), we aimed to determine its optimum horizontal position associated with increased chances of return of spontaneous circulation (ROSC)., Methods: A retrospective, cross-sectional study was performed at a university hospital from 2014 to 2019 on non-traumatic out-of-hospital cardiac arrest (OHCA) victims who underwent chest computed tomography. On absolute x-axis, we designated the x-coordinate of the mid-sternum (x&#95;mid-sternum) as 0 and leftward direction as positive. Re-defining the x-coordinate of Point&#95;max.RV and Point&#95;max.LV as 0 and 1 interventricular unit (IVU), respectively, we could convert x&#95;mid-sternum to "-x&#95;max.RV/(x&#95;max.LV - x&#95;max.RV) (IVU)." Using multiple logistic regression analysis, we investigated whether this converted x&#95;mid-sternum was associated with clinical outcomes, adjusting core elements of the Utstein template., Results: Among 887 non-traumatic OHCA victims, 124 [64.4 ± 16.7 years, 43 women (34.7%)] were enrolled. Of these, 80 (64.5%) exhibited ROSC. X&#95;mid-sternum ranging from -1.71 to 0.58 (-0.36 ± 0.38) IVU was categorised into quintiles: <-0.60, -0.60 to -0.37, -0.37 to -0.22, -0.22 to -0.07 and ≥-0.07 (reference) IVU. The first quintile was positively associated with ROSC (odds ratio [95% confidence interval], 9.43 [1.44, 63.3])., Conclusion: Point&#95;optimum might be located far rightwards to Point&#95;max.RV, challenging the traditional assumption identifying Point&#95;optimum as Point&#95;max.LV., (© 2020 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Sex estimation of skeletal remains is of great importance in the fields of physical and forensic anthropology. Since skeletons are often incomplete, it is essential to estimate sex from as many skeletal remains as possible. The aim of this study was to establish new methods for estimating sex using the morphology of the sternum and the fifth to ninth ribs. We considered two conditions of skeletal preservation: All skeletal elements measured are available, or only a single element is available. Traditional or virtual measurements were carried out on three samples: (1) A skeletal sample from the Hamann-Todd Human osteological collection, Cleveland Museum of Natural History, USA (N = 413), was used to create prediction equations for sex estimation. (2) A recent, CT-based sample from Israel (N = 33) was used to cross-validate the accuracy of the prediction equations. (3) A skeletal sample from the Anthropological Collection at Tel Aviv University (N = 15) was used to test the validity of the virtual measurements. Reliability and validity analyses were carried out via intraclass correlation coefficient analysis. Prediction equations for sex were created using logistic regression. The measurements were found to be highly reliable and valid. Success rates for sex estimation were high (> 80%) and correspond well between the skeletal and recent samples, especially for the left sixth, left eigth, and left ninth ribs. To conclude, measurements of the sternum and ribs are valuable for estimating sex and can be carried out using either traditional or virtual tools. Of all the skeletal elements examined in this study, the sternum, left sixth, left eighth, and left ninth ribs were found to be the most reliable skeletal elements for estimating the sex of an individual.

It is generally accepted that primary spontaneous pneumothorax (PSP) is found mostly in tall, thin young males. However, the precise etiology of PSP is unclear. We compared some thoracic structural angles of PSPs and controls in young males to determine the predominant factor. CT data of 43 male PSPs (age 21.88 ± 5.30) and 30 controls (age 21.47 ± 5.47) were collected. The angle of thoracic vertebrae slope (∠α), sternal slope angle (∠β), and tracheal-sternal stem angle (∠γ) were measured in the sagittal position. Carina angle (∠δ) was measured in the coronal position. After a propensity score match (PSM) of age and smoking history, the angles were comparatively evaluated. There were significant differences in all four angles between two unmatched groups, while only in three (∠β, ∠γ, and ∠δ) after PSM was performed. The correlation between ∠β and PSP was most significant, and R 2 was 0.456. The prediction accuracy of ∠β was 81.3%, OR was 1.386, 95% confidence interval was (1.095-1.754). The sternal slope angles in PSPs are greater than controls indicate the sternal slope angle is associates with the development of PSP and it could be a thoracic structural index to predict the risk of PSP occurrence. Clin. Anat. 33:605-609, 2020. © 2019 Wiley Periodicals, Inc., (© 2019 Wiley Periodicals, Inc.)

We evaluated the applicability of the neck and sternal notch (SN) as anatomical landmarks for paediatric chest compression (CC) depth using chest computed tomography. The external anteroposterior diameter (EAPD) of the neck and chest at the SN level, mid-point between two landmarks (mid-landmark), and EAPD of the chest at the lower half of the sternum (EDLH) were measured. To estimate the depths of the landmarks from a virtual point at the same height as the position for CC, we calculated the differences between the EAPDs of the neck, SN, mid-landmark, and EDLH. We analysed the relationship between the depths of the landmarks and one-third EDLH using Bland-Altman plots. In all, 506 paediatric patients aged 1-9 years were enrolled. The depths of the neck, SN, and mid-landmark were 53.7 ± 10.0, 37.8 ± 8.5, and 45.8 ± 9.0 mm, respectively. The mean one-third EDLH was 46.8 ± 7.0 mm. The means of the differences between the depths of the neck and one-third EDLH, depths of the SN and one-third EDLH, and depths of the mid-landmark and one-third EDLH were 9.0, -6.9, and 1.0 mm, respectively. The SN and neck are inappropriate landmarks to guide compression depth in paediatric CPR.

