animals

Article
Sternal Abnormalities on Thoracic Radiographs of Dogs
and Cats
Dirk H. N. van den Broek * , Siemone C. Vester, Mauricio Tobón Restrepo and Stefanie Veraa

Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Yalelaan 108,
3584 CM Utrecht, The Netherlands
* Correspondence: [email protected]

Simple Summary: The chest bone, or sternum, protects the heart and lungs and aids in breathing
motion. It is included on chest radiographs of dogs and cats, but little information is available for
veterinarians on what abnormalities or diseases affect the chest bone in companion animals. We
reassessed chest radiographs of dogs and cats taken in our hospital over a 2 year period to describe
these changes. We found that abnormalities of the chest bone were visible in 24% of dogs and 29% of
cats, with the most common abnormality being age-related degeneration. Most of the abnormalities
noted were of minor clinical importance, but in some animals, conditions that could be painful or
otherwise affect well-being were seen.

Abstract: Evaluation of the sternum is part of the routine examination of small animal thoracic
radiographs. However, descriptions on frequency and type of abnormalities are lacking. This retro-
spective observational study aimed to describe abnormal radiographic findings of the sternum in a
cross-section of client-owned dogs and cats undergoing thoracic radiography between 1 January 2019
and 1 January 2021 for reasons unrelated to diseases of the sternum. The study population consisted
of 777 dogs (mean age, 7.3 ± 3.9 years) and 183 cats (mean age, 7.3 ± 5.1 years). Sternal abnormalities
were observed in 189/777 (24%) dogs and 53/183 (29%) cats, mostly around the intersternebral
cartilages, accounting for 32/80 (40%) dogs and 20/35 (57%) cats. This was followed by an abnormal
number of sternal segments (8% dogs, range 3–9 sternebrae; 15% cats, range 7–9 sternebra). Pectus
excavatum was observed in 6/777 (0.8%) dogs and 6/183 (3%) cats, and pectus carinatum in 18/777
(2%) dogs and 2/183 (1%) cats. Post-traumatic changes, such as subluxation, were observed in nine
Citation: van den Broek, D.H.N.;
dogs (1.1%) and three cats (1.6%). Presumed prostatic carcinoma metastasis and malignant lymphoma
Vester, S.C.; Tobón Restrepo, M.;
were observed in two dogs (0.2%). Incidental radiographic sternal abnormalities are common in cats
Veraa, S. Sternal Abnormalities on
and dogs but mostly of unknown clinical relevance.
Thoracic Radiographs of Dogs and
Cats. Animals 2023, 13, 1233. https://
Keywords: pectus excavatum; pectus carinatum; dislocation; vacuum phenomenon; osteoarthrosis;
doi.org/10.3390/ani13071233
malformation; companion animals
Academic Editor: Maurizio Mazzoni

Received: 22 February 2023

Revised: 28 March 2023
Accepted: 31 March 2023 1. Introduction
Published: 2 April 2023 An evaluation of the sternum is part of the routine examination of small animal
thoracic radiographs, as it forms the ventral contour of the thoracic cavity. The sternum
contributes to the bony protection of the intra-thoracic cardiopulmonary structures, as well
as to the stability and breathing motion of the thorax.
Copyright: © 2023 by the authors.
The small animal sternum has been defined as an unpaired segmented series of
Licensee MDPI, Basel, Switzerland.
typically eight bones, called sternebrae [1–4]. The cranial first sternebra, or manubrium
This article is an open access article
of the sternum (manubrium sterni), is wider and longer than the other sternal segments.
distributed under the terms and
The manubrium of the sternum is the point of insertion of the sternocephalicus muscle
conditions of the Creative Commons
Attribution (CC BY) license (https://
and has lateral shelves of bone accommodating the attachment of the costal cartilages of
creativecommons.org/licenses/by/
the first pair of ribs. The body of the sternum (corpus sterni) consists of six rectangular
4.0/). to cylindrical-shaped sternebrae. The most caudal last sternebra, or xiphoid process

Animals 2023, 13, 1233. https://doi.org/10.3390/ani13071233 https://www.mdpi.com/journal/animals

