Sternum

Shape of manubrium

The manubrium (Latin for "handle") is the broad upper part of the sternum. It has a quadrangular shape, narrowing from the top, which gives it four borders. The suprasternal notch (jugular notch) is located in the middle at the upper broadest part of the manubrium. This notch can be felt between the two clavicles. On either side of this notch are the right and left clavicular notches.[1]

The manubrium joins with the body of the sternum, the clavicles and the cartilages of the first pair of ribs. The inferior border, oval and rough, is covered with a thin layer of cartilage for articulation with the body. The lateral borders are each marked above by a depression for the first costal cartilage, and below by a small facet, which, with a similar facet on the upper angle of the body, forms a notch for the reception of the costal cartilage of the second rib. Between the depression for the first costal cartilage and the demi-facet for the second is a narrow, curved edge, which slopes from above downward towards the middle. Also, the superior sternopericardial ligament attaches the pericardium to the posterior side of the manubrium.

3D illustration of the body of sternum.

The body, or gladiolus, is the longest sternal part. It is flat and considered to have only a front and back surface. It is flat on the front, directed upward and forward, and marked by three transverse ridges which cross the bone opposite the third, fourth, and fifth articular depressions. The pectoralis major attaches to it on either side. At the junction of the third and fourth parts of the body is occasionally seen an orifice, the sternal foramen, of varying size and form. The posterior surface, slightly concave, is also marked by three transverse lines, less distinct, however, than those in front; from its lower part, on either side, the transversus thoracis takes origin.

The sternal angle is located at the point where the body joins the manubrium. The sternal angle can be felt at the point where the sternum projects farthest forward. However, in some people the sternal angle is concave or rounded. During physical examinations, the sternal angle is a useful landmark because the second rib attaches here.[1]

Each outer border, at its superior angle, has a small facet, which with a similar facet on the manubrium, forms a cavity for the cartilage of the second rib; below this are four angular depressions which receive the cartilages of the third, fourth, fifth, and sixth ribs. The inferior angle has a small facet, which, with a corresponding one on the xiphoid process, forms a notch for the cartilage of the seventh rib. These articular depressions are separated by a series of curved interarticular intervals, which diminish in length from above downward, and correspond to the intercostal spaces. Most of the cartilages belonging to the true ribs, articulate with the sternum at the lines of junction of its primitive component segments. This is well seen in some other vertebrates, where the parts of the bone remain separated for longer.

The upper border is oval and articulates with the manubrium, at the sternal angle. The lower border is narrow, and articulates with the xiphoid process.

3D illustration of the Xiphoid process.

Located at the inferior end of the sternum is the pointed xiphoid process. Improperly performed chest compressions during cardiopulmonary resuscitation can cause the xiphoid process to snap off, driving it into the liver which can cause a fatal hemorrhage.[1]

The sternum is composed of highly vascular tissue, covered by a thin layer of compact bone which is thickest in the manubrium between the articular facets for the clavicles. The inferior sternopericardial ligament attaches the pericardium to the posterior xiphoid process.

The cartilages of the top five ribs join with the sternum at the sternocostal joints. The right and left clavicular notches articulate with the right and left clavicles, respectively. The costal cartilage of the second rib articulates with the sternum at the sternal angle making it easy to locate.[3]

The transversus thoracis muscle is innervated by one of the intercostal nerves and superiorly attaches at the posterior surface of the lower sternum. Its inferior attachment is the internal surface of costal cartilages two through six and works to depress the ribs.[4]

Figure 4 Ossification

Figure 5

Figure 6 Peculiarities

Figure 7

The sternum develops from two cartilaginous bars one on the left and one on the right, connected with the cartilages of the ribs on each side. These two bars fuse together along the middle to form the cartilaginous sternum which is ossified from six centers: one for the manubrium, four for the body, and one for the xiphoid process.