The main purpose of this study is to develop a validated three-dimensional finite element model of sternum closure techniques. For this aim, the finite element method analysis results of three closure methods were compared with experimental test results. Also, three more closure techniques are simulated numerically to study the effect of the number of wires used in the manubrium and xiphoid regions. A three-dimensional model of polyurethane sternum foam was created based on computed tomography images. Six different closure techniques using steel wire, steel bands and ZipFix bands were modeled on the sternum and transferred into a three-dimensional finite element model. The sternum was modeled as an isotropic bilinear-elasto-plastic material, and nonlinear contact conditions were applied. The models were analyzed under lateral distraction loading, and load-displacement curves were obtained from displacements at the incision line. Allowable loads and stiffness values of the methods were evaluated from these curves. The results showed the importance of the including material as well as geometric nonlinearities in the simulations to obtain realistic results from the numerical analyses. Also, the analyses showed that closures that include steel or ZipFix bands are superior to conventional wiring, and addition of a single wire at the manubrium and xiphoid regions significantly improved the efficiency of the closure techniques.

In addition to the pelvis, cranium and phalanges, the sternum is also used for postmortem sex identification. Bone measurements may be obtained on cadaveric bones. Alternatively, computerized tomography may be used to obtain measurements close to the original ones. Moreover, usage of artificial neural networks (ANNs) in the field of medicine has started to provide new horizons. In this study, we aimed to identify sex by an ANN using lengths of manubrium sterni (MSL), corpus sterni (CSL) and processus xiphoideus (XPL) and sternal angle (SA) from computerized tomography (CT) images brought to an orthogonal plane. This study used the thin-slice thoracic CT images of 422 cases (213 female, 209 male) with an age range of 27-60 years brought to the orthogonal plane. Measurements of MSL, CSL, XPL and SA were analyzed with a multilayer artificial neural network that used stochastic gradient descent (SGD) for optimization and two hidden layers. MSL, CSL and XPL were longer, and SA was wider in men (MSL p = 0.000, CSL p = 0.000, XPL p = 0.000, SA p = 0.02). In the case of the two hidden layers of the network with 20 and 14 neurons in the hidden layers, respectively, learning rate of 0.1 and momentum coefficient of 0.9, the accuracy (Acc) of sex prediction was 0.906. In order to define a more realistic performance of the network, bootstrap was run with the confidence interval of 94%. A sensitivity (Sen) value of 0.91 and a specificity (Spe) value of 0.90 were calculated. The success rates that were achieved in sex identification with measurements on the skeleton using ANN were observed to be higher than those achieved by linear models. Also, sometimes all parts of the bones may not be found or might be deformed. In this case, the number of parameters used for the estimation will be incomplete. The ANN has the strong advantage to be able to estimate despite the missing parameter., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Introduction: Massive weight loss is associated with the ptosis of the breast, loss of the upper pole fullness, medialization of the nipples and volume depletion. Post bariatric patients often need breast reshaping with mastopexy or breast reduction. We report the author's experience with the medial central septum based mammoplasty for breast reshaping after massive weight loss., Methods: We retrospectively reviewed the records of 85 women who underwent a medial-central septum based mammaplasty, analyzing patients (age, BMI, comorbidities) and operation specific characteristics' (surgical technique, complications) to identify the advantages and the drawbacks of the adopted technique. All the procedures were performed at a single institution by the senior author of this article., Results: 85 patients were included in the review, in total 170 medial-central septum based mammaplasty were performed over a five years period. Early complications, as hematoma and seroma occurred in 2 patients. No total or partial nipple-areola losses were recorded and the viability of the nipple-areola complex (NAC) was excellent in all the treated patients. Sensation was retained in all breasts. Nine patients showed delayed wound healing at the joint of the T scar; in 5 patients we observed spreading scars., Conclusion: The medial-central septum based mammaplasty seems to be an effective and safe choice for breast reshaping after massive weight loss, as none of our patients experienced nipple loss and all of them reported good nipple sensation. Moreover, the technique is versatile and can be applied to patients with hypertrophic breasts or gigantomastia., (© 2019 Wiley Periodicals, Inc.)

Background: Preoperative airway evaluation in children is an important part of routine preanesthetic evaluation before surgery. External airway measurements, viz., thyromental, mentohyoid, and sternomental distances, while being growth dependent, could identify pediatric patients with potentially difficult airways., Objectives: This study was conducted to validate the age- and height-based formulae, derived from a previous study conducted in our institute, to predict thyromental distance, sternomental distance, and mentohyoid distance in relation with the height and age of pediatric patients., Design: Prospective cross-sectional single arm observational study., Setting: Tertiary level university teaching hospital from July 2015 to December 2016., Patients: Children (202) in the age group of 3-15 years with no obvious external airway anomaly scheduled for elective surgery under general anesthesia., Outcomes Measured: The thyromental, mentohyoid, and sternomental distances were measured preoperatively. The same parameters were then calculated based on age- and height-related formulae derived in the earlier study., Results: Bland-Altman analysis of the sample patients showed a mean difference (bias) between measured and calculated values ranging from 0.14 to -0.60 (3 - 13%). Overall agreement in terms of bias were found to be more with height-based equation for mentohyoid distance and thyromental distance and age-based equation for sternomental distance., Conclusion: Our study validates the formulae derived in the earlier study to predict thyromental, mentohyoid, and sternomental distances in children with no obvious external airway anomalies. Further studies are needed to extend the applicability of these formulae in obese children and those with craniofacial anomalies coming for general anesthesia and surgery., Competing Interests: There are no conflicts of interest.

