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Traumatic manubriosternal joint dislocation in blunt thoracic trauma is of rare occurrence with only few case reports in the literature. We present a rare case of occult manubriosternal dislocation that was evident only after cervico-dorsal spine fracture correction. Thirty-one-year-old gentleman sustained multiple fractures of C6, C7, and D1 vertebral bodies; bilateral transverse process of C7, D1,and D3; left transverse process of D12; right transverse process of D4; and right clavicle fracture along with bilateral multiple rib fractures after fall from bike at high velocity. The patient was awake, alert, and moving all 4 limbs. The patient underwent right chest drain insertion in high dependency unit. His displaced cervico-thoracic spine was fixed with plate and intrapedicular screws. It was after fixation of spine that type II manubriosternal dislocation was clinically appreciated. He underwent fixation of manubriosternal joint using simple steel wires. Post-operatively he remained pain-free with stable manubriosternal joint. Role of manubrio-vertebral column in such a scenario is discussed.

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Manubriosternal joint (MSJ) dislocation is often poorly tolerated, with pain, and both static and dynamic dysfunction in breathing. This injury is rare, and treatment includes both surgical and non-surgical interventions. Moreover, the treatment needs to be personalised to a specific case. We present a case of a 19-year-old Comorian man who had chest pains that were exacerbated by movements after falling from a tree. Careful physical examination revealed that the man had a 'stair step'-looking deformity located at the anterior chest wall at the level of the MSJ. A computed tomography scan confirmed the diagnosis of manubriosternal disruption. The patient underwent a surgical intervention under general anaesthesia and had an uneventful recovery.

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Age-at-death estimation is a crucial component of any forensic anthropological analysis. Despite a variety of research in this field, uncertainties still exist when estimating adult age. The sternum is an under-considered element in terms of adult age estimation. Previous research on an Indian population suggested that this may be a usable region of the skeleton, although results were ambivalent. This study observed the fusion phases of 461 sterna from a black South African population in an attempt to match true age of an individual with the different phases of synostosis of the manubrio-sternal and the sterno-xiphoidal junctions. The results demonstrated that the majority of sterna remain unfused throughout adult life, with complete fusion observed both in young (25 year-old) and old individuals. Significant differences were identified amongst male and female sterna, with males presenting no transitional fusion of the segments, while female sterna demonstrated fusion to a lesser extent. Overall, logistic regression results demonstrated low accuracies (62.5%) for age estimation even when the two sexes were considered separately (male=63.9%; female=61.8%). The synostosis of both junctions is hence considered highly variable and deemed unreliable for adult age-at-death estimation in the black South African population.

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OBJECTIVE: The aim of this study was to evaluate the safe zone for performing blind sternal procedures based on computed tomography (CT) evaluation of congenital midline sternal foramina using multidetector computed tomography (MDCT). MATERIALS AND METHODS: This retrospective study was carried out on 1,180 patients who underwent MDCT of the thorax from March 2015 to February 2016. The MDCT images were evaluated in axial and reformatted planes. Morphometry and prevalence of midline congenital sternal foramina (SF) and manubrio-foraminal distance (MFD) were evaluated. The safe zone was defined for a blinded intervention, based on palpable anatomical landmarks. Data were presented in terms of percentage, mean ± standard deviation and calculations were carried out using Microsoft Excel. RESULTS: The prevalence of SF in our study sample was 11.6 %. The majority of SF were located in a typical position in the lower sternal body at the level of fifth costo-chondral junction (CCJ) in 108 patients (78.8 %). The structure directly beneath the SF was mediastinal fat in 73 patients (53.3 %), followed by anterior pericardium in 44 patients (32.1 %) and lung parenchyma in 20 patients (14.6 %). The mean MFD in our study population was 11.90 ± 1.31 cm. CONCLUSIONS: Sternal interventions should be avoided at the level of fourth to sixth CCJ, which is considered the danger zone. An intervention at the fourth to sixth CCJ may lead to disastrous consequences in patients who have SF.

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Although rare, traumatic abdominal wall hernia associated with handlebar injury is a well-described entity in the pediatric population with about 40 cases and only one laparoscopic repair reported in children. We present two cases of male patients, 9 and 13 years old, who were assessed in our emergency room for blunt abdominal trauma associated with handlebar injury. The patients showed signs of handlebar trauma in the abdominal wall: one presented with a painful mass, and the other with intermittent pain in the area of trauma with no palpable mass. Neither of the patients were hemodynamically unstable or showed any peritoneal signs. Ultrasound and CT scans were performed in both patients to identify abdominal wall hernias containing bowel content in the absence of other injuries. Laparoscopic repair was performed uneventfully in both patients with interrupted non-absorbable multifilament suture with 2 and 3 ports respectively. Oral intake was initiated one day after surgery and both patients were discharged the following day. In the follow-up visit, the patients were asymptomatic and no signs of abdominal wall hernias were found. Laparoscopic repair of blunt traumatic abdominal wall hernias is safe and technically possible in children and should be considered as the standard initial approach in the stable patient.

