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Sternum
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Sternum
Parts of the sternum: manubrium (green), body (blue), xiphoid process (purple)
Position of the sternum (red)
Details
Identifiers
Latinsternum
MeSHD013249
TA98A02.3.03.001
TA21129
FMA7485
Anatomical terms of bone

The sternum (pl.: sternums or sterna) or breastbone is a long flat bone located in the central part of the chest. It connects to the ribs via cartilage and forms the front of the rib cage, thus helping to protect the heart, lungs, and major blood vessels from injury. Shaped roughly like a necktie, it is one of the largest and longest flat bones of the body. Its three regions are the manubrium, the body, and the xiphoid process.[1] The word sternum originates from Ancient Greek στέρνον (stérnon) 'chest'.

Structure

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The sternum is a narrow, flat bone, forming the middle portion of the front of the chest. The top of the sternum supports the clavicles (collarbones) and its edges join with the costal cartilages of the first two pairs of ribs. The inner surface of the sternum is also the attachment of the sternopericardial ligaments.[2] Its top is also connected to the sternocleidomastoid muscle. The sternum consists of three main parts, listed from the top:

In its natural position, the sternum is angled obliquely, downward and forward. It is slightly convex in front and concave behind; broad above, shaped like a "T", becoming narrowed at the point where the manubrium joins the body, after which it again widens a little to below the middle of the body, and then narrows to its lower extremity. It is usually longer in the male than in the female.[3]

Manubrium

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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 1.5 pairs 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.

Body

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Body of Sternum
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.[citation needed]

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.

Xiphoid process

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Main article: Xiphoid process
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.

Joints

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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.[4]

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.[5]

Development

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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.[6] 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.[citation needed]

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. Sternum development is completed earlier in females than in males.[7]

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.

The body of the sternum is formed by the fusion of four segments called sternebrae.[8]

Variations

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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.[9] In extremely rare cases, multiple foramina may be observed. Fusion of the manubriosternal joint also occurs in around 5% of the population.[10] Small ossicles known as episternal ossicles may also be present posterior to the superior end of the manubrium.[11] Another variant called suprasternal tubercle is formed when the episternal ossicles fuse with the manubrium.[12]

Clinical significance

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Bone marrow biopsy

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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.

Sternal opening

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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.[13] They are usually without symptoms but can be problematic if acupuncture in the area is intended.[14]

Manubrium sternal dislocation

Fractures

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Main article: Sternal fracture

Fractures of the sternum are 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.[15]

Dislocation

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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.[16]

Sternotomy

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The breastbone is sometimes cut open (a median sternotomy) to gain access to the thoracic contents when performing cardiothoracic surgery. Surgical fixation of sternotomy is achieved through the use of either wire cerclage or a plate and screw technique. The incidence of sternotomy complications falls within the narrow range of 0.5% to 5%. Nevertheless, these complications can have severe consequences, including increased mortality rates, the need for reoperation, and a mortality rate as high as 40%. Such complications often entail issues like dehiscence and sternal non-union, primarily stemming from lateral forces exerted during post-operative activities such as coughing and sneezing.

Resection

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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).

Bifid sternum or sternal cleft

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A bifid sternum is an extremely rare congenital abnormality caused by the fusion failure of the sternum.[17] This condition results in sternal cleft which can be observed at birth without any symptom.[17]

Other animals

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The sternum, in vertebrate anatomy, is a flat bone that lies in the middle front part of the rib cage. It is endochondral in origin.[18] It probably first evolved in early tetrapods as an extension of the pectoral girdle; it is not found in fish. In amphibians and reptiles, it is typically a shield-shaped structure, often composed entirely of cartilage. It is absent in both turtles and snakes. In birds, it is a relatively large bone and typically bears an enormous projecting keel to which the flight muscles are attached.[19] Only in mammals does the sternum take on the elongated, segmented form seen in humans.

Arthropods

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Main article: Sternum (arthropod anatomy)

In arthropods, a sternum is the ventral part of a segment of thorax or abdomen.