Animals 2023, 13, 1233 2 of 11

(processus xiphoideus), is flat and long, occasionally with a foramen in its caudal half. The
xiphoid process is prolonged caudally by the xiphoid cartilage (cartilago xiphoidea), which
supports the cranial part of the ventral abdominal wall and from which the linea alba
extends caudally to the symphysis pelvis. The individual sternebrae are connected by
intersternebral cartilages, forming cartilaginous joints (synchondroses sternales), and the
sternum is covered on the ventral and dorsal surface by thickened periosteum, forming
the sternal membrane (membrana sterni). Whilst the costal cartilages of the first pair of
ribs articulate directly with the manubrium of the sternum, the costal cartilages of the
second to seventh ribs articulate with the consecutive intersternebral cartilages between the
individual sternal segments, and both the costal cartilages of the eighth and ninth rib pairs
articulate with the intersternebral cartilage between the seventh sternebra and the xiphoid
process. The first eight paired sternocostal joints are synovial joints, but no synovial joint
was found at the ninth sternocostal articulation The costal cartilages of the last four pairs
of ribs do not directly articulate with the sternum but connect via the costal arch or are
floating ribs, and these ribs are therefore considered asternal ribs [1–4].
Species differences in the shape of the sternum exist. In dogs the sternum is curved
and the sternebrae of the body of the sternum are rectangular in form, with the height
exceeding the width. In cats, the shape of the sternum is described as a straight and uniform
cylinder [4,5]. On thoracic radiographs, only the sternebrae are visible as individual
structures because their high mineral content results in increased x-ray beam attenuation,
and therefore higher opacity, on the digital image. The soft tissue structures of the sternum,
such as the intersternebral cartilages, are generally not individually identifiable on a
radiograph because of border effacement with the neighboring soft tissue of the thoracic
wall [6].
Congenital malformation of the sternum can consist of dorsal or ventral deviations
(pectus excavatum and pectus carinatum, respectively), as well as numeric or shape changes,
such as cleft sternum. Sternal malformations sometimes form a part of a larger congenital
defect with expansion to the adjacent thoracic and abdominal structures as well as diaphrag-
matic cupula [7–13]. Acquired sternal abnormalities include neoplasia [14], traumatic or
pathological fracture and luxation [15–17], infection [18–20], and degenerative disease of
the intersternebral cartilage [21].
No reports on occurrence of sternal abnormalities, either congenital or acquired, as a
part of routine radiographic thoracic evaluation are available in dogs and cats. Although
not all congenital variations in sternal conformation might be clinically relevant, some of
these malformations and abnormalities are causing clinical signs. Being familiar with these
abnormalities and the normal variation present, is therefore considered essential in image
interpretation. The aim of this study was to describe the occurrence of sternal abnormalities
on routine thoracic radiographs of dogs and cats.

2. Materials and Methods

This observational study had a cross-sectional and retrospective design. Thoracic
radiographic examinations of dogs and cats performed between 1 January 2019 and 1
January 2021 were retrieved from the Picture Archiving and Communication System
(Agfa Healthcare Enterprise Imaging, Agfa Healthcare N.V., Belgium) of the Division
of Diagnostic Imaging of the Faculty of Veterinary Medicine, Utrecht University, The
Netherlands. Images from client-owned animals that had thoracic radiography performed
for reasons unrelated to diseases of the sternum were used with anonymity preserved.
Examinations were excluded if the thoracic radiographs did not include the entire sternum
in the field of view. For animals with repeat examinations performed within the study
period, only the first performed radiographic study of the thorax was included for analysis.
The thoracic radiographic studies were obtained with a direct radiography system (Op-
timus NZR136, Philips, Best, The Netherlands) using a radiographic technique optimized
for examination of the thorax (i.e., exposure during maximum inspiration and high kV, low
mAs technique) with exposure factors based on patient body size, typically 105–110 kV;
Animals 2023, 13, 1233 3 of 11

1.2–1.4 mAs for dogs and 50 kV; 5 mAs for cats. A grid was used if object thickness was
>10 cm. Animals were not routinely sedated and were positioned using manual restraint
by trained personnel wearing protective clothing and personal dosimeters.
Assessment of the sternum was performed on left lateral and dorsoventral thoracic
radiographs displayed on medical-grade greyscale monitors (Coronis Fusion 6MP DL,
Barco, Kortrijk, Belgium). Images were independently reviewed by two European College
of Veterinary Diagnostic Imaging resident (DHNB and SCV) and two European College of
Veterinary Diagnostic Imaging diplomates (MTR and SV). For each animal, the sternum
was subjectively assessed on alignment, number, shape, and opacity of sternebrae, and
width and opacity of the intersternebral cartilages on orthogonal radiographs. A total
number of eight sternebrae, including the manubrium of the sternum and xiphoid process,
was considered the normal number of sternal segments in both cats and dogs [1,3], and any
animal with a higher or lower number of sternal segments was considered abnormal for
the purpose of this study.
The vertebral index was calculated as a measure of severity of pectus excavatum
using the vertebra overlying the deviation at the most depressed point of the thoracic
wall [11,12,22]. The severity of pectus excavatum was characterized as mild if the vertebral
index was >9, moderate if the vertebral index was 6–8.99, and severe if the vertebral index
was <6, as previously described [11,23]. The type of pectus excavatum was determined
based on the anatomical location of the deformity of the sternum and rib cartilage. Pectus
excavatum was characterized as the typical form when the condition affected the caudal
sternum from the 5th to 8th sternebrae and as an atypical form when the dorsal deviation
was noted in the cranial to mid-region of the sternum [10,22].
Numerical data are reported as mean (standard deviation [SD]) if normally distributed
or as median (range) if the distribution was skewed. Data were analyzed using IBM SPSS
Statistics (Version 28). Independent samples t-test was used to assess differences in age
between groups of animals with and without degenerative changes affecting the sternum.
Statistical significance was set at p < 0.05.

