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.

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.

Early sternal erosion and luetic aneurysms of thoracic aorta: report of 6 cases and analysis of cause-effect relationship

Six patients with luetic aneurysm of the ascending aorta eroding the sternum are presented. The erosion was an early and principal presentation and the site of erosion and location and morphology of aneurysm were identical in all six patients. The erosion mainly affected the right half of the manubrium and medial end of right clavicle. The aneurysms arose from the junction of the ascending and transverse arches of the thoracic aorta and had narrow opening close to the origin of the innominate artery. The identical presentation, aetiology, angiographic location and morphology, corroborated further at surgery, suggests that syphilitic aneurysms in this location have a strong tendency to cause early sternal erosion.

Primary tubercular osteomyelitis of the sternum

Tubercular involvement of the sternum, leading to osteomyelitis, is a rarely described entity even in countries where tuberculosis is endemic. Presentation in pediatric age group is even more uncommon. We describe a 12 year old girl who presented with a mass over the manubruim sterni and fever. CT chest demonstrated a soft tissue mass in the anterior mediastinum, eroding the cortex of the manubrium. Tubercular etiology was suggested by presence of epithelioid granulomas and acid fast bacilli in the Ziehl-Neelsen staining of the aspirate from the lesion. The patient responded well to antitubercular treatment.

The role of the external auditory canal in the development of the malleal manubrium in humans

OBJECTIVE

To determine if the external auditory canal (EAC) plays a role in the induction and proper positioning of the malleal manubrium in humans.

STUDY DESIGN

Retrospective study between 1994 and 2002.

SETTING

Academic, tertiary care referral medical center. Patients Fifty-five ears of 50 patients with congenital atresia (n = 47) or stenosis (n = 8) of the EAC, for which meatoplasty was performed at the University hospital between 1994 and 2002.

MAIN OUTCOME MEASURES

The presence of the manubrium was examined during surgery, and the corre-lation between the presence of the manubrium and the grade of the microtia was evaluated.

RESULTS

The manubrium was identified in all ears with EAC stenosis, whereas it was absent in all ears with EAC atresia. No correlation was observed between manubrium formation and auricular deformity.

CONCLUSIONS

Our results demonstrated a close relationship between the formation of the EAC and that of the malleal manubrium in humans. This is consistent with the recent findings in knockout mice. This information is useful for surgical intervention in cases of congenital EAC anomalies.

Blastomycosis of long bones

The presentation of blastomycosis clinically and radiographically is nonspecific and often mistaken for a neoplasm. Delay in diagnosis is common. Patients with osseous blastomycosis present with pain and swelling. Radiographs usually show an eccentric lucency in the distal ends of long bones. These patients frequently are referred for a neoplastic workup and a diagnosis is made only after biopsy. We review the cases of five patients diagnosed with a bone tumor who had blastomycosis osteomyelitis. The time to diagnosis from original symptoms was 4.7 months (range, 3-8 months). The average age of the patients was 45.6 years (range, 20-59 years). A Musculoskeletal Tumor Society functional assessment was done. Early radiographs of the current patients ranged from normal to showing faint osteopenia in the involved location. As the disease progressed, the area of lucency appeared with either diffuse or well-marginated borders. Treatment included surgical debridement with antifungals. The mean functional score was 93.3%. All patients are disease-free. Blastomycosis, similar to tuberculosis, often is mistaken for a neoplasm. Blastomycosis osteomyelitis can be treated with excellent results. The key is diagnosis and including endemic fungal infections in the differential diagnosis of bone tumors. In addition, every potential neoplasm should include cultures of specimens obtained at biopsy.

Pseudomass of the sternal manubrium in osteogenesis imperfecta

Skeletal abnormalities such as hypertrophic callus formation and "popcorn" calcifications are rare radiological findings of osteogenesis imperfecta, causing tumor-like appearances on imaging. We report on a 7-year-old girl with osteogenesis imperfecta presenting with hepatomegaly and palpable lymphadenopathy in the left inguinal region on physical examination. Computed tomography examination revealed a high-density mass-like lesion of the manubrium sterni. Ultrasonography and a lateral roentgenogram of the chest verified that this was a pseudomass caused by a bowed sternal manubrium.

Manubrium sterni in patients with diastrophic dysplasia--radiological analysis of 50 patients

BACKGROUND

Patients with diastrophic dysplasia (DD) have many typical and some peculiar radiological findings in their skeleton. Currarino reported recently that 6 of his 12 patients with DD had accessory ossification centers of the manubrium sterni.