Etymology

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English sternum is a translation of Ancient Greek στέρνον, sternon.[20] The Greek writer Homer used the term στέρνον to refer to the male chest,[21][22] and the term στῆθος, stithos to refer to the chest of both sexes.[21][22] The Greek physician Hippocrates used στέρνον to refer to the chest,[21][22] and στῆθος to the breastbone.[21][22] The Greek physician Galen was the first to use στέρνον in the present meaning of breastbone.[21][22]

The sternum as the solid bony part of the chest[23] can be related to Ancient Greek στερεός/στερρός, (stereós/sterrós),[23] meaning firm or solid.[22] The English term breastbone is actually more like the Latin os pectoris,[24][25] derived from classical Latin os, bone[26] and pectus, chest or breast.[26] Confusingly, pectus is also used in classical Latin as breastbone.[26]

Additional images

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  • Position of sternum (shown in red). Animation.
    Position of sternum (shown in red). Animation.
  • Sternum seen posteriorly
    Sternum seen posteriorly
  • Sternum cut along the frontal plane showing interior of the bone
    Sternum cut along the frontal plane showing interior of the bone
  • Sternum, lateral aspect
    Sternum, lateral aspect
  • Position of the sternum the thoracic cage
    Position of the sternum the thoracic cage
  • Computer-generated image of ribcage turntable highlighting the sternum
    Computer-generated image of ribcage turntable highlighting the sternum
  • Sternum anatomy

See also

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This article uses anatomical terminology.

References

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[edit]
Revisions and contributorsEdit on WikipediaRead on Wikipedia

Sternum

View on Grokipedia
from Grokipedia
The sternum, commonly known as the breastbone, is a long, flat, partially T-shaped bone that forms the central anterior portion of the thoracic cage in humans. It consists of three primary segments: the superior manubrium, the elongated central body (or mesosternum), and the inferior cartilaginous xiphoid process, which gradually ossifies with age. The sternum measures approximately 17 cm in length in adults and serves as a critical attachment point for the clavicles and the costal cartilages of the first seven ribs, forming the sternoclavicular and sternocostal joints. Through these articulations, it contributes to the structural integrity of the chest wall, protecting vital mediastinal organs such as the heart and major blood vessels. Functionally, the sternum plays a key role in respiration by providing a yet flexible for rib movements, allowing the to expand during as the sternum displaces anteriorly and superiorly. Its development involves , beginning with multiple ossification centers that fuse progressively; fusion between the manubrium and body occurs variably in late adulthood, often remaining incomplete or after age 40, while the may remain partially cartilaginous until the fourth or fifth decade of life, with full occurring variably by age 40 to 60. Blood supply to the sternum is derived primarily from the and its perforating branches, with venous drainage via accompanying veins and lymphatic flow toward axillary and internal thoracic nodes. Clinically, the sternum is a vital surgical landmark, often accessed via median sternotomy for procedures like coronary artery bypass grafting or thymectomy, due to its central position overlying the heart. Congenital anomalies, such as cleft sternum (incidence of 1 in 50,000 to 100,000 births) or pectus excavatum (1 in 400 to 1,000 births), can affect its form and function, potentially leading to respiratory or cardiac complications. Additionally, its dimensions and ossification patterns aid in forensic anthropology for sex estimation, though age determination is less reliable due to individual variability.

Anatomy

Manubrium

The manubrium is the broad, superior segment of the sternum, characterized by a thick, trapezoidal shape that widens superiorly. In adults, it measures approximately 5 cm in length (superoinferior dimension), with a width of about 5 cm at its broadest superior point. Positioned at the level of the third and fourth thoracic vertebrae, it forms the uppermost portion of the anterior thoracic wall. The anterior surface of the manubrium is smooth and slightly convex transversely, providing minimal attachment sites for soft tissues. In contrast, the posterior surface is rougher and concave, facilitating attachments for muscles such as the sternohyoid and sternothyroid. At its superior border lies the jugular notch, also known as the , a U-shaped depression that serves as a palpable landmark between the clavicles. The lateral borders feature smooth depressions for the clavicular articulations and costal facets. The manubrium articulates superiorly and laterally with the medial ends of the clavicles via the sternoclavicular joints, which are reinforced by ligaments for stability. It also connects to the costal cartilages of the first two : a full facet for the first on each side and a demifacet for the superior half of the second . Inferiorly, it joins the body of the sternum at the manubriosternal joint, a secondary cartilaginous . Vascular supply to the manubrium is provided by medial horizontal branches of the internal thoracic arteries, which arise from the subclavian arteries and course along the posterior aspect of the sternum. These branches ensure nutrient delivery to the bone and adjacent structures.