Aim: To determine the sexual dimorphism of the sternum with standard measurements in a contemporary Croatian population sample using multi-slice computed tomography (MSCT) and to compare the data obtained by an automatic with those obtained by a manual approach., Methods: Five sternal measurements were obtained from MSCT images of 73 men and 55 women and three sternal indices were calculated. Custom image analysis software was developed for automatic segmentation and calculation of sternal measurements. Measurements of sexual dimorphism were automatically calculated and compared with manual measurements., Results: All of the sternal measurements exhibited significant differences between men and women. The discrepancies between manual and automatic measurements ranged from 2.8% to 3.6% of the mean average values obtained with the automatic approach. The most accurate single-variable discriminant function was sternal body length (82.8%), the most accurate index was sternal area (89.1%), and the discriminant function using three variables was manubrium width, sternal body length, and sternal body width (90.6%)., Conclusion: Sternal measurements are a reliable sex indicator and can be used in forensic casework. Computer-aided measurement methods can accelerate sex estimation and improve its precision and accuracy.

Many anatomical variants on the sternocleidomastoid muscle have been reported. In this study, supernumerary clavicular heads of sternocleidomastoid muscle in a Korean female cadaver were bilaterally displayed. The observed supernumerary heads were classified as follows: one sterno-mastoid, one cleido-occipital and one cleido-mastoid on the right side, and one sterno-mastoid-occipital, four cleido-occipitals, and one cleido-mastoid on the left side. The sterno-mastoid and sterno-mastoid-occipital and the cleido-occipital made the superficial layer of the sternocleidomastoid muscle, while others made deep layer. We discussed clinical relevance and developmental basis of these muscular variations important for clinicians and anatomists.

Background: The aim of the present study was to describe the prevalence and topography of the dominant nutrient foramen at the clavicle., Methods: 317 macerated human clavicles (167 right and 150 left) were available for the study. After detecting the dominant nutrient foramen, the total distance from the sternal surface to the examined nutrient foramen was measured. A foramen index (FI) was used for further data processing., Results: We detected a dominant foramen in 300/317 (94.64%) clavicles, which was located in the middle third in 287/300 (95.7%) clavicles. The average clavicular length was measured at 14.9 cm ± 1.0 cm (range 11.6-17.5 cm) with an average foraminal distance from the sternoclavicular joint surface of 7.9 cm ± 1.3 cm (range 0.9-12.6 cm) in total. The mean FI was 53.2% ± SD 7.4% (range 5.5-79.3%)., Conclusion: The present study provides a topographic mapping of the foraminal area (46-60% of the total clavicular length). The findings help to assess clavicular fracture patterns, which pass through the foraminal area.

Purpose: With emphasis on the clinical setting, knowledge of anatomical variation decreases misdiagnoses and surgical complications. We report a previously undocumented variant of sternalis muscle and recommend an augmented classification scheme., Methods: Dissection of the anterior thoracic wall on an 83-year-old female cadaver revealed bilateral sternalis muscles. The Snosek et al. classification system was referenced to describe the variant types., Results: The right sternalis muscle has a single belly and can be classified using the Snosek et al. classification system as a simple type, right single. The left sternalis muscle presented with three muscle bellies, each having a unique pattern of superior attachments (heads). This variation is previously undocumented and requires a more detailed classification., Conclusions: We propose the addition of a new subtype of sternalis classification, as well as a modification to the Snosek et al. (Clin Anat 27:866-884, 2014) classification scheme, to include classification of different muscle bellies when multiple are present.

Keel bone damage may be painful to birds and affect their production. In order to better understand the frequency, position, and timepoint of keel bone damage that occur during production, the integrity of W-36 laying hen keel bones housed in enriched colony cages at 748.4 cm2 (116 in2) was evaluated. At four time points, 120 birds (10 per cage; three cages per each of four rooms) had keel bones evaluated. Each hen was placed in a motion limiting restraint, scanned using computed tomography (CT), fitted in vests containing tri-axial accelerometers, and placed back in their cages for 21 d. After 21 d, the hens were rescanned and returned to their cages. This process was repeated after 133 d. The CT scans were imported into Mimics analysis software (Materialise, Plymouth, MI, USA); 3D models were made of each keel bone at each time point and exported to 3-matic analysis software (Materialise, Plymouth, MI, USA). Each laying hen's keel bone model was superimposed onto scans from multiple time points resulting in four bone pairings representative of each 21-d period, the 133-d period, and the entire duration of the project. Next, the proximal portion of each bone pairing was edited to normalize bone shape according to a strict protocol. Additionally, each pairing was divided into three portions: distal aspect (3 cm), proximal aspect (2 cm), and middle portion (remaining). Whole bone pairing and each bone portion was analyzed using the Part Comparison tool in 3-matic. Raw data were compiled into three datasets and analyzed in SAS 9.3 using the GLIMMIX procedure using a three-level random intercept model. The model controlled for time, part, part(time), and system with random intercepts of bird(cage) and cage. Overall, results revealed that the greatest morphological changes occurred during the first 21-d period with regards to time (P = 0.03) and in the distal aspect of the keel with regards to part (P < 0.0001)., (© 2018 Poultry Science Association Inc.)

The sternum is central in binding the bilateral costal structures to form the anterior wall of the thorax. The airtight subatmospheric pressure cavity of the thorax during respiration and episodes of cough produces significant dynamic forces acting perpetually on its walls, influencing functions of the contained viscera. The embryonic development of the sternum concurs with that of the heart and parts of the pectoral girdle. Any imperfection of the sternum, whether congenital or iatrogenic, can significantly compromise the normal physiology of the thoracic wall and cardio-respiratory systems. Midsagittal osteochondrotomy (division) of the sternum is a necessary step to access the mediastinum for an open cardiac procedure. To return the thorax to its normal function, it is imperative that surgeons have thorough working knowledge of the surgical anatomy of the sternum and the biomechanics of an intact and disrupted thoracic wall. Patient-based outcome measures of an index cardiac surgery can only be considered conclusive if the divided sternum heals over time to have full benefit of the surgery. Here, the essential topographical anatomy and embryology of the sternum, thoracic biomechanics, fracture biology, and surgical access to the mediastinum are reviewed to provide a better understanding of the performance and importance of the healed sternum.

