A review of the embryological development and associated developmental abnormalities of the sternum in the light of a rare palaeopathological case of sternal clefting

Does sternal body shape reflect family relationships? A study on a genealogically documented Central European osteological sample (19th-20th centuries)

In forensic contexts, sternal anatomical varieties represent useful tools for the identification of an individual, either by comparison of ante-mortem and post-mortem data, or by potential comparison of data from biologically related individuals. Sternal body variation is also used to detect the biological affinity of individuals in bioarchaeology. However, no study has been made available to date on the degree to which the overall shape of the sternal body reflects the degree of biological relatedness. We, therefore, analyzed the sternal body shape of 10 individuals with known genealogical data, members of one family over three generations including inbred individuals (19th-20th centuries, Bohemia, Czech Republic), and a control sample of 12 biologically unrelated individuals. First, closely biologically related individuals were compared with unrelated individuals based on 10 variables expressing the morphological characteristics of the sternum, and then all individuals were compared based on Fourier analysis depending on their degree of relationship. The results showed that there is a greater degree of shape similarity in biologically related individuals than in unrelated individuals, and variability decreases with an increasing degree of relatedness. Inbred individuals showed the lowest sternum-shape distances and degree of variability, while unrelated individuals, showed the highest distances and variability. Moreover, in some cases, the documented relationships were also supported by a similar morphology of the ossified and fused xiphoid process. Thus, sternal shape analysis expands the possibilities for individual identification and the detection of the biological affinity of individuals for both the forensic sciences and bioarchaeology.

OUP accepted manuscript

Sternal clefts are rare congenital chest-wall deformities, which can be complete or incomplete; therefore, reconstruction with autologous tissue is essential to protect the heart and prevent respiratory infection. In this report, we present the case of a 16-month-old baby girl from a preterm, twin pregnancy with a partial superior sternal cleft. A moist dressing for promoting wound healing was used until cutaneous layer complete epithelialization at which time we performed reconstruction with autologous tissue. After surgery the patient recovered with close-to-natural chest wall contour and adequate heart and lung function.

Reconstruction of Congenital Sternal Clefts: Surgical Experience and Literature Review

Background:

Sternal cleft is a rare anomaly with a reported incidence of 1:100,000 cases per live births. Surgical intervention represents a crucial factor altering the overall patient prognosis, since they are at high risk of impaired oxygenation, as well as multiple chest infections. Herein, we are reporting our experience of surgical management of such rare cases, alerting plastic surgeons to their possibly crucial role in the reconstructive team.

Methods:

A retrospective chart review of 2 cases presenting with chest wall defects. All perioperative data were collected and presented.

Results:

Two patients with sternal clefts of variable degrees were managed. The first was an 18-month-old boy with partial inferior sternal cleft, who was otherwise asymptomatic. The patient underwent reconstruction at the same age using autologous rib graft and pectoralis major flaps due to ectopia cordis that was putting the patient at higher risk for cardiac trauma. The second patient was a 3-month-old girl having a V-shaped partial superior cleft with lung herniation. Surgical reconstruction was applied due to difficulty in weaning the patient off of ventilator support. Initially, reconstruction was applied with SurgiMend dermal matrix, but this was complicated by chest retraction and high oxygen requirement. Definitive reconstruction was later applied with allogeneic bone graft and pectoralis major flaps.

Conclusions:

Meticulous patient assessment and screening for associated anomalies are crucial. Surgical intervention is warranted at an early age. The use of acellular dermal matrix products in the reconstruction is of interest, but should be approached with caution.

Sternal malformations and anesthetic management

Shamberger and Welch classify sternal malformations into four types: thoracic ectopia cordis, cervical ectopia cordis, thoraco-abdominal ectopia cordis, and cleft sternum. Cleft sternum is the most common subset, with a reported incidence of 1 in 50,000 to 100,000 live births, representing 0.15% of all anterior chest wall malformations. Acostello et al further classify cleft sternum into complete or partial (superior, medium, inferior) with a simple superior partial cleft sternum being by far the most common with an orthotopic heart, intact pericardium, and normal skin coverage. Associated anomalies with superior partial cleft sternum are rare, but can include cervicofacial hemangiomas, midline raphe from the tip of the cleft to the umbilicus, and PHACES (posterior fossa malformations, facial hemangiomas, arterial anomalies with coarctation of aorta, cardiac defects, eye abnormalities, sternal cleft, and supraumbilical raphe) syndrome. The more rare inferior partial clefts are associated with thoraco-abdominal ectopia cordis as part of the Pentalogy of Cantrell (omphalocele, anterior diaphragmatic hernia, sternal cleft, ectopia cordis, ventricular septal defect/left ventricular diverticulum). This review summarizes the current knowledge of all four types of sternal malformations, and provides guidance for optimal anesthetic and perioperative care of these children.

Developmental instability and its relationship to mental health in two historic Dutch populations

This study aimed to assess the magnitude and patterns of fluctuating asymmetry as an indicator of developmental instability between two urban archeological Dutch populations. The sample comprised of 209 adult individuals representing the general population of Alkmaar, the Netherlands, dating to the 18th to early 19th century (Grote Kerk, n=134), and a psychiatric hospital sample of the 19th to early 20th century (Meerenberg, n=75). Fluctuating asymmetry was assessed from left and right measurements recorded from various traits on the cranium, mandible, and dentition. Three non-specific skeletal indicators of stress were documented to aid in the interpretation of the differences in asymmetry. No significant difference in developmental instability, as reflected by fluctuating asymmetry, was apparent between the two populations. However, individuals who presented with skeletal lesions indicative of stress were significantly more asymmetric than individuals who did not present with any of the lesions. The observed frequencies of the pathological changes and socio-economic history suggest that the two populations experienced similar levels of stress, even though the source and duration of the stress might have been different. The possibility that the mentally institutionalized are not as developmentally unstable as suggested by previous research should be considered.

Isolated Sternal Cleft in a Patient With Coronary Artery Disease

A cleft sternum is a very rare developmental anomaly. It is caused by failure of fusion of the two lateral mesodermal sternal bars which later form the sternum. Diagnosis of cleft sternum is generally made in the neonatal period, and it is usually associated with other congenital defects. Occasionally, patients with cleft sternum may be reported late in the childhood or even in adulthood. We present the case of an adult patient with sternal cleft diagnosed incidentally in the perioperative period at the time of off-pump coronary artery bypass grafting. No other skeletal or cardiac congenital anomalies had been noted previously in this patient.