3. Results
3.1. Dogs
The study population consisted of 777 dogs. The group of dogs had a mean age of 7.3
(SD, 3.9) years and consisted of 400 males (188 neutered) and 377 females (252 neutered) of
various breeds, the most common being mixed breed (n = 145), Labrador Retriever (n = 62),
Chihuahua (n = 28), Bernese Mountain Dog (n = 26), Golden Retriever (n = 23), French
Bulldog (n = 23), Labradoodle (n = 22), and German Shepherd (n = 21). One hundred
and fourteen dogs were of brachycephalic breed. The three most common indications
for thoracic radiography in dogs were metastasis screening (n = 252), cough (n = 94), and
dysphagia (n = 57). An example of a thoracic radiographs of a dog on which the sternum
was considered unremarkable is provided in Figure 1.
Sternal abnormalities were observed in 189/777 (24%) dogs (Table 1). Nineteen dogs
had more than one sternal abnormality, being degenerative changes in combination with
abnormal number of sternebrae (n = 8), post-traumatic changes (n = 5) or shape deformity
of the sternum (n = 1), and an abnormal number of sternebrae in combination with shape
deformity (n = 4) or post-traumatic changes (n = 1).
Abnormalities were most frequently observed in the area of the intersternebral carti-
lages in dogs (n = 108; 14%), most of which were considered degenerative type changes
such as mineralisation of the sternal cartilages or formation of bony spurs (n = 98; 13%).
Marked degenerative changes, such as narrowing of the intersternebral cartilage space
(n = 13), vacuum phenomenon (n = 13), and subluxation (n = 5), were mainly observed
in the mid-section of the sternum, between the 3rd and 4th and 4th and 5th sternebrae
(Figures 1 and 2). Predominantly medium to large breed dogs were affected, with Labrador
Retriever as the most common breed (n = 16). The mean age of dogs with degenerative
Animals 2023, 13, 1233 4 of 11

changes
Animals 2023, 13, x FOR PEER REVIEW (mean, 9.8; SD, 2.5 years) was significantly higher than the mean age of4 dogs
of 13
without these changes (mean, 6.9; SD, 3.9 years; p <0.001).

Figure 1. (Left) panel: Example of a left lateral radiograph of a dog with a sternum that was
Figure 1. (Left) panel: Example of a left lateral radiograph of a dog with a sternum that was
considered normal. (Right) panel: Abnormally short sternum in a 9-year-old, female neutered
considered
Bearded normal.
Collie. (Right)
Caudad panel:
to the Abnormally
manubrium short
of the sternumfusion
sternum, in a 9-year-old,
of two to female neutered
three shortened
Bearded Collie.
sternebrae withCaudad toabsence
complete the manubrium of the part
of the caudal sternum,
of thefusion of two
sternum to three
is noted. shortened
The sternebrae
diaphragm shows
with complete
cranial absence
excursion, of the
and the caudal
cardiac part of
silhoue the
e is sternum
mildly is noted.
dorsally The diaphragm
displaced. shows cranial
Vacuum phenomenon is
excursion,
visible and the
between thecardiac silhouette
manubrium of theissternum
mildly dorsally
and seconddisplaced. Vacuum phenomenon is visible
sternebra.
between the manubrium of the sternum and second sternebra.