Body

The body of the sternum, also known as the mesosternum or gladiolus, forms the central, elongated portion of the sternum and is its longest segment. It articulates superiorly with the manubrium at the manubriosternal joint. This flat bone is roughly quadrilateral in outline, longer and narrower than the manubrium, and typically measures about 10 cm in length in adults, with a width that increases inferiorly to a maximum of around 4 cm near the level of the fifth rib. Developmentally derived from four separate sternebrae, the body fuses into a single unit by early adulthood, marked by three horizontal transverse ridges that delineate the former segments. The anterior surface is nearly flat and slightly convex, directed forward and upward, featuring these faint transverse ridges that indicate the sites of sternebrae fusion; it also provides attachment for muscles such as the . The posterior surface is slightly concave, with less prominent transverse lines and small demifacets for articulation with the costal cartilages of the . Nutrient foramina on the posterior surface allow entry of vascular branches from the internal thoracic arteries to supply the bone. Along its lateral borders, the body bears seven costal notches that articulate with the costal cartilages of ribs 2 through 7, forming the sternocostal joints; these notches are shallow superiorly and progressively deepen inferiorly to accommodate the rib attachments more securely.

Xiphoid process

The xiphoid process, also known as the xiphisternum, is the smallest and most inferior component of the sternum, forming a small, cartilaginous structure at birth that typically measures 2 to 5 cm in length. It is primarily composed of hyaline cartilage proximally and elastic cartilage distally, often exhibiting a triangular or pointed shape that is directed inferiorly or slightly posteriorly, though it attaches to the inferior border of the sternal body via the xiphisternal joint, a symphysis that may ossify with age. Shape variations are common, including bifid (forked), perforated (with foramina), elongated, curved, or broad forms, which do not typically impact function but can influence palpation. This structure serves as a key insertion point for several abdominal muscles, including the rectus abdominis anteriorly and the diaphragm posteriorly, contributing to trunk stability and aiding in the anchoring of the linea alba at its tip. patterns vary widely, beginning in childhood with centers appearing between ages 5 and 18; it typically progresses variably, with completion occurring as late as 40 to 60 years and remaining incomplete in some adults. The allows limited mobility in youth, but reduces this flexibility over time. In many cases, is incomplete throughout life, preserving a degree of flexibility. Clinically, the is readily palpable in the epigastric region at the level of the T10 vertebra, serving as a critical anatomical for procedures such as (CPR), where hand placement is positioned just superior to it to avoid fracture, and for or other subxiphoid injections. Its superficial position and variability necessitate careful assessment during physical examinations to distinguish it from potential pathologies like xiphoid , which involves localized pain and swelling.

Joints and ligaments

The sternoclavicular is a saddle-type that articulates the medial end of the with the clavicular notch of the manubrium and the first , featuring an intra-articular fibrocartilaginous disc that divides the joint cavity and permits limited multidirectional movement. This disc attaches superiorly to the and inferiorly to the first , enhancing stability while allowing approximately 35° of elevation-depression, 70° of protraction-retraction, and 45° of axial rotation. The is primarily stabilized by the anterior and posterior sternoclavicular ligaments, which extend from the to the manubrium and prevent excessive displacement, as well as the , which anchors the to the first and provides the strongest restraint against superior and anteroposterior translation. An additional interclavicular connects the medial ends of both over the manubrium, reinforcing superior stability. The costosternal joints, also known as sternocostal joints, connect the costal cartilages of the first seven ribs to the lateral margins of the sternum, with the first joint typically forming a synchondrosis and the second through seventh as synovial plane joints enclosed by fibrous capsules. These joints facilitate thoracic cage expansion during respiration, with the second joint often featuring an intra-articular ligament that partially divides its cavity. Stability is provided by the radiate sternocostal ligaments, which fan out from each costal cartilage to the sternum's anterior and posterior surfaces, supplemented by intra-articular ligaments in select joints. Intrastemal joints unite the segments of the sternum, including the manubriosternal joint—a between the manubrium and body at the —and the between the body and , both typically cartilaginous unions reinforced by intersternebral ligaments and periosteal fibers. The manubriosternal joint allows slight anteroposterior and vertical mobility, while the exhibits variable fibrocartilaginous characteristics that permit limited movement, often ossifying into a synostosis by middle age. These connections are supported by fibrous discs or discs that maintain alignment during thoracic excursions. Biomechanically, the sternum's joints exhibit limited mobility to safeguard thoracic viscera, with ligaments such as the costoclavicular and radiate sternocostal types constraining excessive and during and respiratory movements, thereby distributing forces across the thoracic ring. This design ensures the sternum acts as a anchor for the , minimizing displacement risks while accommodating the 13 articulations per thoracic level.