The ossification centers appear in the intervals between the articular depressions for the costal cartilages, in the following order: in the manubrium and first piece of the body, during the sixth month of fetal life; in the second and third pieces of the body, during the seventh month of fetal life; in its fourth piece, during the first year after birth; and in the xiphoid process, between the fifth and eighteenth years.

The centers make their appearance at the upper parts of the segments, and proceed gradually downward. To these may be added the occasional existence of two small episternal centers, which make their appearance one on either side of the jugular notch; they are probably vestiges of the episternal bone of the monotremata and lizards.

Occasionally some of the segments are formed from more than one center, the number and position of which vary [Fig. 6]. Thus, the first piece may have two, three, or even six centers.

When two are present, they are generally situated one above the other, the upper being the larger; the second piece has seldom more than one; the third, fourth, and fifth pieces are often formed from two centers placed laterally, the irregular union of which explains the rare occurrence of the sternal foramen [Fig. 7], or of the vertical fissure which occasionally intersects this part of the bone constituting the malformation known as fissura sterni; these conditions are further explained by the manner in which the cartilaginous sternum is formed.

More rarely still the upper end of the sternum may be divided by a fissure. Union of the various centers of the body begins about puberty, and proceeds from below upward [Fig. 5]; by the age of 25 they are all united.

The xiphoid process may become joined to the body before the age of thirty, but this occurs more frequently after forty; on the other hand, it sometimes remains ununited in old age. In advanced life the manubrium is occasionally joined to the body by bone. When this takes place, however, the bony tissue is generally only superficial, the central portion of the intervening cartilage remaining unossified.

In early life, the sternum's body is divided into four segments, not three, called sternebrae (singular: sternebra).[5]

In 2.5–13.5% of the population, a foramen known as sternal foramen may be presented at the lower third of the sternal body.[6] In extremely rare cases, multiple foramina may be observed. Fusion of the manubriosternal joint also occurs in around 5% of the population.[7] Small ossicles known as episternal ossicles may also be present posterior to the superior end of the manubrium.[8] Another variant called suprasternal tubercle is formed when the episternal ossicles fuse with the manubrium.[9]

Because the sternum contains bone marrow, it is sometimes used as a site for bone marrow biopsy. In particular, patients with a high BMI (obese or grossly overweight) may present with excess tissue that makes access to traditional marrow biopsy sites such as the pelvis difficult.

A somewhat rare congenital disorder of the sternum sometimes referred to as an anatomical variation is a sternal foramen, a single round hole in the sternum that is present from birth and usually is off-centered to the right or left, commonly forming in the 2nd, 3rd, and 4th segments of the breastbone body. Congenital sternal foramina can often be mistaken for bullet holes.[10] They are usually without symptoms but can be problematic if acupuncture in the area is intended.[11]

Manubrium sternal dislocation

Fractures of the sternum are rather uncommon. They may result from trauma, such as when a driver's chest is forced into the steering column of a car in a car accident. A fracture of the sternum is usually a comminuted fracture. The most common site of sternal fractures is at the sternal angle. Some studies reveal that repeated punches or continual beatings, sometimes called "breastbone punches", to the sternum area have also caused fractured sternums. Those are known to have occurred in contact sports such as hockey and football. Sternal fractures are frequently associated with underlying injuries such as pulmonary contusions, or bruised lung tissue.[12]

A manubriosternal dislocation is rare and usually caused by severe trauma. It may also result from minor trauma where there is a precondition of arthritis.[13]

The breastbone is sometimes cut open (a median sternotomy) to gain access to the thoracic contents when performing cardiothoracic surgery.

The sternum can be totally removed (resected) as part of a radical surgery, usually to surgically treat a malignancy, either with or without a mediastinal lymphadenectomy (Current Procedural Terminology codes # 21632 and # 21630, respectively).

A bifid sternum is an extremely rare congenital abnormality caused by the fusion failure of the sternum.[14] This condition results in sternal cleft which can be observed at birth without any symptom.[14]

In arachnids, the sternum is the ventral (lower) portion of the cephalothorax. It consists of a single sclerite situated between the coxa, opposite the carapace.