Purpose: Ultrasound has been shown to be a highly accurate adjunct for confirming endotracheal tube (ETT) placement, however there is no universally accepted scanning technique. The objective of this study was to determine which ultrasound technique provides the highest rate of adequate airway visualisation in a sample of stable emergency department (ED) patients., Methods: We conducted a prospective observational study using a convenience sample of ED patients. Airway imaging was performed using the following five techniques: 1) transcricothryoid membrane (TCM), 2) suprasternal notch (SSN) without transducer pressure, 3) SSN with pressure, 4) SSN with pressure to the left of the trachea and 5) SSN with pressure to the right of the trachea. A blinded reviewer scored the adequacy of airway visualisation for each technique., Results: A total of 100 patients were enrolled in the study. SSN to the left of the trachea with pressure had the highest rate of adequate airway visualisation (93.0%, 95% CI 86.1-97.1%), followed by 82.0% (95% CI 73.1-89.0%) for SSN with pressure, 74.0% (95% CI 64.3-82.3%) for TCM, 44.0% (95% CI 34.1-54.3%) for SSN without pressure, and 1.0% (95% CI 0.0-5.4%) for SSN to the right of the trachea. In 76.0% (95% CI 66.4-84.0%) of patients, the SSN view was improved by moving the probe off the midline towards the patient's left., Conclusions: In a sample of ED patients, the airway anatomy relevant for use in endotracheal intubation is best visualised at the SSN to the left of the trachea with transducer pressure applied., (Copyright © 2018 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.)

Objectives: The optimum chest compression site (P&#95;optimum) in children is debated: European Resuscitation Council recommends one finger breadth above the xiphisternal joint, whereas American Heart Association proposes the lower sternal half. Using a coordinate system imposed on CT, we aimed to determine the pediatric P&#95;optimum to maximize stroke volume, the key point for successful cardiopulmonary resuscitation, while minimizing hepatic injury., Design: Retrospective, cross-sectional study., Setting: University hospital., Patients: Children 1-15 years old who underwent chest CT., Interventions: None., Measurements and Main Results: We defined zero point (0, 0) as the center of the xiphisternal joint designating leftward and upward directions of the patients as positive on each axis. P&#95;optimum (x&#95;max. left ventricle, y&#95;max. left ventricle) was defined as the center of the maximum diameter of the left ventricle, whereas P&#95;aorta (x&#95;aorta, y&#95;aorta) as that of the aortic annulus. To compress the left ventricle exclusively, y&#95;max. left ventricle should range above the y coordinate of hepatic dome (y&#95;liver&#95;dome) and below y&#95;aorta. Data were presented as median (interquartile range) and compared among age groups 1.0-5.0, 5.1-10.0, and 10.1-15.0 years using Kruskal-Wallis test. For universal application regardless of age, y coordinates were converted into relative ones with unit of sternal top: 1 unit of sternal top was the y coordinate of the sternal top. A total of 163 patients were enrolled, median age 8.8 year (4.2-14.3 yr). Among age groups, no significant difference was observed in y&#95;max. left ventricle, relative y&#95;max. left ventricle, y&#95;aorta, and y&#95;liver&#95;dome: 1.0 cm (0.1-1.9 cm), 0.10 unit of sternal top (0.01-0.18 unit of sternal top), 0.39 unit of sternal top (0.30-0.47 unit of sternal top), and -0.14 unit of sternal top (-0.25 to -0.03 unit of sternal top), respectively. The probability to compress the left ventricle exclusively was greater than or equal to 96% when placing hand at 0.05-0.20 unit of sternal top. Subgroup analysis demonstrated the following regression equation: x&#95;max. left ventricle (mm) = 0.173 × (height in cm) + 13 (n = 106; p < 0.001; R = 0.278)., Conclusions: Theoretically, pediatric P&#95;optimum is located 1 cm (or 0.1 unit of sternal top) above the xiphisternal joint.

The sternalis muscle is an infrequent, non-pathological anatomical variant typically misrepresented in a clinical context. It presents with 3-8% prevalence, according to cadaveric studies. The muscles were identified during routine cadaver prosection at the School of Anatomical Sciences, University of the Witwatersrand. Here, we report two cases of the sternalis muscle in two South African White cadavers. Analysis of the sternalis muscles revealed unilaterally present, distinctly defined muscle masses on the right (case number 1, female) and left (case number 2, male) hemithorax, lateral to the sternum. The muscles occurred with a prevalence of 2.25% within the cadaveric population examined. The prevalence of the sternalis muscle is generally low, especially in the European population. Their presence represents the remnants of the cutaneous muscles in the ventral thorax of lower animals. Clinically, the sternalis muscle may be misinterpreted as a pathological mass or lesion, thus accurate knowledge regarding its variations and prevalence is of importance.