1. Radiographic
TableSternal findingswere
abnormalities and breeds per in
observed category of sternal
189/777 abnormality
(24%) dogs (Table in
1).dogs.
Nineteen dogs
had more than one sternal abnormality, being degenerative changes in combination with
Group Findings Breeds *
abnormal number of sternebrae (n = 8), post-traumatic changes (n = 5) or shape deformity
of the sternum (n = 1), andLabrador Retriever
an abnormal (16/62);
number mixed (13/145);
of sternebrae Boxer (7/13); with
in combination Flatcoated
shape
Retriever (7/15); Cavalier King Charles Spaniel (5/11); German
deformity (n = 4) or post-traumatic changes (n = 1).
Shepherd (5/21); Bernese Mountain Dog (4/26); Belgian Shepherd
(3/8); Dachshund (3/19); English Cocker Spaniel (3/13); American
Table
New bone 1. Radiographic
formation (n = 98); findings and breeds
Bulldog (2/6);per categoryPatrijshond
Drentsche of sternal abnormality
(2/6); Golden inRetriever
dogs. (2/23);
collapse (n = 13); Irish Setter (2/3); Labradoodle (2/22); Welsh Springer Spaniel (2/3);
Degeneration Group Findings Breeds *
vacuum phenomenon (n = 13); White Swiss Shepherd Dog (2/14); Anatolian Shepherd Dog (1/1);
(n = 98) Labrador Retriever (16/62);
sclerosis (n = 9); Border Collie (1/10); Border Terrier (1/4); Bouvier desmixed (13/145);
Flandres (1/2);
dislocation (n = 5) Chow Chow (1/3); English Boxer (7/13);Spaniel
Springer Flatcoated
(1/4); Retriever (7/15);
Frisian Water Dog
(1/2); Hovawart (1/2); Irish Wolfhound (1/2); Jack Russell
Cavalier King Charles Spaniel (5/11); Terrier
(1/15); Kooikerhondje (1/5);German
Newfoundland
Shepherd (1/5); Dobermann
(5/21); Bernese(1/2);
Rottweiler (1/10); Spanish Water Dog (1/3); Stabyhoun (1/12); West
Highland White TerrierMountain Dog (4/26);
(1/3); Wirehaired Belgian
Pointing Shepherd
Griffon (1/1)
(3/8); Dachshund (3/19); English Cocker
Labrador Retriever (7/62); Dachshund (2/19); Beagle (1/7);
9 sternebrae Spaniel
Australian shepherd (1/4); (3/13);
English American
Cocker SpanielBulldog (2/6);
(1/13); Irish
Abnormal
(n = 16) Drentsche Patrijshond (2/6);
Wolfhound (1/2); mixed (1/145); Rhodesian Ridgeback (1/9); Golden
number New bone formation (n = 98);
(n = 62) Whippet
Retriever(1/5)
(2/23); Irish Se er (2/3);
collapse (n =(10/145);
Mixed 13); Chihuahua (6/28); Pomeranian (5/14);Springer
Labrador
Degeneration Labradoodle (2/22); Welsh
vacuum phenomenon (n = Pug
Retriever (4/62); 13); (4/7); French Bulldog (3/23); Staffordshire Bull
(n = 98) Spaniel (2/3); White Swiss Shepherd Dog
<8 sternebrae sclerosisTerrier (2/10); West Highland White Terrier (2/3); American
(n = 9);
Staffordshire Terrier (1/8);(2/14); Anatolian
Australian ShepherdShepherd Dog (1/1);
(1/4); Bearded Collie
(n = 46) dislocation (n = 5)
Border Collie
(1/2); Boxer (1/13); Drentsche (1/10);
Patrijshond Border
(1/6); GreatTerrier (1/4);
Dane (1/2);
Miniature Pinscher (1/1); Dobermann (1/2); Shih Tzu (1/6);
Bouvier des Flandres (1/2); Chow Chow Spanish
Water dog (1/3)
(1/3); English Springer Spaniel (1/4);
Frisian Water Dog (1/2); Hovawart (1/2);
Irish Wol ound (1/2); Jack Russell Terrier
(1/15); Kooikerhondje (1/5);
Newfoundland (1/5); Dobermann (1/2);
Ro weiler (1/10); Spanish Water Dog (1/3);
Animals 2023, 13, 1233 5 of 11

Table 1. Cont.

Group Findings Breeds *

Pectus excavatum Pug (2/7); Boxer (1/13); Dachshund (1/19); French Bulldog (1/23);
Shape deformity
(n = 6) mixed (1/145)
(n = 24)
Pectus carinatum French Bulldog (8/23); Chihuahua (5/28); mixed (3/145); Pug (1/7);
(n = 18) Welsh Springer Spaniel (1/3)
Dislocation (n = 5); Labrador Retriever (3/62); mixed (2/145); Alaskan Malamute (1/4);
Post-trauma
collapse (n = 8); Boxer (1/13); Chihuahua (1/28); Chow Chow (1/3); German
(n = 12)
fracture (n = 2) Shepherd (1/21); Labradoodle (1/22); Welsh Springer Spaniel (1/3)
Aggressive bone Osteolysis; Chihuahua (n = 1);
lesion (n = 2) pathological fracture Labradoodle (n = 1)
Animals 2023, 13, x FOR PEER REVIEW 6 of 13
* The numbers between brackets represent the number of dogs of the breed with the condition/total number of
dogs of the breed in the study population.