Development and variations

Embryonic development

The sternum originates from paired bands of mesenchymal tissue derived from the parietal layer of the in the ventral body wall, forming around the sixth week of . These sternal bands, initially located lateral to the midline, consist of concentrations of mesenchymal cells that condense and migrate medially toward the developing heart tube. By the seventh week, the within these bands undergoes chondrification to form a primary cartilaginous model, divided into three main segments—the future manubrium, body, and —comprising up to six cartilaginous sternebrae. The paired bands then fuse progressively in a craniocaudal direction along the midline, starting around the ninth week, to create a single sternal plate by the tenth week; this fusion process establishes the foundational structure that will later ossify. Ossification of the sternum proceeds via endochondral mechanisms, beginning . The manubrium develops its primary around the fifth fetal month (approximately 20 weeks ), followed by the first sternebra between 5 and 7 months , with additional centers appearing progressively in the body segments. The sternebrae of the sternal body typically initiate around birth or shortly thereafter, enveloped by growth plates that facilitate expansion. Neural crest cells contribute to the development of the sternoclavicular , particularly through the interclavicular that connects the forming manubrium to the clavicles; this shares an origin with neural crest-derived portions of the clavicle undergoing . Fusion of the ossified sternebrae occurs gradually during childhood and adolescence, typically completing by the late teens to early twenties, while the ossifies and fuses later, often remaining partially cartilaginous into adulthood.

Anatomical variations

The sternum exhibits several anatomical variations arising from differences in and fusion during development. One common variation is the sternal , a typically resulting from incomplete fusion of the sternebrae in the lower third of the sternal body. This oval or round defect has a of approximately 5-8% in the general , though reported rates range from 2.5% to 13.8% across studies, and it measures about 6 mm in average diameter. Asymmetry in the sternum can manifest in the costal notches and sternebrae fusion lines. The costal notches, which articulate with the costal cartilages of 2-7, may show displacement, such as the second costal notch being misplaced (prevalence ~2.6%) or the seventh notch shifted (prevalence ~13.2%), often more frequently on the right side. Fusion lines between sternebrae, normally complete by age 25, can remain visible or irregular in some individuals, leading to non-fusion of segments and subtle asymmetric contours in the sternal body. Variations in the include differences in elongation, curvature, and shape. The process may elongate beyond 4 cm, exhibit ventral or dorsal deflection, or adopt hook-like, reverse "S," or V-shaped forms, with bifid or trifid endings occurring in about 32.8% and 4.6% of cases, respectively. These morphological differences, such as broad, thin, or curved structures, are observed in up to 37% of individuals for double-ended forms. Suprasternal ossicles, small accessory bones in the jugular notch, represent a rare variation with a prevalence of 1.5-6.9%, though higher rates up to 15.5% have been reported in specific populations; they appear as unilateral, bilateral, or midline pyramidal or ovoid structures. Population differences influence the incidence of these variations. Sternal foramina show higher prevalence in South American (up to 13.9%) and African groups compared to European or Asian populations, with some studies noting elevated rates in indigenous Bolivians (12.8-13.4%). Suprasternal ossicles are more common in Asian populations (up to 50%) than in Europeans (12.2%), while costal notch displacements and xiphoid trifurcations also vary by ethnicity, with the latter more frequent in Asians (7%). Gender trends are inconsistent but often indicate slightly higher rates of foramina and ossicles in males.

Function

Respiratory role

The sternum functions as the central anchor for the , allowing elevation of the through the costosternal joints during inspiration, which expands the to facilitate air intake. This attachment via costal cartilages to the second through seventh enables the dynamic movements essential for respiration, with the sternum's stability providing a fixed point for articulation. The stability of the sternum supports the characteristic bucket-handle motion of the lower , which increases the transverse diameter of the , and the pump-handle motion of the upper , which elevates the sternum anteriorly to enhance the anterior-posterior diameter. These motions are driven by the contraction of , allowing the to pivot outward and upward relative to the sternum. In with the diaphragm, which descends to increase the vertical dimension of the , and the , the sternum elevates the anterior chest wall, collectively optimizing lung expansion during quiet breathing. The further aids this process by serving as an attachment site for the diaphragm, integrating sternal mechanics with primary respiratory musculature. In pathological conditions such as , inflammation and fusion at the costosternal joints restrict sternal and rib mobility, leading to reduced chest expansion and impaired ventilation. Patients exhibit diminished chest wall motion, with expansions limited to approximately 4 cm at key intercostal spaces, correlating with lower (around 58% of predicted) and (85% of predicted), thereby compromising overall respiratory efficiency.