Identification of the dead is significant in examination of unknown, decomposed and mutilated human remains. Establishing the biological profile is the central issue in such a scenario, and stature estimation remains one of the important criteria in this regard. The present study was undertaken to estimate stature from different parts of the sternum. A sample of 100 sterna was obtained from individuals during the medicolegal autopsies. Length of the deceased and various measurements of the sternum were measured. Student's t-test was performed to find the sex differences in stature and sternal measurements included in the study. Correlation between stature and sternal measurements were analysed using Karl Pearson's correlation, and linear and quadratic regression models were derived. All the measurements were found to be significantly larger in males than females. Stature correlated best with the combined length of sternum, among males (R = 0.894), females (R = 0.859), and for the total sample (R = 0.891). The study showed that the models derived for stature estimation from combined length of sternum are likely to give the most accurate estimates of stature in forensic case work when compared to manubrium and mesosternum. Accuracy of stature estimation further increased with quadratic models derived for the mesosternum among males and combined length of sternum among males and females when compared to linear regression models. Future studies in different geographical locations and a larger sample size are proposed to confirm the study observations., (Copyright © 2018 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

Aim: Cardiopulmonary resuscitation guidelines suggest the lower sternal half be compressed. However, stroke volume has been assumed to be maximized by compressing the 'point' (P&#95;max.LV) beneath which the left ventricle (LV) is at its maximum diameter. Identifying 'personalized' P&#95;max.LV on computed tomography (CT), we derived and validated rules to estimate P&#95;max.LV using posteroanterior chest radiography (chest&#95;PA)., Methods: A retrospective, cross-sectional study was performed with non-cardiac arrest (CA) adults who underwent chest&#95;PA and CT within 1h (derivation:validation = 3:2). On chest&#95;PA, we defined CD (cardiac diameter), RB (distance from right cardiac border to midline) and CH (cardiac height, from carina to uppermost point of left hemi-diaphragm). Setting P&#95;zero (0, 0) at the midpoint of xiphisternal joint and designating leftward and upward directions as positive on x and y axes, we located P&#95;max.LV (x&#95;max.LV, y&#95;max.LV). Mathematically, followings were inferable: x&#95;max.LV = α 0 *CD-RB; y&#95;max.LV = ß 0 *CH + γ 0 . (α 0 : mean of (x&#95;max.LV + RB)/CD; ß 0 , γ 0 : representative coefficient and constant of linear regression model, respectively). We investigated their feasibility by applying them to in-hospital (IHCA) and out-of-hospital CA (OHCA) adults., Results: Among 266 (57.6 ± 16.4 years, 120 females), followings were derived: x&#95;max.LV = 0.664*CD-RB; y&#95;max.LV = 40 - 0.356*CH. Estimated P&#95;max.LV was closer to the reference than other candidates and thus validated: 15 ± 9 vs 17 ± 10 (averaged P&#95;max.LV, p = 0.025); 76 ± 13, 54 ± 11 and 63 ± 13 mm (3 equidistant points as per guidelines, all p < 0.001). Among IHCA and OHCA patients, 70.7% (106/150) and 38.0% (57/150) had previous chest&#95;PA with measurable parameters to estimate P&#95;max.LV., Conclusion: Personalized P&#95;max.LV, which is potentially superior to the lower sternal half and feasible in CA, is estimable with chest&#95;PA., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Identification of deceased with unclear identity is a common problem in forensic science, whereby radiologic comparison can be applied as method for identification. As this comparison is mostly made on a visual basis, it is highly dependent on the examiner and often lacks standardized procedures and statistical support. The aim of this study therefore was to develop a reproducible and examiner independent method for radiologic identification (RADid) based on morphometric and morphological features of sternal bone computed tomography (CT). Furthermore, the feasibility of an automated comparison of a post-mortem (PM) case against a database of ante-mortem (AM) cases was evaluated. 44 in situ PM CT scans of sternal bone and their corresponding AM CT scans were analysed and reproducible features were selected based on intra- and interrater reliability assessments. The selected features were further tested by contrasting AM and PM data. Moreover, an automated identity evaluation was developed by calculating the number of matching features between each PM case and an AM database consisting of 94 cases including the 44 with corresponding PM scans. Several features showed to be reliable according to their resulting correlation coefficient values (greater or equal to 0.60). The suitability and stability of these features was confirmed by contrasting AM and PM CT scans. Finally, the automated comparison was successful in 76.7% of the cases, whereby an unambiguous identification was possible in 65.1%. The present study reflects the benefits of a standardized and statistically established identification method and demonstrates the high potential of the sternal bone as a suitable structure for RADid., (Copyright © 2018 Elsevier B.V. All rights reserved.)

The fourth rib has been used commonly in order to estimate age at death and even sex in skeletal remains but many often, Iscan's estimates do not adjust to the real age of the individual. Population specific references for sex and age-at-death estimation from the sternal end of the fourth rib are presented for a contemporary Mexican sample. A total of 504 ribs with known sex and age from a morgue sample were studied (444 males, 60 females, 17 to 92 years old). The height and breadth of the sternal end of the rib were sexually dimorphic (p = .000), and allowed a correct sex assignment in 73.3% to 84% of the cases from univariate and multivariate discriminant functions. With regard to age-at-death estimation, the morphological changes summarized by the phases of the sternal end of the fourth rib are correlated with known age in this sample (Spearman's Rho, p = .000). However, the original age intervals tend to underestimate age at death and inaccuracy increases with phase scored in males. Descriptive statistics for rib phase are provided for males and females, and new age-at-death estimates based on transition analysis and Bayesian statistics are provided for the male sample. The test of universally applied methods and the development of population specific references is an important task for forensic anthropology around the world., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objectives: To verify accurate placement of the precordial ECG leads by identifying the 4th and 5th intercostal spaces as a function of the length of the sternum. This should decrease the percentage of lead misplacement leading to misdiagnoses., Methods: The population consisted of patients and healthy volunteers. The proposed method compared palpation of the 4th and 5th intercostal spaces to a percentile of the sternal length. Location of the 4th and 5th intercostal space using a simple device was evaluated to assist in proper placement of the precordial leads to obtain accurate diagnosis., Results: The location of the 4th and 5th intercostal space is related to the length of the sternum. It is 77% of the sternal length that measures 15cm for the 4th intercostal space. The position of the V1 and V2 electrodes decreases to 57% when the sternal length is 26cm. Similar data was obtained to locate the 5th intercostal space with proper position of V4-V6 electrodes. Tables are provided to facilitate this process. An instrument was designed to measure the 4th and 5th intercostal space as a function of the sternal length., Conclusions: The location of the 4th and 5th intercostal space is identified based on the length of the sternum., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: We propose an addition to the Snosek et al. classification to include a subtype variant of sternalis muscle: mixed type and triple subtype., Methods: Dissection of the anterior thorax of a 96-year-old female cadaver revealed bilateral sternalis muscles with an undocumented variant of the right sternalis muscle., Results: The left sternalis muscle presented as a simple type-left single using the Snosek et al. classification scheme. The right sternalis muscle revealed a previously undocumented classification type. It consisted of three bellies and two heads, with the lateral head formed by two converging bellies and the medial head formed from the superficial medial belly., Conclusions: The unique presentation of right sternalis muscle can be classified by expanding the Snosek et al. classification scheme to include triple-bellied subtypes. This presentation is classified as a mixed type-right triple, with single bicipital converging and single bicipital diverging. Documentation of sternalis muscle variations can prevent misdiagnoses within the anterior thorax.