Figure 2. (Top left) panel: Degeneration of the intersternebral joint space in an 11-year-old, neutered
Figure 2. (Top left) panel: Degeneration of the intersternebral joint space in an 11-year-old, neutered
female Welsh Springer Spaniel. The intersternebral cartilage space between the 4th and 5th
female Welsh
sternebrae Springer Spaniel.
is narrowed, The intersternebral
shows vacuum phenomenon, cartilage
and isspace between
surrounded bythe 4thbone
new and 5th sterne-
formation.
brae is narrowed, shows vacuum phenomenon, and is surrounded by new bone formation.
The 5th sternebra is mildly displaced ventrally relative to the fourth sternebra. (Bo om left): Pectus The
5th sternebra is mildly displaced ventrally relative to the fourth sternebra. (Bottom left):
excavatum in a 12-year-old male Pug. Dorsal deviation was noted in the caudal part of the sternum Pectus
with borderineffacement
excavatum of the
a 12-year-old ventral
male Pug. thoracic diaphragmatic
Dorsal deviation surface
was noted andcaudal
in the the caudal ventral
part of cardiac
the sternum
silhoue e and an altered position of the heart. (Top right): Luxation of the second sternebra
with border effacement of the ventral thoracic diaphragmatic surface and the caudal ventral cardiac in a 10-
year-old male neutered mixed-breed dog. The second sternebra is displaced in
silhouette and an altered position of the heart. (Top right): Luxation of the second sternebra incraniodorsal
adirection and male
10-year-old is overriding
neuteredthe manubriumdog.
mixed-breed of the sternum.
The second (Bo om right):
sternebra Pathologic
is displaced fractures of
in craniodorsal
multiple sternebrae in 10-year-old male Chihuahua with malignant lymphoma.
direction and is overriding the manubrium of the sternum. (Bottom right): Pathologic fractures of
multiple sternebrae in 10-year-old male Chihuahua with malignant lymphoma.
An abnormal number of sternal segments was the second most seen abnormality in
dogsAn(n abnormal
= 62; 8%). number
Less thanof eight
sternalsternal segments
segments was the were observed
second most 46
seendogs (6%): seven
abnormality in
sternebrae were visible in 40 dogs, six sternebrae in four dogs,
dogs (n = 62; 8%). Less than eight sternal segments were observed 46 dogs (6%): and three andseven
four
sternebraewere
sternebrae in onevisible
dog each.
in 40The
dogs,la six
er sternebrae
resulted ininmorphologically abnormal
four dogs, and three short
and four sternum
sternebrae
(Figure 2). The lower number of sternebrae predominantly affected
in one dog each. The latter resulted in morphologically abnormal short sternum (Figuresmall breed dogs,2).
including four out of seven Pugs (57%), five out of fourteen Pomeranians
The lower number of sternebrae predominantly affected small breed dogs, including four (36%), and six
of twenty-eight
out of seven PugsChihuahuas (21%)
(57%), five out in the study
of fourteen population.
Pomeranians (36%),Inand
eight
sixdogs, the lower
of twenty-eight
number was due to fusion of two (n = 5) or four (n = 2) sternebrae.
Chihuahuas (21%) in the study population. In eight dogs, the lower number was due Three dogs with lowerto
number
fusion of of
two sternebrae showed
(n = 5) or four (n = border effacement
2) sternebrae. Threeof thewith
dogs ventral thoracic
lower number diaphragmatic
of sternebrae
surface border
showed and the caudal ventral
effacement cardiacthoracic
of the ventral silhouediaphragmatic
e due to cranial excursion
surface of the
and the caudal
diaphragm, but none of these animals had evidence of peritoneopericardial herniation.
Supernumerary sternal segments (9 sternebrae in all) were observed in 16 dogs (2%),
affecting predominantly medium and large breed dogs. The most common breed affected
was Labrador Retriever (n = 7).
Pectus excavatum was observed in six dogs (0.8%), and the severity was considered
Animals 2023, 13, 1233 6 of 11

ventral cardiac silhouette due to cranial excursion of the diaphragm, but none of these
animals had evidence of peritoneopericardial herniation. Supernumerary sternal segments
(9 sternebrae in all) were observed in 16 dogs (2%), affecting predominantly medium and
large breed dogs. The most common breed affected was Labrador Retriever (n = 7).
Pectus excavatum was observed in six dogs (0.8%), and the severity was considered
mild in five dogs and moderate in one dog based on vertebral indices (median vertebral
index, 10.5; range, 8.6–11.2). Pectus excavatum involved the caudal sternum in five cases
and the mid-sternum in one mixed breed dog. One case was considered likely to have a
traumatic instead of congenital origin based on clinical history. Four of the five dogs with
suspect congenital pectus excavatum were brachycephalic breeds, including two out of
seven Pugs (Figure 2). Mild pectus carinatum was observed in 18 dogs (2%) and affected
the caudal part of the sternum in all cases. French Bulldog (n = 8) and Chihuahua (n = 5)
were overrepresented.
Presumed post-traumatic changes were observed in 12 dogs (1.5%), although none
of these dogs were presented for thoracic radiography because of a history of trauma or
suspect traumatic lesions of the sternum; the indication in eight of these dogs was metastasis
screening. The presumed post-traumatic changes mainly consisted of dislocation (n = 9, of
which five were in combination with other degenerative changes) (Figure 2). These changes
affected predominantly the mid-section of the sternum. Changes compatible with chronic
fracture of sternebrae were observed in two dogs.
One Chihuahua with malignant lymphoma had multiple pathological fractures associ-
ated with osteopenia (Figure 2). An aggressive bone lesion, suspect prostatic carcinoma
metastasis affecting the second and third sternebrae, was observed in another dog.