Protective role

The sternum forms the anterior wall of the thoracic cavity, serving as a rigid shield that protects vital structures such as the heart, lungs, and great vessels from external trauma and blunt force impacts. This protective barrier is essential in absorbing and dissipating energy during collisions or falls, preventing direct injury to the mediastinal contents and adjacent pulmonary tissues. By integrating with the rib cage, the sternum creates a bony enclosure that maintains the integrity of the thoracic compartment under mechanical stress. As an attachment site for key pectoral muscles, including the , the sternum contributes to stability and overall postural support. These muscular connections enable the sternum to anchor forces that stabilize the during arm movements and upright posture, reducing strain on the spine and facilitating balanced weight distribution across the . This role enhances functional stability, allowing efficient load-bearing in daily activities and preventing compensatory imbalances that could lead to musculoskeletal issues. The sternum plays a critical role in load distribution during by resisting compressive forces transmitted through the upper body. It helps redistribute mechanical stresses from the and spine, minimizing localized pressure on and underlying organs during bending, lifting, or impact scenarios. This biomechanical function is supported by the sternum's flat, compact structure, which provides enhanced rigidity for protection while keeping overall mass low—an evolutionary adaptation seen in mammalian thoracic for efficient skeletal support without excessive weight. In terms of biomechanical strength, the intact sternum can withstand substantial compressive forces before fracturing, as demonstrated in cadaveric studies simulating blunt trauma.

Clinical significance

Trauma and fractures

Trauma to the sternum typically arises from blunt or penetrating forces impacting the anterior chest wall, such as those encountered in high-energy events, rendering its relatively thin bony structure vulnerable to injury. Sternal fractures are common in accidents, which account for 40-70% of cases, with isolated sternal fractures occurring in 3-8% of chest traumas overall. These fractures are classified into types including transverse (the most common, typically at the sternal body), comminuted, and depression fractures. Patients often present with symptoms such as localized , upon , and dyspnea, and these injuries are associated with myocardial contusion in 5-20% of cases. is primarily achieved through chest , which detects most fractures on lateral views, or computed tomography (CT) for detailed assessment of fracture extent and associated injuries; severity can be evaluated using the sternal fracture index alongside imaging findings. Treatment for most sternal fractures is conservative, emphasizing pain control with analgesics, respiratory monitoring to prevent complications like , and observation, reserved for cases without instability or significant associated injuries.

Surgical interventions

The is the standard surgical approach for accessing the during open-heart procedures, involving a longitudinal midline incision from the sternal notch to the , followed by division of the sternum with a saw and closure using wires passed through drill holes in the halves. This technique provides optimal exposure for cardiac surgeries such as coronary artery bypass grafting and valve replacements, used in the majority of open-heart operations, though minimally invasive approaches have increased to over 30% in certain procedures like as of the 2010s, with further growth in robotic-assisted techniques reaching 10-20% in specialized centers by 2025. Bone marrow biopsy and aspiration at the sternum, performed via a needle inserted into the manubrium or body, have largely been supplanted by posterior iliac crest sites in modern practice because of the higher risk of complications at the sternal location, including potential cardiac or vascular from bone penetration. The posterior iliac crest offers a safer alternative with lower rates of serious adverse events, such as hemorrhage or organ damage, making it the preferred site for routine hematologic diagnostics. For traumatic sternal s, particularly unstable transverse or comminuted types that fail conservative management, surgical fixation employs techniques such as wiring to approximate fragments or rigid systems like locks to restore stability and prevent paradoxical chest wall motion. Wiring involves passing multiple loops around the edges for simple transverse s, while uses self-tapping screws to secure contoured plates across the line in more complex cases, promoting faster healing and reducing respiratory compromise. Common risks associated with sternal surgeries include deep sternal wound infection (occurring in 0.5-5% of cases), dehiscence (0.3-1%), and non-union (up to 34% in high-risk patients), often exacerbated by factors like , , or prolonged ventilation. Postoperative typically involves multimodal analgesia, including opioids, nonsteroidal drugs, and intercostal blocks, to mitigate chronic discomfort from tissue retraction and hardware. Since the 1990s, advances in minimally invasive techniques have reduced the reliance on full , with partial upper or lower sternotomies—such as J- or L-shaped incisions limited to the manubrium and proximal body—enabling procedures like isolated through smaller exposures that decrease blood loss, hospital stay, and recovery time while maintaining comparable outcomes. These approaches, often combined with endoscopic assistance, have expanded to over 20% of eligible cardiac surgeries at specialized centers, prioritizing patient and faster return to function.