OBJECTIVES

This study analyzed abnormalities of the manubrium sterni in patients with DD to find out more about the prevalence and natural history.

MATERIALS AND METHODS

A total of 50 patients with DD (22 male, 28 female) were included in this retrospective analysis. The average age of patients at the time of the first radiograph,was 7.1 years (range: newborn-34.7 years). Lateral radiographs of the spine or the chest were included. Follow-up was of 20 patients (40%) with an average age of 8 years (range: 1-24 years). The number, location, and time of the radiological fusion of accessory ossification centers were analyzed. Additionally, the form of the manubrium was evaluated using an arbitrary scale with three grades.

RESULTS

Accessory ossification centers were seen in the first radiograph of 16 (32%) patients. The first radiographs of 16 patients were taken before the age of 18 months; 13 (81%) of them had accessory ossification centers. The most common finding was an accessory ossification center located ventral to the cranial part of the manubrium (a double-layered manubrium). In older patients, the manubrium was usually bulging anteriorly, resembling an asymmetric club. It was as if there had been an accessory ossification center that had fused with the main part of the manubrium.

CONCLUSIONS

The manubrium sterni is abnormal in almost all patients with DD. The prevalence of accessory ossification centers in childhood is high. The presence of an accessory ossification center ventral or cranial to the manubrium in radiographs may help in making the diagnosis of DD.

[Manubriosternal dislocation caused by indirect flexion-compression trauma. A case report and review of the literature]

Manubriosternal dislocation caused by indirect flexion-compression trauma is an extremely rare condition. Two forms of manubriosternal luxation are distinguished: in type I the sternum is dislocated posterior and in type II anterior to the manubrium. Direct or indirect trauma may cause manubriosternal dislocation. Mode of injury in direct trauma is mostly a head-on collition in a motor accident resulting either in type I or type II luxation. The unusual origin of manubriosternal dislocation by indirect trauma is put down to flexion-compression injuries of the thoracic spine and results in a type II dislocation. Predisposition to manubriosternal dislocation by indirect trauma consists in rheumatoid arthritis or extreme forms of kyphosis. Outcome of many patients treated conservatively after initial reposition with adhesive tape, symptomatic pain therapy, cryotherapy and prohibition of any physical training over several weeks is subluxation or complete luxation of the manubriosternal joint. This condition may lead to chronic pain, periarticular calcification with ankylosis and progredient deformation. Lacking a controlled study for treatment of manubriosternal dislocation a standard therapeutic regime could not be established yet. In the literature only a few case-reports of patients undergoing operative therapy are published. We report a type II dislocation of the manubriosternal joint caused by indirect flexion-compression trauma. We achieved a very good long-term result using a 8-hole 1/3 tubular plate for fixation of the manubriosternal joint after reposition.

Double-layered manubrium sterni in young children with diastrophic dysplasia

A review of the roentgenograms, which included a lateral view of the sternum in 12 children with diastrophic dysplasia, revealed that 4 children (2 newborns, and 2 aged 1.5 years) had a double-layered manubrium with the accessory ossification located ventral to the normal manubrium. In the other 2 children, aged 5 and 11.5 years, the manubrium showed a deformity consistent with a previous double-layered manubrium in which the ventral ossification had fused with the normal dorsal element. The nature of this anomaly is not certain, but a survey of the embryology of the manubrium raises the possibility of a persistence and ossification of a primitive midline embryonic structure that normally is resorbed in its cartilaginous state.

CT anatomy of the mediastinal structures at the level of the manubriosternal angle

The mediastinal structures said to lie on a horizontal plane at the level of the manubriosternal joint (manubriosternal plane) in the cadaver include the bifurcation of the trachea, the concavity of the arch of the aorta, and the azygos vein as it arches over the right principal bronchus to enter the superior vena cava. We have reviewed CT scans of the thorax in 51 subjects to determine 1) whether these structures lie consistently at this level in the living thorax and 2) the vertebral level of this plane. We found that the bifurcation of the trachea lay at the plane in 41% of subjects, that the plane passed through the concavity of the arch of the aorta in 49% of subjects, and that, although there was notable individual variation, the manubriosternal plane passed through the upper part of the fifth thoracic vertebra in 53% of cases.