3.2. Cats
The study population consisted of 183 cats. The group of cats had a mean age of 7.3
(SD, 5.1) years and consisted of 105 males (89 neutered) and 78 females (66 neutered) of
various breeds, most commonly Domestic Shorthair (n = 112), Maine Coon (n = 16), mixed
breed (n = 11), and British Shorthair (n = 10). The most common indications for thoracic
radiography in cats were dyspnea (n = 40), metastasis screening (n = 37), and post-accident
trauma (n = 18). An example of a thoracic radiographs of a cat on which the sternum was
considered unremarkable is provided in Figure 3.
Sternal abnormalities were observed in 53/183 (29%) cats (Table 2). Six cats had more
than one sternal abnormality, being abnormal number of sternebrae in combination with
pectus excavatum (n = 3) or degenerative changes (n = 3).

Table 2. Radiographic findings and breeds per category of sternal abnormality in cats.

Group Findings Breeds *

Intersternebral
New bone formation (n = 15); Domestic Shorthair (10/112); Bengal (1/3); British Shorthair
cartilage
sclerosis (n = 5) (1/10); mixed (1/11); Norwegian Forest (1/4); Siamese (1/4)
(n = 15)
9 sternebrae Domestic Shorthair (4/112); Bengal (1/3); mixed (1/11);
Abnormal number
(n = 7) Siamese (1/4)
(n = 27)
< 8 sternebrae Domestic Shorthair (13/112); British Shorthair (2/10); Ragdoll
(n = 20) (2/7); Oriental Shorthair (1/1); Persian (1/1); Sphynx (1/2)

Shape Pectus excavatum

Domestic Shorthair (6/112)
deformity (n = 6)
(n = 8) Pectus carinatum
Domestic Shorthair (1/112); Norwegian Forest (1/4)
(n = 2)
Post-trauma
Dislocation (n = 3) Domestic Shorthair (3/112)
(n = 3)
* The numbers between brackets represent the number of cats of the breed with the condition/total number of
cats of the breed in the study population.
 (SD, 5.1) years and consisted of 105 males (89 neutered) and 78 females (66 neutered) of
various breeds, most commonly Domestic Shorthair (n = 112), Maine Coon (n = 16), mixed
breed (n = 11), and British Shorthair (n = 10). The most common indications for thoracic
radiography in cats were dyspnea (n = 40), metastasis screening (n = 37), and post-accident
Animals 2023, 13, 1233
trauma (n = 18). An example of a thoracic radiographs of a cat on which the sternum7 wasof 11
considered unremarkable is provided in Figure 3.

Figure 3. (Top left) panel: Example of a left lateral radiograph of a cat with a sternum that was
Figure 3. (Top left) panel: Example of a left lateral radiograph of a cat with a sternum that was
considered normal. (Bo om left): Abnormal low number of sternebrae in a 12-year-old female
considered
Domestic normal. A(Bottom
Shorthair. left):
total of six Abnormal
individual low number
sternebrae of sternebrae
are present, caused byin fusion
a 12-year-old female
of the fifth and
Domestic
sixth Shorthair.
sternebrae and A
antotal of six
absence ofindividual
the seventhsternebrae
sternebra.are present,
(Top right):caused
Pectus by fusion ofin
excavatum theanfifth
11-
and sixthfemale
year-old sternebrae and an
neutered absence Shorthair.
Domestic of the seventh
(Bo sternebra.
om right):(Top right):
Chronic Pectus excavatum
subluxation in an
of the fourth
11-year-old
sternebra infemale neutered male
an 11-year-old Domestic Shorthair.
neutered Domestic(Bottom Chronic
right): The
Shorthair. subluxation
fourth sternebra of
is the fourth
displaced
dorsally
sternebraand fused
in an with the third
11-year-old male sternebra.
neutered Domestic Shorthair. The fourth sternebra is displaced
dorsally and fused with the third sternebra.