Congenital conditions

Congenital conditions of the sternum arise primarily from disruptions in the normal embryonic fusion of the sternal bars along the midline, leading to structural defects that can range from cosmetic concerns to life-threatening exposures of thoracic organs. These anomalies occur due to incomplete fusion between the 6th and 10th weeks of , resulting in varying degrees of sternal clefting or deformities. Sternal cleft, also known as bifid sternum, is a rare congenital defect characterized by a of midline fusion of the sternal primordia, with an estimated incidence of 1 in 50,000 to 100,000 live births. It accounts for approximately 0.15% of all chest wall deformities and is more common in females. The condition is classified by severity and extent: type A (superior partial cleft, the most common, involving only the manubrium); type B (subtotal cleft, extending to the lower sternum); type C (total cleft, complete longitudinal split); and type D (thoracoabdominal extension, often the most severe).00112-X/pdf) Most cases are isolated, but up to 72% are associated with other anomalies, including cardiac or diaphragmatic defects. Ectopia cordis frequently accompanies sternal cleft, particularly in complete or type D forms, where the heart is partially or fully exposed outside the due to defects in the , diaphragm, and . This severe manifestation occurs in about 1 in 126,000 live births and is often linked to chromosomal abnormalities or syndromic conditions. Surgical correction is typically performed in infancy to cover the heart and restore chest integrity, often involving multidisciplinary approaches with cardiothoracic and plastic surgeons. Pectus excavatum and pectus carinatum represent common sternal deformities, affecting approximately 1 in 400 to 1,000 births, with a male predominance of 3:1 to 4:1. involves posterior depression of the sternum, potentially compressing the heart and lungs, while features anterior protrusion. These are thought to result from uneven growth of relative to the sternum during puberty, though genetic factors contribute in up to 40% of cases. Genetic associations include rare syndromes such as pentalogy of Cantrell, which combines sternal cleft, , , pericardial defect, and , with an incidence of less than 1 in 100,000 births and a poor without early intervention. Other linked conditions may involve chromosomal anomalies like trisomy 18. Management of sternal cleft focuses on primary closure within the first 3 months of life, when the chest wall is most pliable, using techniques like sliding chondroplasty or prosthetic interposition for larger defects to achieve midline approximation without tension. For , staged repairs in the neonatal period aim to reposition the heart and close the defect, with survival rates improving to over 50% in specialized centers. Pectus deformities are addressed cosmetically and functionally; the , a minimally invasive repair for excavatum, involves inserting a convex bar to remodel the sternum, typically removed after 2-3 years, with low recurrence rates of 2-5%. Pectus often responds to bracing in adolescents, with surgical options like the Ravitch procedure reserved for refractory cases.

Comparative anatomy

In mammals

The sternum in mammals exhibits considerable variation in shape, size, and segmentation, reflecting adaptations to diverse locomotor demands and body plans. In carnivores such as dogs, the sternum typically comprises eight fused sternebrae, presenting a laterally compressed and medially constricted form that supports agile quadrupedal movement. This configuration, with a narrow xiphoid cartilage, facilitates efficient thoracic flexibility during predation and pursuit. In contrast, herbivores like the horse and ox possess a sternum of seven sternebrae, often elongated anteroposteriorly and featuring a keeled or canoe-shaped profile in the horse, which enhances ventral stability for weight-bearing in grazing postures. The ox sternum transitions from lateral compression to flattening, providing a broad base for pectoral muscle attachments that aid in sustained locomotion and load distribution. Compared to quadrupedal mammals, the human sternum is notably simplified, consisting of three primary elements—the manubrium, body, and xiphoid process—rather than the six to eight sternebrae common in other species, which may relate to the reduced mechanical demands of bipedal posture. Specialized adaptations further diversify sternal morphology; for instance, bats possess a prominent keel on the sternum, serving as a robust anchor for the enlarged pectoral flight muscles essential for powered aerial locomotion. In monotremes, the sternum is markedly reduced and segmented, paralleling evolutionary modifications to the shoulder girdle and reflecting their basal mammalian position with retained cartilaginous elements. Ossification of the mammalian sternum originates from ventral , undergoing endochondral formation similar across species, but fusion timing of sternebrae varies with body size and developmental pace. In smaller mammals like , ossification centers appear perinatally and fuse rapidly, whereas in larger forms such as equids, the process extends into later growth stages to accommodate prolonged skeletal maturation. Specific examples illustrate these patterns: the canine sternum features eight distinct segments that fuse early to form a unified structure supporting dynamic thoracic excursions, while the equine sternum culminates in a prominent bony , the terminal sternebra that ossifies last and contributes to anchorage.