Sex estimation is an essential step for identifying unknown individuals and usually depends on the presence of highly dimorphic bones, such as the pelvis and skull. Nevertheless, the body integrity can be compromised in certain circumstances, and these bones might be absent; therefore, the ability to use other bones for sex estimation is crucial. The aims of this study were to collect baseline data for sternal dimensions in Saudi adults, assess the existence of sexual dimorphism in the sternum, and generate population-specific equations to estimate sex using sternal dimensions. During 2014-2015, 200 thoracic/thoraco-abdominal computed tomography (CT) images (100 men, 100 women) were anonymously collected from King Abdulaziz Medical City. Six measurements were obtained and two indices calculated after 3D reconstruction of the CT scans. Descriptive statistics were calculated, and sexual dimorphism was assessed using independent t-tests. Discriminant function equations were developed for these measurements. Except for the sternal index, men had significantly larger dimensions than women. Sexual dimorphism was highly significant (p<0.001). The best predictor was the combination of the manubrium and sternal body lengths (89.5%). In the stepwise analysis, the best predictors were the manubrium length, sternal body length, manubrium width, and corpus width at the first sternebra, with a cross-validated accuracy of 90.5%. Cross-validated accuracy for all measurements ranged between 62.5% and 90.5%. The findings of the study may have important anatomical, anthropological, and forensic applications., (Copyright © 2017 Elsevier GmbH. All rights reserved.)

Background: In forensic sciences to determine one's sex is quite important during the identity defining stage. The reliability of sex determination depends on the completeness of the remains and the degree of sexual dimorphism inherent in the population. Computed Tomography is the imaging modality of choice for two- and three-dimensional documentation and analysis of many autopsy findings., Objective: The aim of the present work was to assess the reliability of Three-dimensional Multislice Computed Tomography (3D MSCT) to determine sexual dimorphism from certain chest measurements; sternum and fourth rib using the 3D MSCT and to develop equations for sex determination from these bones among adult Egyptians sample., Subjects and Methods: The present study was performed on 60 adult Egyptians. Their age ranged from 21 up to 74 years and they were equally divided between both sexes. Sixty virtual chests (reconstructed Multislice Computed Tomography 3D images) were examined for detection of Sternal measurements; Manubrium length (ML), Sternal body length (BL), Manubrium width (MW), Sternal body widths(BWa&BWb), Sternal area (SA) [(ML + BL) × (MW + BWa + BWb)/3]and Fourth rib width (FRW)., Results: All the studied measurements were significantly higher in males than in females. Multiple regression analysis was used to and three significant regression equations were developed for predicting sex using the different studied chest measurements; the sternal measurements, the sternal area and the widths of the right and left fourth ribs with their accuracies 96.67%.95.0%.72.68% respectively., Conclusion: Sterunm and fourth rib width revealed significant metric sex differences with the use of Multislice Computed Tomography 3D images thus provide a great advantage in the analysis of skeletal remains and badly decomposed bodies., (Copyright © 2017 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

Purpose: To evaluate the variations of the sternum and provide the prevalence of sternal foramen and its anatomical relationships., Methods: In this retrospective study, 544 subjects ranging in age from 18 to 95 years were evaluated. Sternal variations, prevalence of sternal foramen and its anatomical relationships to mediastinal structures were examined with the axial, sagittal and coronal reformat images of the patients who underwent thoracic computerized tomography., Results: In 500 subjects, following sternal variations were found: sternal sclerotic band in 120 (24%), sternal cleft in 3 (0.6%), sternal foramen in 26 (5.2%), focal cortical notch and defect in 44 (8.8%) patients. The manubriosternal fusion was partial in 65 (13%) patients and complete in 112 (22.4%) patients. The sternoxiphoid fusion was partial in 201 (40.2%) and complete in 153 (30.6%) patients. There was no xiphoid process in 9 patients (1.8%; 29-51 years; mean age 38 years). Xiphoidal ending types were as follows: single-ended 361 (72.2%), double-ended 125 (25%), and triple-ended xiphoid 5 (1%) patients. The sternal foramen was adjacent to the lung in 13 (2.6%), to the pericardium of heart in 3 (0.6%), and to mediastinal fat in 10 (2%) patients., Conclusion: The sternum is a very critical anatomic structure of the anterior chest wall with several variations that can be confused with pathologic conditions. Radiologists' familiarity with these variations is important for better radiologic evaluation in making differential diagnosis.