Degenerative
Sternal changes,
abnormalities consistent
were ofin
observed mineralization of the
53/183 (29%) cats sternal
(Table cartilages
2). Six cats hador for-
more
mation of bony spurs, were observed in 15 cats (8%). Cats with degenerative
than one sternal abnormality, being abnormal number of sternebrae in combination with changes
were
pectussignificantly
excavatum (n older
= 3) than those without
or degenerative (mean,
changes (n 11.2;
= 3). SD, 5.6 years versus mean, 6.9;
SD, 4.9 years; p = 0.002). Concurrent gas opacity in the intersternebral cartilage space or
associated subluxation of sternebrae was not observed in any of the cats with signs of
degenerative changes of the intersternebral cartilages.
An abnormal number of sternebrae was observed in 27 cats (15%), of which seven
cats had nine sternebrae. Nineteen cats had seven individual sternal segments, which, in
ten cats was caused by complete fusion of the first and second sternebrae (n = 5) or sixth
and seventh sternebrae (n = 5). The other nine cats with seven sternebrae had an absence
of one sternal segment. One Domestic Shorthair had six individual sternebrae, caused by
complete fusion of the fourth and fifth sternebrae and the absence of one sternal segment
(Figure 3).
Pectus excavatum was observed in six cats (3%), and the severity was considered mild
in four cats and moderate and severe in one cat each (median vertebral index, 9.8; range,
5.8–11.4) (Figure 3). The typical form of pectus excavatum, affecting the caudal sternum,
was observed in 2/6 cats and the atypical form, affecting the cranial or mid-region of the
sternum, was observed in 4/6 cats. Mild forms of pectus carinatum were observed in two
cats (1%).
Signs of traumatic luxation were observed in three cats (1%). One cat had under-
gone recent cardiopulmonary resuscitation, and the other two cases showed more chronic
changes with malformed fusion of the dislocated sternebrae. One of these cats had a
history of sternal fracture 10 years prior and the other cat had no known history of trauma
(Figure 3). Other abnormalities observed in cats were a kinked manubrium of the sternum
(n = 2), partial fusion of sternebrae (n = 3), and narrowing of the intersternebral cartilage
space without signs of degeneration (n = 1).
Animals 2023, 13, 1233 8 of 11

4. Discussion
The sternum develops from the fusion of bilateral mesodermal bars which unite
from day 25 of gestation in dogs and day 28 of gestation in cats, starting cranially at the
manubrium of the sternum and ending caudally at the xiphoid process [1,24]. Ossification
starts at day 40 in dogs but is inhibited at rib attachment sites, resulting in the individ-
ual sternebrae with interposed intersternebral cartilages in those areas where the ribs
attach. However, this is not the case for the first rib pair, which connects to the ossified
manubrium of the sternum but attaches at a later time than the other costal cartilages
during development. Nonunion of the caudal part of the sternal bars, anomalous ribs,
and uneven apposition of ribs can lead to various morphological abnormalities of the
body of the sternum and its individual sternebrae [1]. Sternal defects have been reported
with concurrent congenital midline anomalies, such as peritoneopericardial diaphragmatic
hernia and cranioventral abdominal wall hernia in dogs and cats [7–9,13,25,26]. Abnormal
number, fusion, and shape alterations of sternebrae were observed in both cats and dogs
in our study population, but in none of these animals was clear evidence of bifid sternum
or other ventral abdominal wall anomalies seen. This could in part be explained by the
limited visibility of the sternum on straight dorsoventral radiographic projections, caused
by superimposition of the vertebral column on the sternum. In addition, mineralized rib
cartilage was often superimposed on the most caudal aspect of the sternum on left lateral
views. Oblique dorsoventral radiographic views and computed tomography would be
more sensitive techniques to identify cleft sternum and concurrent ventral abdominal wall
defects [5].
As in previous reports, pectus excavatum mostly affected the caudal sternum in dogs
in our study population, which is the typical form of pectus excavatum [12]. Komsta and
colleagues (2019) observed pectus excavatum in a large percentage of brachycephalic dogs
(44.4%) [10], whilst we observed this condition in only 3.5% of brachycephalic dogs and
0.8% of dogs of all breeds. In that study, Maltese and English Bulldog breed dogs were
overrepresented, but in our study population none of the three dogs for each of these two
breeds showed evidence of pectus excavatum. A large proportion (67%) of affected cats in
our study population had an atypical location of pectus excavatum, in which the dorsal
deviation affects the cranial and mid-section of the sternum. This was also reported in
a recent publication on computed tomographic features of pectus excavatum in cats, in
which half the cats had the atypical form of the disorder [11]. That study found mild pectus
excavatum in only 21.5% of cats, whilst most of the cats included had moderate or severe
pectus excavatum. In contrast, a larger proportion of pectus excavatum was considered
mild in cats in the present study (67%). In part, this could be explained by the fact that none
of the cats included in our study were presented for radiographic examination because of
complaints related to their thoracic malformation. However, although a strong positive
correlation has been reported in brachycephalic dogs with the atypical form of pectus
excavatum, no clear association has been found between the radiographic classification
and the severity of clinical signs in brachycephalic dogs with the typical form of pectus
excavatum [12] or in a group of kittens with pectus excavatum [27]. Moreover, it should
be noted that our results are based on thoracic radiographs made on a single time point
for each patient, whilst motion of the sternum in severely dyspneic animals could mimic
conditions such as pectus excavatum [28]. Therefore, the number of animals with abnormal
alignment of the sternum could be overestimated in our study population.
In agreement with a previous publication by Hassan and colleagues (2018), we ob-
served pectus carinatum predominantly in small breed dogs, except for in one English
Springer Spaniel [12]. In that previous report, the Pug and French Bulldog were at increased
risk of this disorder, with 41% and 18% of the dogs of these breeds affected, respectively. In
our study population French Bulldog and Chihuahua were the most common breeds with
pectus carinatum, with 8/23 (35%) and 5/28 (18%) animals affected, respectively. Only 1/7
(14%) Pugs showed radiographic evidence of pectus carinatum in our study.
Animals 2023, 13, 1233 9 of 11