Aunque rara, la hernia traumática de la pared abdominal asociada a una lesión en el manubrio es una entidad bien descrita en la población pediátrica, con aproximadamente 40 casos y solo se informó una reparación laparoscópica en niños. Presentamos dos casos de pacientes varones, de 9 y 13 años de edad, que fueron evaluados en nuestra sala de emergencias por un traumatismo abdominal cerrado asociado con una lesión en el manubrio. Los pacientes mostraron signos de traumatismo del manubrio en la pared abdominal: uno presentó una masa dolorosa y el otro con dolor intermitente en el área de trauma sin masa palpable. Ninguno de los pacientes presentaba inestabilidad hemodinámica ni signos peritoneales. Se realizaron ecografías y tomografías computarizadas en ambos pacientes para identificar las hernias de la pared abdominal que contenían contenido intestinal en ausencia de otras lesiones. La reparación laparoscópica se realizó sin incidentes en ambos pacientes con sutura discontinua no reabsorbible interrumpida con 2 y 3 puertos respectivamente. La ingesta oral se inició un día después de la cirugía y ambos pacientes fueron dados de alta al día siguiente. En la visita de seguimiento, los pacientes estaban asintomáticos y no se encontraron signos de hernias de la pared abdominal. La reparación laparoscópica de las hernias de pared abdominal traumáticas romas es segura y técnicamente posible en los niños y debe considerarse como el abordaje inicial estándar en el paciente estable.

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BACKGROUND: Malpositioning of endotracheal tube may lead to serious complications like endobronchial intubation or accidental extubation. Using anatomical measurements for prediction of airway length would be more practical in resource constrained settings. MATERIALS AND METHODS: One hundred adult patients of American Society of Anesthesiologists (ASA) grade 1 or 2, without any evidence of difficult airway, were randomly allocated to two cohorts - a model cohort of 70 (50 males) and test cohort of 30 (20 males) subjects. Height, the straight length from the upper incisor to manubrio-sternal joint in fully extended head position (IncManustL), the length from upper incisor to the carina in neutral head position (IncCarinaL), and degree of neck extension were measured in all subjects. Relationship between the two lengths in the model cohort was explored by Pearson's coefficient (r). Predictions were made for subjects in the test cohort and actual and predicted values assessed for agreement using intra-class correlation coefficient (ICC). RESULTS: Good agreement was found between IncManustL and IncCarinaL for both male (r = 0.69) and female (r = 0.54) subjects. Multiple regression analysis suggested height to be another significant predictor, unlike age, weight, and neck extension. The gender-specific regression equations were used to predict IncCarinaL for the test cohort. ICC for absolute agreement between the actual and predicted values was 0.723 (95% CI 0.495-0.858). CONCLUSIONS: It is possible to predict airway length in adult Indian subjects by making two simple anatomical measurements, namely stature and incisor manubrio-sternal joint length.

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El conocimiento morfométrico de las estructuras del oído medio, incluidos cada uno de los oscículos, es importante para la comprensión de su complejidad biomecánica. Las características estructurales y dimensionales del martillo son registradas en 23 martillos de población mestiza adulta Colombiana. Las medidas registradas involucran el área de la cabeza, el cuello, el manubrio, el proceso anterior y lateral y el área de la articulación incudo-maleolar. Tres de los diecinueve registros tomados en este estudio pudieron ser comparados concienzudamente con otros estudios que mostraron similitudes. El largo total del martillo fue de 8,18 mm DE 0,24, la longitud del manubrio fue de 4,91 mm DE 0,25 y la proporción del largo del manubrio y el largo total fue de 60,11 % DE 3,47. Conforme a la población estudiada no se logro encontrar variación individual o pareada en la anatomía del martillo lo que lo hace un hueso morfométricamente uniforme y estable.

Morphometric knowledge of middle ear structures, including each of the oscicles, is important for the understanding of its biomechanics complexity. The structural and dimensional characteristics of the malleus are registered in 23 samples of Colombian adult mestizo population. Registered measures involve the area of the head, neck, the manubrium, the anterior and lateral process and the area of the incudo-maleolar joint. Three of nineteen records taken in this study could be carefully compared to other studies, which showed similarities. The total length of the malleus was 8,18 mm SD 0.24, the length of the handle was 4.91 mm SD 0.25 and the ratio of the length of the manubrium and the malleus total length was 60,11% of 3.47. In accordance with the studied population, individual or paired variations were not found in the anatomy of the malleus that makes it a morphometrically uniform and stable bone.

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Os autores relatam a ocorrência de lesão oculta da articulação manúbrio-esternal na avaliação inicial de um paciente com fratura da coluna torácica (T9). Foi diagnosticada fratura de T9 no paciente do sexo masculino de 37 anos de idade associada a déficit neurológico parcial. No atendimento inicial, as radiografias realizadas não demonstraram a lesão da articulação manúbrioesternal. Durante a reabilitação, após a estabilização cirúrgica da fratura da coluna torácica, subitamente o paciente sentiu dor intensa, acompanhada de deformidade ao nível do esterno, tendo sido diagnosticada luxação manúbrio-esternal nos exames de imagem. Devido à recidiva da luxação e de dor incapacitante, foi necessária a realização da redução aberta e fixação da articulação manúbrio-esternal. Na avaliação após 12 meses, o paciente apresentou recuperação completa da lesão neurológica, consolidação da artrodese do segmento vertebral T7-T11, e manutenção da redução da articulação manúbrio-esternal, que era assintomática durante a realização das atividades cotidianas.

The authors report the occurrence of an occult manubriosternal joint injury in the initial evaluation on a patient with a thoracic spine fracture (T9). This T9 fracture was diagnosed in a 37-year-old man and was associated with a partial neurological deficit. At the initial evaluation, the radiographs produced did not show the manubriosternal joint injury. During rehabilitation, after surgical stabilization of the thoracic spine fracture, the patient suddenly felt an intense pain accompanied by deformation at the sternal level. From imaging examinations, manubriosternal dislocation was diagnosed. Because of recurrence of the dislocation and the incapacitating pain, open reduction and fixation of the manubriosternal joint had to be performed. At the 12-month follow-up, the patient presented complete recovery of the neurological lesion, consolidation of the arthrodesis on the T7-T11 vertebral segment and maintenance of the reduction of the manubriosternal joint, which was asymptomatic during daily activities.

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