In non-mammalian vertebrates

In non-mammalian vertebrates, the sternum and its homologs exhibit significant variation, reflecting adaptations to diverse locomotor and respiratory demands, with evolutionary origins tracing back to precursors in early tetrapods that transitioned to more integrated endochondral structures in derived forms. The interclavicle and —ventral abdominal ribs—served as key precursors in basal tetrapods, providing ventral support before the development of a unified sternum. In , no true sternum exists; instead, the pectoral includes a bar or process that supports the pectoral fins and anchors associated musculature, functioning as a structural analog to the sternum by bracing the against the body wall. This arrangement remains attached to the in many , differing from the axial integration seen in . Amphibians typically possess a cartilaginous sternum or lack a fully ossified one, often integrated with the bones of the pectoral girdle to form a flexible ventral support for the ribcage. In frogs like Rana esculenta, the sternum appears as a dotted cartilaginous element amid the epicoracoids and omosternum, emphasizing pliability suited to jumping and aquatic transitions. Salamanders, such as Cryptobranchus alleganiensis, feature a thin, cartilaginous sternum that attaches to the body wall via thickenings, with the similarly delicate and unossified for minimal rigidity. Reptiles show further diversification, with the interclavicle and persisting as dermal elements in many lineages, while a true sternum—often large and cartilaginous or bony—develops in most but is absent in snakes and . In , the complete lack of a sternum accommodates their elongate, limbless body, relying instead on expanded for ventral enclosure. incorporate sternal elements into the plastron, fusing them with for protective armor. Birds represent a specialized extreme, with the sternum prominently featuring a , or carina, that projects ventrally to maximize attachment area for flight muscles like the pectoralis. This carina, formed by fused sternal plates, ossifies early in embryonic development—beginning in the and extending outward—to provide robust support for powered flight, as seen in species like where midline fusion occurs progressively. In flying birds, the carina extends nearly the full length of the sternum, contrasting with reduced forms in flightless ratites.

In arthropods

In arthropods, the sternum is not a true but rather the ventral portion of a body segment, formed by sclerotized plates called sternites that constitute part of the chitinous . These sternites, along with the dorsal tergites and lateral pleurites, create a segmented protective covering for the body. Unlike the internal seen in sterna, arthropod sternites originate from ectodermal epidermal cells that secrete the as an . Growth occurs through periodic molting (), where the old exoskeleton is shed and replaced by a new one, allowing expansion before hardening. The primary function of sternites is to shield the ventral nerve cord and internal viscera from mechanical damage and , while also providing attachment sites for muscles and articulation points with the pleurae on either side. In insects, for instance, the thoracic sterna support the coxae of the legs and contribute to the rigid structure of the , where they connect via pleural sutures to the dorsal notum (tergum), sometimes forming fused elements in specialized taxa for enhanced stability during flight or locomotion. In crustaceans like , the sternum forms the ventral boundary of the branchial chamber, enclosing the gills and facilitating respiration by maintaining a protected space for water flow over the respiratory structures. This arrangement allows for flexibility in movement while ensuring compartmentalization of vital organs. Developmentally, sternites arise from the during embryogenesis, with the underlying hypodermis (epidermal layer) depositing layers of , proteins, and sometimes minerals to form the rigid sclerites. Molting is hormonally regulated by ecdysteroids, enabling juveniles to increase in size across instars, a process absent in the continuous, remodeling growth of endoskeletal elements. Evolutionarily, sternites exemplify convergent adaptation for ventral protection, paralleling the role of sterna in safeguarding thoracic contents, but achieved through external plating rather than internal mineralization.