Prospective study of anterior chest wall involvement in ankylosing spondylitis and psoriatic arthritis

A prospective study of anterior chest wall involvement was conducted in 50 ankylosing spondylitis patients and 50 psoriatic arthritis patients in the absence of palmoplantar pustulosis. All patients underwent a physical examination, tomograms, and a radionuclide bone scan. Magnetic resonance imaging with gadolinium was done in some cases. Half the patients in both groups had anterior chest wall involvement. Enthesitis was the mechanism of the lesions. The manubriosternal symphysis and sternocostoclavicular joints were the most common sites of involvement, although other entheses in the region were affected in some patients.

Radiation dose by spiral CT and conventional tomography of the sternoclavicular joints and the manubrium sterni

OBJECTIVE DESIGN AND PATIENTS: Conventional frontal tomography of the sternum has to some extent been replaced by spiral computed tomography (CT). The objective of this study was to analyse this change of procedure in terms of dosimetry by measurement of the radiation dose to individual organs using an anthropomorphic Rando Alderson phantom.

RESULTS

The total effective radiation dose in examination of the sternoclavicular joints and the manubrium sterni was found to be lower using spiral CT than conventional tomography, the values being 0.6 and 0.8 mSv, respectively.

CONCLUSION

As spiral CT is diagnostically comparable and in some respects superior to tomography, its use is recommended for studies of the sternum.

Spiral CT with three-dimensional and multiplanar reconstruction in the diagnosis of anterior chest wall joint and bone disorders

Twenty-seven patients with symptoms or clinical findings suggesting joint or bone disorders of the anterior chest wall (ACW) were evaluated by spiral CT with 3-dimensional (3-D) and multiplanar reconstructions. Preceding conventional ACW tomography was performed in 10 patients. ACW joint and bone changes were visualized more adequately by coronal 2-D reconstructions based on spiral CT than by conventional tomography. In addition, nonossified costal cartilages and soft tissues lesions were demonstrated. 3-D reconstructions sometimes added information, especially in patients with fracture and dislocation.

99mTc-MDP scintigraphy in ankylosing spondylitis

99mTechnetium-MDP bone scintigrams in 11 patients with ankylosing spondylitis were reviewed. Increased activity in sacroiliac joints was present in five of 11 cases, all of whom had symptoms of less than 5 years duration. Patients with longstanding disease had normal or low sacroiliac joint activity. In the spine, appearances included diffuse symmetrical, unifocal or multifocal asymmetrical increased uptake involving the costovertebral, costotransverse and facet joints as well as the spinous processes. In advanced disease with extensive ankylosis, the lumbar spine was featureless on scintigraphy, except for focal increased activity at the site of previous fracture in one patient. Of six available views of the sternum, increased uptake was present in five at the manubriosternal joint and five at the sternoclavicular joints. Increased peripheral uptake was mainly in the hips and knees in advanced cases. Plain radiographic changes correlated poorly with scintigraphic changes, scintigraphy detecting considerably more lesions than radiography. Awareness of the scintigraphic appearances of ankylosing spondylitis may lead to diagnosis before the development of radiographic changes and avoid confusion with other pathology. Clinical indications for bone scintigraphy in ankylosing spondylitis are suggested.

Pathogenesis of discovertebral and manubriosternal joint abnormalities in rheumatoid arthritis: a cadaveric study

The precise pathogenesis of discovertebral lesions in rheumatoid arthritis has long been debated with the emergence of 2 conflicting theories: discovertebral extension of synovial inflammation from a neighboring articulation (Luschka, costovertebral joint) and repetitive discal trauma with Schmorl's nodes. In order to address this controversy, we performed a radiographic-pathologic correlation of a rheumatoid cadaver and compared the alterations seen in the cervical and lumbar discovertebral junction; we further included an evaluation of the manubriosternal joint, another cartilaginous articulation. Our data confirmed that advanced discovertebral lesions in the cervical and lumbar spine are related primarily to endplate failure that itself is caused by apophyseal joint destruction and segmental spinal instability, although inflammatory rheumatoid lesions of the cervical intervertebral discs probably arising from the Luschka joints are also evident. Conversely, the lesions of the manubriosternal joint were produced by inflammatory changes related to the development of a synovial cavity in the articulation.

Persistent sternum synchondroses on bone scintigraphy

This report describes the case history of two patients who showed a hyperactive midsternal area on bone scintigraphy due to a persistent sternal synchondrosis. Whereas this anatomical variant is diagnosed infrequently, midsternal hotspots can sometimes be related to arthrotic degeneration of these extra joint spaces. In the differential diagnosis of midsternal hotspots on bone scintigraphy, persistent sternum synchondroses should be considered.

