Sternal Cleft

Sternal cleft is a congenital abnormality that involves a separation of the sternum, or breastbone. The sternum is a long, flat bone located in the center of the chest that provides protection for the heart and lungs. A cleft or split in the sternum can result in a range of medical issues, including difficulties with breathing, feeding, and heart function.

There are several different types of sternal cleft, each with its own unique set of symptoms and treatment options. The most common types of sternal cleft include complete cleft sternum, incomplete cleft sternum, bilateral cleft sternum, and a cleft sternum associated with other congenital abnormalities.

  1. Complete Cleft Sternum: A complete cleft sternum is the most severe form of sternal cleft and involves a separation of the entire sternum into two halves. This type of cleft can result in significant respiratory distress, as the separation of the sternum can cause the lungs to collapse. Individuals with a complete cleft sternum may also experience difficulties with feeding, as the cleft can make it difficult for the baby to suckle effectively.
  2. Incomplete Cleft Sternum: Incomplete cleft sternum is a less severe form of sternal cleft and involves a partial separation of the sternum. This type of cleft is typically less serious than a complete cleft sternum and may not result in significant respiratory distress. However, individuals with an incomplete cleft sternum may still experience difficulties with feeding.
  3. Bilateral Cleft Sternum: Bilateral cleft sternum is a rare form of sternal cleft that involves a separation of the sternum on both sides of the body. This type of cleft can result in serious respiratory distress and may also cause difficulties with feeding.
  4. Cleft Sternum Associated with Other Congenital Abnormalities: In some cases, a cleft sternum may be associated with other congenital abnormalities, such as heart defects, chromosomal abnormalities, or skeletal malformations. These additional abnormalities can increase the severity of the sternal cleft and may result in additional medical problems.

Causes

The condition can range from a small bony defect to a complete separation of the entire sternum. The causes of sternal cleft can be divided into two categories: genetic and environmental.

  1. Genetics

Genetic factors play a major role in the development of sternal cleft. Some of the genetic causes include:

a. Chromosomal Abnormalities: Chromosomal abnormalities such as Down syndrome and Turner syndrome can cause sternal cleft.

b. Inherited Disorders: Some inherited disorders such as Marfan syndrome, Ehlers-Danlos syndrome, and Osteogenesis imperfecta can cause sternal cleft.

c. Familial Tendency: Sternal cleft can run in families and may be passed down from one generation to the next.

  1. Environmental Causes

Environmental factors can also play a role in the development of sternal cleft. Some of the environmental causes include:

a. Maternal Substance Abuse: Substance abuse during pregnancy such as alcohol, tobacco, and certain drugs can cause sternal cleft.

b. Maternal Illnesses: Certain maternal illnesses such as rubella, cytomegalovirus, and syphilis can cause sternal cleft.

c. Maternal Medications: Certain medications taken during pregnancy such as thalidomide and retinoids can cause sternal cleft.

d. Maternal Malnutrition: Malnutrition during pregnancy can also cause sternal cleft.

e. Premature Birth: Premature birth can increase the risk of sternal cleft.

f. Low Birth Weight: Low birth weight can also increase the risk of sternal cleft.

g. Oxygen Deprivation: Oxygen deprivation during delivery can cause sternal cleft.

h. Trauma: Trauma during delivery such as forceps delivery or vacuum extraction can cause sternal cleft.

  1. Congenital Heart Defects

Sternal cleft can also be associated with certain congenital heart defects. Some of the congenital heart defects that can cause sternal cleft include:

a. Atrial Septal Defect: An atrial septal defect is a hole in the wall between the two upper chambers of the heart.

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b. Ventricular Septal Defect: A ventricular septal defect is a hole in the wall between the two lower chambers of the heart.

c. Patent Ductus Arteriosus: Patent ductus arteriosus is a condition in which the ductus arteriosus, a blood vessel that connects the aorta and the pulmonary artery in the fetus, fails to close after birth.

d. Tetralogy of Fallot: Tetralogy of Fallot is a combination of four heart defects that can cause sternal cleft.

Symptoms

This condition can result in various symptoms, which can range from mild to severe. Here is a list of potential symptoms of a sternal cleft:

  1. Chest deformity: The most obvious symptom of a sternal cleft is a noticeable deformity in the chest area, which can be seen as a gap or separation in the sternum.
  2. Breathing difficulties: A sternal cleft can cause breathing difficulties, especially in infants and young children. This can result from the gap in the sternum interfering with the normal expansion of the chest during breathing.
  3. Chest pain: Chest pain is another common symptom of a sternal cleft, which can be caused by the gap in the sternum putting pressure on the surrounding structures, such as the ribs and muscles.
  4. Heart palpitations: Some individuals with a sternal cleft may experience heart palpitations, which are sensations of the heart beating rapidly, irregularly, or strongly.
  5. Fatigue: Fatigue is another common symptom of a sternal cleft, which can be caused by the body having to work harder to compensate for the gap in the sternum, leading to increased energy expenditure.
  6. Shortness of breath: Shortness of breath is a common symptom of a sternal cleft, which can be caused by the gap in the sternum interfering with the normal expansion of the chest during breathing.
  7. Rapid breathing: Rapid breathing is another common symptom of a sternal cleft, which can be caused by the body having to work harder to compensate for the gap in the sternum, leading to increased breathing rate.
  8. Wheezing: Wheezing is a common symptom of a sternal cleft, which is a high-pitched sound that is produced when breathing is difficult or labored.
  9. Chest infections: Chest infections are another common symptom of a sternal cleft, which can occur as a result of the gap in the sternum allowing bacteria to enter the chest cavity more easily.
  10. Coughing: Coughing is another common symptom of a sternal cleft, which can be caused by the gap in the sternum interfering with normal breathing and causing irritation in the airways.
  11. Chest tightness: Chest tightness is another common symptom of a sternal cleft, which can be caused by the gap in the sternum putting pressure on the surrounding structures, such as the ribs and muscles.
  12. Chest wall instability: Chest wall instability is another common symptom of a sternal cleft, which can result from the gap in the sternum affecting the stability of the chest wall and making it more prone to injury or deformity.
  13. Swallowing difficulties: Swallowing difficulties are another common symptom of a sternal cleft, which can be caused by the gap in the sternum putting pressure on the esophagus and interfering with normal swallowing.

Diagnosis

Diagnosis of a sternal cleft typically involves a combination of clinical examination, medical history, and imaging studies. Here is a list of possible diagnostic tests and procedures that may be used to diagnose a sternal cleft:

  1. Physical examination: A physical examination is the first step in diagnosing a sternal cleft. The doctor will look for signs of a cleft or separation in the sternum and check for any other physical anomalies that may be associated with the condition.
  2. Chest X-ray: A chest X-ray is a type of imaging test that uses radiation to produce images of the inside of the body, including the bones, organs, and tissues. A chest X-ray can show the presence of a sternal cleft and the extent of the separation.
  3. CT scan: A CT (computed tomography) scan is a type of imaging test that uses X-rays and a computer to produce detailed images of the inside of the body. A CT scan can provide a more detailed view of the sternal cleft and the surrounding structures.
  4. MRI: An MRI (magnetic resonance imaging) is a type of imaging test that uses a strong magnetic field and radio waves to produce detailed images of the inside of the body. An MRI can provide a more detailed view of the sternal cleft and the surrounding soft tissues.
  5. Echocardiogram: An echocardiogram is a type of ultrasound test that uses high-frequency sound waves to produce images of the heart and its structures. An echocardiogram can help to determine if there is any damage to the heart or major blood vessels caused by the sternal cleft.
  6. Cardiac catheterization: Cardiac catheterization is a procedure in which a small, flexible tube is inserted into a blood vessel in the arm or leg and guided to the heart. This procedure can be used to measure the pressure in the heart and check for any abnormalities in the blood flow.
  7. Pulmonary function tests: Pulmonary function tests are a series of tests that measure how well the lungs are functioning. These tests can help to determine if the sternal cleft is causing any problems with breathing.
  8. Blood tests: Blood tests can be used to check for any underlying medical conditions that may be contributing to the development of a sternal cleft.
  9. Electrocardiogram (ECG): An electrocardiogram (ECG) is a test that measures the electrical activity of the heart. An ECG can help to determine if there is any damage to the heart or if the sternal cleft is causing any problems with the heart’s electrical system.
  10. Chromosomal analysis: Chromosomal analysis is a test that looks at the chromosomes in a person’s cells to check for any genetic abnormalities. Chromosomal analysis can help to determine if a genetic condition is causing the sternal cleft.
  11. Genetic testing: Genetic testing is a type of test that looks at a person’s DNA to check for any genetic mutations or abnormalities that may be causing the sternal cleft.
  12. Endoscopy: An endoscopy is a procedure in which a small, flexible tube with a camera on the end

Treatment

Here is a list of treatments for sternal cleft:

  1. Observation and Monitoring
  2. Physiotherapy
  3. Bracing
  4. Non-operative Management
  5. Sternum Stabilization Surgery
  6. Sternum Closing Surgery
  7. Sternum Reconstruction Surgery
  8. Rib Cage Expansion Surgery
  9. Pectus Excavatum Repair Surgery
  10. Nuss Procedure
  11. Ravitch Procedure
  12. Modified Ravitch Procedure
  13. MIRPE (Minimally Invasive Repair of Pectus Excavatum)
  14. Thoracoscopic Repair of Pectus Excavatum
  15. Hybrid Repair of Pectus Excavatum
  16. Pectus Carinatum Repair Surgery
  17. Stenting
  18. Vacuum Bell Therapy
  19. Balloon Kyphoplasty
  20. External Skeletal Fixation
  21. Observation and Monitoring: In some mild cases of sternal cleft, observation, and monitoring may be the best course of action. This approach is typically used when the cleft is not causing any functional or aesthetic problems. The patient will be monitored for any changes or developments, and treatment can be initiated if necessary.
  22. Physiotherapy: Physiotherapy can help to improve breathing and chest expansion in patients with a sternal cleft. The therapist may use exercises, breathing techniques, and posture correction to help the patient improve their breathing and overall respiratory function.
  23. Bracing: Bracing can be used to stabilize the sternum and prevent further separation of the cleft. A brace is typically worn for a few hours each day and can help to correct any deformities and improve the patient’s appearance.
  24. Non-operative Management: In some cases, non-operative management may be an option for treating sternal cleft. This approach involves a combination of observation, physiotherapy, bracing, and other non-surgical interventions to manage the condition and prevent progression.
  25. Sternum Stabilization Surgery: Sternum stabilization surgery is a surgical procedure that involves placing screws or other fixation devices into the sternum to hold the cleft together and prevent further separation. This procedure is typically performed in severe cases where the cleft is causing significant functional or aesthetic problems.
  26. Sternum Closing Surgery: Sternum closing surgery is a procedure that involves closing the gap or separation in the sternum. This procedure can be performed using a variety of techniques, including the use of a metal plate or other fixation device, sutures, or a combination of both.
  27. Sternum Reconstruction Surgery: Sternum reconstruction surgery is a more complex procedure that involves repairing or rebuilding the sternum. This procedure may be necessary in severe cases where the cleft has caused significant damage to the sternum and surrounding structures.
  28. Rib Cage Expansion Surgery: Rib cage expansion surgery is a procedure that involves expanding the rib cage to correct any deformities and improve chest shape. This procedure is typically performed in conjunction with other surgical procedures, such as sternum closing or reconstruction.
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Medications

Drugs that are used to treat sternal cleft, along with a brief explanation of each drug’s mechanism of action and potential side effects:

  1. Antibiotics: Antibiotics are used to treat infections that may develop in the cleft area. Examples of antibiotics that may be used include penicillin, amoxicillin, and clindamycin.
  2. Analgesics: Analgesics, such as acetaminophen and ibuprofen, are used to relieve pain and reduce inflammation.
  3. Anti-inflammatory drugs: Nonsteroidal anti-inflammatory drugs (NSAIDs), such as naproxen and ibuprofen, are used to reduce inflammation and relieve pain.
  4. Steroids: Steroids, such as prednisone, are used to reduce inflammation and swelling.
  5. Hormonal therapy: Hormonal therapy, such as testosterone replacement therapy, may be used to treat hormonal imbalances that can contribute to the development of sternal cleft.
  6. Vitamin and mineral supplements: Vitamin and mineral supplements, such as calcium and vitamin D, may be used to support bone health and promote healing.
  7. Pain management: Pain management medications, such as opioids and nerve block injections, may be used to control pain.
  8. Antacids: Antacids, such as omeprazole and ranitidine, are used to treat acid reflux and other digestive problems that may develop in individuals with a sternal cleft.
  9. Bronchodilators: Bronchodilators, such as albuterol, are used to relax the muscles in the airways and improve breathing.
  10. Mucolytics: Mucolytics, such as acetylcysteine, are used to break down mucus and improve breathing.
  11. Antihistamines: Antihistamines, such as diphenhydramine, are used to relieve symptoms of allergies and hay fever.
  12. Decongestants: Decongestants, such as pseudoephedrine, are used to relieve nasal congestion and improve breathing.
  13. Antispasmodics: Antispasmodics, such as dicyclomine, are used to relieve muscle spasms and improve breathing.
  14. Antifungal drugs: Antifungal drugs, such as fluconazole, are used to treat fungal infections that may develop in the cleft area.
  15. Antiviral drugs: Antiviral drugs, such as acyclovir, are used to treat viral infections that may develop in individuals with a sternal cleft.
  16. Antibacterial drugs: Antibacterial drugs, such as ciprofloxacin and doxycycline, are used to treat bacterial infections that may develop in the cleft area.
  17. Antiviral vaccines: Antiviral vaccines, such as the influenza vaccine, may be used to prevent viral infections that can be particularly dangerous for individuals with a sternal cleft.
  18. Blood thinners: Blood thinners, such as warfarin, may be used to prevent blood clots and reduce the risk of stroke or heart attack.

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References