In patients undergoing repeat sternotomy, the risk of injury to cardiac structures can be reduced by utilizing a technique that provides sustained visualization of structures adherent to underside of the sternum. We discuss the use of a retractor specifically designed for this purpose: the Rultract Resternotomy Retractor™., (© 2017 Wiley Periodicals, Inc.)

The sternum as an important part of the skeleton and not only provides a crucial attachment site for the pectoral muscles and protects internal organs such as the heart and lungs for meat duck, but may also be considered as the primary ventilator in the avian respiratory system. Therefore, this study focuses on the sternum growth and mineralization kinetics of ducks from 35 d to 63 d of age. A total of 72 one-d-old males and 72 females were chosen and fed with the same diet until the age of 9 weeks. The sternum and serum were harvested at 35 d, 42 d, 49 d, 56d, and 63 d of feeding. Results showed that the sternum width rapidly grew from 35 d to 42 d and the value changed little after 42 d, while the keel length and the sternum depth did not significantly change until 49 d age. The sternum defatted weight and density increased assumed to "S" with ducks' age and their plateau in the 56 d. The sternum ash content, calcium (Ca), and phosphate (P) levels increased with duck age, then all three reached a plateau in 49 days. Similarly, serum alkaline phosphatase (ALP) activity was higher in the ducks at both 35 and 42 days, followed by 49 days, and the value was lowered to a minimum on both days 56 and 63. Conversely, serum tartrate resistant acid phosphatase (TRAP) activity substantially increased until 49 days irrespective of duck gender. Results indicate that the dimensions of the sternum were already at the maximum in 49-day-old ducks and the sternum of the ducks rapidly mineralized from 42 d to 49 d of age and achieved a plateau phase after 49-days resulting from the high activity of ALP at the sternum early mineralization., (© 2017 Poultry Science Association Inc.)

Introduction: Various screening tests are done for predicting difficult laryngoscopy with variable diagnostic accuracy. Difficult laryngoscopy is being considered a surrogate indicator of difficult intubation, though it is not the exact measure of intubation difficulty. Our objectives were to find out the better predictor of difficult laryngoscopy amongst the routinely used tests and also to find the ability of difficult laryngoscopy to predict difficult intubation., Methods: This prospective, observational study involved 314, ASA I/II adult patients requiring endotracheal intubation. Measurement of sternomental, thyromental and inter-incisor distances and gradings of mandibular protrusion and modified Mallampati were done. Statistical values including sensitivity and specificity of these tests were calculated to find the better predictor of difficult laryngoscopy. Cormack and Lehane laryngoscopy grade III/IV was defined as difficult laryngoscopy. Requirement of >3 attempts for endotracheal intubation was defined as difficult intubation., Results: The sensitivity of the Modified Mallampatti Test for predicting difficult laryngoscopy was highest, 83% compared to other tests. Total 12 (3.8%) patients had difficult laryngoscopy. Intubation was difficult in 7 (2.2%) patients, of which four had difficult laryngoscopy (P<0.001)., Conclusions: Modified Mallampati test was better for predicting difficult laryngoscopy compared to other bedside screening tests. Difficult laryngoscop could significantly predict difficult intubation in our patients.

"Broiler-type" chickens are fast-grow-ing, heavy-bodied birds with high demands on bone quality. Phenamil increased mineralization in cultured murine mesenchymal stem cells. Phenamil effects were tested in 2 groups of weight and gender matched day-old broiler chickens (n = 13). Oral administration of 30 mg phenamil/kg body weight d 1 to 13 reduced growth of chicks d 5 to 14 (P = 0.002); with phenamil-treated (PT) chick body weight being 84% of vehicle-treated (VT) chicks' body weight on d 14. Tissues collected on d 15 showed that femur lengths and widths did not differ, but tibias from PT chicks were 6% shorter (P = 0.002) and 13% narrower (P = 0.012) with 18% thinner tibial cross-sections (P < 0.008) than in VT chicks. Angles of the caudal aspect of the anterior surface of keeled-sternums were 166° in PT chicks, flatter than the 148° found in VT chicks (P = 0.000). Total mineral content of both tibia and femur were lower in PT chicks (P = 0.005 for both). Bone Ca, P, and Mg (ppm) in ash were similar, but Ca:P was lower (1.70 vs 1.75) in PT versus VT chicks (P < 0.05). Osteocalcin was ∼20% lower (P = 0.020), PINP was ∼45% higher (P = 0.000) in PT chicks. Carboxy-terminal telopeptide type I collagen (ICTP) and cross-linked N-telopeptide of type I collagen (NTX1) were similar in the 2 groups. Phenamil had unexpected and detrimental effects on bone formation in growing broiler chicks, reducing linear skeletal growth and markedly changing bone architecture., (© 2017 Poultry Science Association Inc.)