Monarthritis of the manubriosternal joint. A follow-up study

Six women and three males, who initially had seronegative monarticular arthritis of the manubriosternal joint (MSJ) were followed for a mean period of 7.1 years (range 0.8-17 years). Rather severe, progressive disease occurred in five patients, three of whom had pustulosis palmoplantaris (PPP) and one acne vulgaris. The course was milder in four patients who had either psoriasis vulgaris, psoriasis in the family or HLA-B27, and the disease remained localized to the MSJ in these patients. None of the patients developed sacroiliitis or peripheral erosive joint changes, but one patient with PPP developed paravertebral ossification.

Septic manubriosternal arthritis in a patient with Reiter's disease

A man with a quiescent Reiter's disease presented with abrupt upper chest pain. This symptom resulted from a septic arthritis of the manubriosternal joint due to staphylococcus aureus cultured from the synovial fluid.

Psoriatic arthritis affecting the manubriosternal joint

Manubriosternal synovitis in the absence of peripheral arthritis or spondylitis, in a patient with pustular psoriasis, is described. The radiologic changes noted on lateral chest radiograph consisted of erosions, sclerosis, and joint space widening. This coincidence of manubriosternal joint arthritis and pustular psoriasis is unusual in western populations.

Manubriosternal joint dislocation in rheumatoid arthritis: the role of thoracic kyphosis

A case report of manubriosternal joint (MSJ) dislocation in a rheumatoid patient with thoracic kyphosis is presented together with a review of the relevant literature. Variations in the anatomical nature of the MSJ between normal individuals are described. In 43% of the population its characteristics are noted to be such that it may be involved in rheumatoid arthritis (RA). A joint thus involved can be dislocated by forces generated by longstanding thoracic kyphosis and transmitted to the manubrium via the first rib. Xeroradiographs of the MSJ region in our patient showed dislocation of the joint in the upright position and its subsequent reduction on lying the patient flat. We suggest that this demonstrated reduction is secondary to the lessening of the thoracic kyphosis that occurs in the supine position. It is concluded that in RA MSJ dislocation is a function of thoracic kyphosis.

Sclerosis and hyperostosis of the manubrium sterni

Seven females and one male with almost identical sclerotic and hyperostotic changes of the manubrium sterni are reported. The clinical course was prolonged and characterized by intermittent periods of exacerbation followed by improvement. Malignancies, bacterial inflammatory processes, and Paget disease, which were first suspected, could be excluded. Pustulosis-palmoplantaris was present in four patients and one had psoriasis vulgaris. None of the patients had sacroiliitis or peripheral joint changes, but the three youngest patients had sclerotic changes of other bones, including the lumbar spine, the pubic bone, and the clavicle. This may indicate that this is an adult disease analogous to "chronic recurrent multifocal osteomyelitis", a disease mainly present in children and adolescents.

Primary septic arthritis of the manubriosternal joint in a heroin user

A 20-year-old heroin user developed staphylococcus septic arthritis of the manubrium joint. The diagnosis was established by a culture of the infected tissue and blood culture. The clinical impression was aided by 99mTc radionuclide scintimetry. Early diagnosis localized the infection. Immediate antibiotic therapy solved a problem in the sternum that seems not to have been reported in the English literature.

Septic arthritis involving the manubriosternal joint

Infection of the manubriosternal joint is an exceedingly rare event. We report a case of a 38-year-old patient with systemic lupus erythematosus who developed staphylococcal septic arthritis of this joint after bacteremia. Pathogenic factors are discussed. Physicians should be aware of this unusual complication of staphylococcal bacteremia.

Monarticular involvement of the manubriosternal joint

Four females and two males with seronegative monoarthritis of the manubriosternal joint are reported. Two patients had pustulosis palmoplantaris, one psoriasis vulgaris, and one HLA-B27. The arthritis is considered to be a monoarticular manifestation of seronegative spondylarthritis. Two patients had no other diseases or signs. Four patients were followed for a mean of 8.5 years (range 2-16 years) during which time affection of other joints or the spine was not seen.