Nomenclature and history

Etymology

The term "sternum" derives from the New Latin sternum, borrowed from the Latin sternum meaning "breastbone," which in turn originates from the stérnon (στέρνον), denoting "chest," "breast," or "breastbone." In ancient , including Homeric epics, stérnon primarily referred to the male chest as the seat of and strength, while stêthos (στέθος) more specifically indicated or breastbone in anatomical contexts. The , a collection of ancient medical texts attributed to and his followers from the 5th–4th centuries BCE, employed stérnon to describe the chest region, often in discussions of thoracic injuries and affections, marking an early medical usage of the term for the structure now known as the sternum. The nomenclature for the sternum's subdivisions emerged during the , with anatomist providing detailed descriptions in his seminal 1543 work De humani corporis fabrica. The manubrium, the superior handle-like portion, derives its name from the Latin manubrium meaning "handle," reflecting its shape and position. The , the inferior cartilaginous extension, originates from the Greek xiphoeidḗs (ξιφοειδής), meaning "sword-shaped," due to its pointed form resembling a tip. distinguished these parts—manubrium, body (or , from Latin for "small "), and xiphoid—as the three components of the sternum, correcting earlier misconceptions from and standardizing their identification through dissection-based observations. The modern anatomical terminology for the sternum was formalized with the adoption of the Basle Nomina Anatomica (BNA) in 1895 by the German Anatomical Society, which established sternum as the standard Latin term for international use, alongside its subdivisions, to promote uniformity in and . This standardization persisted through subsequent revisions, such as the Nomina Anatomica (1955), (1998), and its second edition (2019), ensuring consistent for the sternum and its parts. In English, the sternum is commonly called the "breastbone," a term evoking the protective "breastplate" metaphor from biblical translations, particularly Ephesians 6:14 in the King James Version, where the "breastplate of righteousness" symbolizes moral defense over the vital chest area, paralleling the bone's role in safeguarding the heart and lungs.

Historical perspectives

The study of the sternum dates back to ancient times, with the Greek physician Galen (c. 129–c. 216 CE) providing one of the earliest detailed descriptions during his anatomical dissections in the 2nd century. Galen referred to it as the "breastbone" (στέρνον in Greek), portraying it as a flat, elongated structure composed of seven bony segments that formed the anterior wall of the thorax, protecting vital organs like the heart and lungs. His observations, drawn primarily from animal dissections due to restrictions on human cadaver use, emphasized its role in supporting the rib cage and facilitating respiration, though they included inaccuracies such as overestimating the number of segments based on comparisons to primate anatomy. During the , advanced the understanding of the sternum through direct human dissections, challenging Galen's errors in his seminal 1543 work De Humani Corporis Fabrica. Vesalius accurately illustrated the sternum as consisting of three main parts—the manubrium, body (gladiolus), and —using detailed engravings that depicted its segmented, cartilaginous nature and articulations with the clavicles and costal cartilages. These illustrations not only corrected the segmental count to reflect human anatomy but also highlighted its patterns, marking a shift toward empirical over classical and influencing subsequent anatomical texts. In the , anatomists conducted studies on the developmental aspects of the sternum, particularly its from multiple centers within the cartilaginous sternum, beginning and continuing into , providing insights into age-related fusion and variations. The discovery of X-rays by Wilhelm Conrad Röntgen in 1895 revolutionized sternal diagnostics, enabling non-invasive visualization of fractures for the first time; by the early , radiographs were routinely used to assess sternal integrity in trauma cases, improving accuracy over and reducing surgical exploration. The saw surgical innovations centered on the sternum, with emerging as a standard approach. In the 1930s, American surgeon popularized the technique through his 1936 performance of the first successful transsternal , splitting the sternum longitudinally to access the , which not only treated thymic tumors but also yielded unexpected benefits for patients. This method, refined for cardiac and thoracic procedures, transformed access to the anterior chest while highlighting the sternum's biomechanical role in load-bearing. Advancements in imaging since the 1970s further refined sternal analysis, with computed tomography (CT), invented by in 1971, and (MRI), developed in the mid-1970s, allowing three-dimensional visualization of congenital variations and post-traumatic changes. These modalities enabled precise mapping of irregularities and soft-tissue interactions, surpassing plain in detecting subtle anomalies. Post-2000 research has increasingly incorporated computational , using finite element modeling to simulate sternal stresses during fixation after sternotomy, informing prosthetic designs and predicting fracture risks under dynamic loads. During the (8th–14th centuries), scholars like (Ibn Sina) advanced knowledge of thoracic anatomy, including the sternum's structure and role in protecting vital organs, building on Greek texts and incorporating dissections where permitted, influencing global anatomical understanding.

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