Background: Reduction mammaplasty is one of the most commonly performed plastic surgery operations. For a majority of techniques, the most common long-term complication is pseudoptosis. It has previously been proposed that upper breast suspensory ligaments (SL) are weaker than lower breast SL. We tested this hypothesis through anthropometry of the proxies for upper and lower SL strength: the sternal notch-nipple (SN-N) distance and the nipple-inframammary fold (N-IMF) distance, respectively., Methods: An institutional review board-approved retrospective review of patients undergoing reduction mammoplasty in an academic faculty practice between 2008 and 2015 was conducted. Patient demographics included age, race, and body mass index (BMI); patient comorbidities included smoking status, diabetes, and hypertension. Breast anthropometric measurements included SN-N and N-IMF. Sternal notch-nipple was used as the primary metric of the upper SL strength, whereas N-IMF was used as the primary metric of the lower SL strength. Intraoperative details included reduction technique and resection mass. Postoperative complications were recorded, including nipple areola complex necrosis and hematoma. Linear regression analysis was performed with the primary endpoint of the relationship between SN-N and N-IMF distance in macromastia., Results: Data from 208 patients, totaling 400 individual breast measurements, were collected. The mean SN-N length was 35.1 cm, mean N-IMF length was 16.0 cm, and mean resection weight was 1094 g. Linear regression found that N-IMF distance could be predicted as 45% of the SN-N distance (N-IMF = 0.454 * SN-N). This was a strong relationship, demonstrated by univariate analysis of SN-N and N-IMF (R, 0.624; P < 0.001). A Wise pattern was used in 89.9% of cases; an inferior pedicle was used in 83.7% of cases. Nipple areola complex necrosis occurred in 15 breasts (3.75%). Sternal notch-nipple (R, 0.127; P = 0.011) and N-IMF (R, 0.119; P = 0.017) were both predictive of nipple areola complex necrosis (Table 4)., Conclusions: In our series, the N-IMF distance increased 0.45 cm for every 1 cm increase in the SN-N distance. This relationship strengthens our primary hypothesis that the lower pole ligaments stretch at a significantly slower rate than the upper pole ligaments. Taking this into consideration, we suggest that surgeons seeking to minimize pseudoptosis rates should favor techniques that minimally disrupt the lower SL.

Background: Pregnancy and obesity each increase the chance of difficult tracheal intubation. This study assessed the performance of the neck circumference and other bedside tests in predicting difficult intubation, and aimed to identify the optimal cutoff point of the test(s) with the highest performance., Methods: Parturients with a body mass index ≥30kg/m 2 , undergoing a cesarean delivery employing conventional tracheal intubation, were enrolled. Preoperative neck circumference, sternomental distance and modified Mallampati test were examined. Difficult intubation was defined as intubation difficulty scale score ≥5., Results: Five hundred and seventy parturients of mean body mass index 34.1 (±SD 3.8) kg/m 2 were recruited. The incidence of difficult intubation was 3.5%. The performance of the neck circumference test, conducted with the patient sitting or supine, and using the area under the receiver operating characteristic (ROC) curves, was 0.6 (95% CI 0.5 to 0.7) and 0.6 (95% CI 0.4 to 0.7) respectively. The area under the ROC for the modified Mallampati test was 0.6 (95% CI 0.5 to 0.7) and for the sternomental distance test was 0.7 (95% CI 0.6 to 0.8). A sternomental distance less than 14.5cm, and a ratio of neck circumference in the sitting position to sternomental distance of greater than or equal to 2.7, were optimal cutoff points to identify difficult intubation., Conclusion: The neck circumference, the sternomental distance, the modified Mallampati test and the ratio of neck circumference to the sternomental distance show limited performance as screening tests to predict difficult intubation among obese parturients., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Patients undergoing coronary artery bypass graft (CABG) procedures have higher incidence of difficult laryngoscopy and intubation than general surgery population. Accurate prediction of difficult laryngoscopy in CABG patients is desirable to reduce the hemodynamic response and myocardial oxygen requirements. Recently, thyromental height test (TMHT) has been proposed as one of the highly sensitive and specific bedside tests to predict difficult airway. We, in our prospective observational study, evaluated the accuracy of the TMHT in predicting difficult laryngoscopy., Methodology: A total of 345 patients undergoing CABG of either sex, in the age group of 35-80 years, American Society of Anesthesiologists 111, undergoing CABG, were studied. Airway assessment was performed with modified Mallampati test with the addition of thyromental distance, sternomental distance, and TMHT. Intraoperatively, direct laryngoscopy was done in accordance with Cormack and Lehane grade of laryngoscopy. The preoperative data and laryngoscopic findings were used together to evaluate the accuracy of TMHT. The sensitivity, specificity, positive and negative predictive values of other three tests were calculated according to standard formula., Results: A total of 345 patients were in the group with mean age of study population at 56.7 (standard deviation 9.1) years (35-80 years). This study showed that almost all tests had good specificity, but sensitivity was poor. However, sensitivity of TMHT was 75% with accuracy of 95%. Receiver operating characteristic curve analysis of TMHT-derived cutoff was 52.17 which increased sensitivity to 81.25% and specificity to 92.3%., Conclusion: TMHT had a higher sensitivity compared to other tests along with good positive and negative predictive value and a very high specificity.

Aim of the Study:: Methods based on the positive linear relationship existing between stature and long bones are most commonly used to estimate living stature in forensic anthropology. The length of the sternum and its parts has been advanced as a plausible alternative to estimate stature when such long bones are missing or damaged., Material and Methods: This meta-analysis aims to quantify evidence on the correlation between the sternum/sternal parts length and stature. Nine studies were included with 1118 sternal bones., Results: Analyses showed that the length of the meso-sternum (manubrium + body) yielded the best correlation with stature; 53.5% and 55.42% for men and women, respectively. The second best variable is the total sternal length with correlations of 44.3% and 55% for men and women, respectively. Subgroup analysis of autopsy studies demonstrated even a higher correlation of 58.2% for the meso-sternal length. Manubrium and body lengths showed the least correlation values. Except for the body length, females exhibit a better correlation than man between all other sternal lengths and stature., Conclusions: While the meso-sternal length is found to be the most correlated variable with stature, all sternal lengths are to be considered with caution when estimating stature. The relatively low values of the weighted correlation results should raise the question of reliability and limit the use of sternal length when long bones are available. Future research using larger samples from different populations and taking into account the fusion status of the sternum are needed.