Sclerotic changes of the manubrium sterni

Six females with nearly identical sclerotic and hyperostotic changes of the manubrium sterni are reported. Malignancies, bacterial inflammatory processes, and Paget disease, which were first suspected, could be excluded. The youngest patients also had sclerotic changes of other bones, including the lumbar spine, the pubic bone, and the clavicle, and may be classified as having "chronic recurrent multifocal osteomyelitis" (CRMO). The two oldest patients had ossification of the costoclavicular ligament(s) and may be classified as having "inter-sterno-costo-clavicular ossification" (ISCCO). One had only hyperostotic and sclerotic changes as seen in "sterno-costo-clavicular hyperostosis" (SCCH). The pathogenesis of these uncommon diseases is unknown, but they are all frequently associated with pustulosis palmo-plantaris and have similar clinical courses and laboratory abnormalities. None of the present patients had HLA-B27. The similarity of the radiological abnormalities of the manubrium sterni suggests that the diseases themselves may be similar, but with different courses depending on age, CRMO being present in children and young adults and ISCCO or SCCH in older adults.

The Angle of Louis. A potential pitfall ("Louie's Hot Spot") in bone scan interpretation

Evaluation of 100 consecutive Tc-99m MDP bone scans revealed in 36 patients a well defined area of increased accumulation of radiotracer at the Angle of Louis--the palpable ridge along the anterior surface of the sternum at the fibrocartilaginous junction of the sternum and manubrium. Twenty-five of the 36 patients had comparison radiographs; all were normal. None had sternal pain or a prior history of chest trauma. Increased uptake at the Angle of Louis ("Louie's Hot Spot") is a relatively common finding (36%) and should be recognized as a normal bone scan finding. It should not be confused with increased uptake due to an osseous abnormality, i.e., metastasis, degenerative disease, trauma, etc.

Computed tomography of the normal sternum

The normal CT anatomy of the sternum was studied in 35 patients. In addition to the normal appearance of the sternum, normal variants that may mimic disease were often noted. In the manubrium, part of the posterior cortical margin was unsharp and irregular in 34 of 35 patients. Part of the anterior cortical margin was indistinct in 20 of the 35 patients. Angulation of the CT gantry to a position more nearly perpendicular to the manubrium improved the definition of the cortical margins. The body of the sternum was ovoid to rectangular and usually had sharp cortical margins. Sections through the manubriosternal joint and xyphoid often demonstrated irregular mottled calcifications and indistinct margins again simulating bony lesions. The rib insertions, sternal clavicular joints, and adjacent soft-tissue appearance also were evaluated.

The manubriosternal joint in rheumatoid disease

Manubriosternal joint abnormalities are often undetected causes of chest pain. Twenty-five normal patients and 40 cadaver specimens were evaluated to establish the normal radiographic anatomy of this articulation. Analysis of the manubriosternal joint was carried out in rheumatoid diseases in order to ascertain the incidence and variety of abnormalities. Twenty-seven of 100 manubriosternal joints were abnormal in rheumatoid arthritis. Of 25 patients with ankylosing spondylitis 20 (80%) revealed abnormalities either with erosions or fusion. None of 25 patients with psoriatic arthritis and none of 20 with Reiter syndrome showed erosions or ankylosis. The articulation should be evaluated in rheumatoid diseases and in non-arthritic patients with chest and/or shoulder pain.

Unusual personal identification with characteristic features in chest roentgenograms

This case illustrates the unexpected aspects of radiographic personal identification. A skeletonized body without the neck and head, upper extremities, and feet was discovered on a seashore. No positive results were obtained from the remains concerning either the cause of death, the manner of death, or precise identification of the body. Roentgenologic examinations of the remains revealed a marked eminence of the manubrium sterni with characteristic crossing shadows. A successful partial superimposition of the ante- and postmortem lateral chest x-ray films helped to place the personal identification as that of a fisherman, 58 years old, missing in the sea for 21 days.

[Partial sternectomy for metastatic tumor with reconstruction using a methylmethacrylate plate]

A case of partial sternectomy for metastatic thyroid carcinoma is reported. En bloc excision was followed by reconstruction using a molded plate of methylmethacrylate. Sternal tumours are rare and operations for cure of metastases are justified only if the general condition of the patient permits and in the patient with a single metastasis whose primary cancer operation was a radical one. Extensive en bloc excision is based on preoperative investigation in which computerized axial tomography has an important place in delineating the extent of the tumour and providing accurate knowledge of the margins of the section. Reconstruction with methyl-methacrylate allows a rigid setting with a material that can be molded, is radiolucent, inert and well tolerated. In the upper sternum it contributes to the stability of the shoulder girdle and protects the underlying mediastinal structures in a cosmetically acceptable way.