Although neoplastic disease was the most common indication for thoracic radiogra-
phy in dogs, only two cases presented with radiographic aggressive bone lesions affecting
the sternum. One dog diagnosed with malignant lymphoma presented with pathological
fractures of multiple sternebrae, the other dog was diagnosed with prostatic carcinoma
and had an aggressive bone lesion affecting the second and third sternebrae. However, the
sternal lesions were not biopsied in these dogs and therefore it remains unknown if these
aggressive bone lesions indeed were caused by neoplastic disease. Skeletal involvement
affecting the spine has been described in canine multicentric lymphoma [29,30], but to the
author’s knowledge it was not specifically affecting the sternum. Skeletal metastases are
common in canine prostatic carcinoma, often accompanied by extraskeletal metastases, and
the lumbar vertebra, pelvis, and proximal femur are mostly affected [31]. Metastases to
the sternum from prostatic carcinoma appear uncommon, but have been documented in a
dog [32]. In a necropsy study, metastatic lesions were observed in the sternum in nine out
of twenty-one dogs with metastatic or multicentric tumors with bone involvement, and
mammary carcinoma and lung carcinoma were the most common primary tumors [14].
Only one dog with prostatic carcinoma was included in that study, which did not have evi-
dence of bone metastasis. Sternal osteomyelitis, caused by foreign body, systemic mycosis,
following sternotomy or hematogenous spread of bacteria, is the main differential diagnosis
to neoplasia for sternal aggressive bone lesions [18–20,33,34]. The dogs with aggressive
bone lesions affecting the sternum included in this study had no other clinical signs or
history indicative of infectious disease, but sternal osteomyelitis cannot be completely ruled
out because the specific lesions were not biopsied.
Age-related degeneration of the synchondroses sternales, mostly consistent of mineral-
ization of the sternal cartilages or formation of bony spurs, was the most common finding
in our study, with a prevalence of 14% in dogs and 8% in cats. In 13 of the dogs affected,
gas opacity was observed in between the sternebrae on the left lateral view radiograph.
Gas accumulation within synovial joints and intervertebral disc spaces is termed vacuum
phenomenon. This gas consists of 90–92% nitrogen and its presence has been associated
with intervertebral disc degeneration in dogs [35–37]. The sternal vacuum phenomenon
has previously been described in three dogs [21] and, in agreement with our findings, this
was reported in large breed dogs, frequently surrounding the fourth sternebra, and was
associated with intersternebral joint space narrowing. Those authors proposed laxity of
the intersternebral fibrocartilage and tractile forces caused by radiographic positioning
as potential causes for vacuum phenomenon in the intersternebral cartilage space or su-
perimposed sternocostal joints [21]. In our population, vacuum phenomenon was only
observed in the intersternebral cartilage space in conjunction with other degenerative
changes, such as narrowing of the intersternebral cartilage space, new bone formation or
even dislocation of sternebrae. Gas opacity in the intersternebral cartilage space could
therefore be considered a sign of degeneration of the synchondrosis sternalis in dogs, similar
to the above-mentioned association between vacuum phenomenon in the intervertebral
disc space and intervertebral disc degeneration in dogs [36,37].
Sternal dislocation is infrequently reported in veterinary literature and is most often
considered to be of traumatic origin [15–17]. Based on history and other findings, a
traumatic origin was suspected in all three cats with sternal dislocation included in our
study population. In five dogs, marked degenerative changes of the intersternebral joints
coincided with sternal subluxation, which might suggest spontaneous dislocation following
instability or arthropathy of these joints. However, due to the cross-sectional study design, it
cannot be determined if dislocation preceded or followed intersternebral joint degeneration
signs in these dogs. Future research is warranted to examine if sternal degeneration, now
considered an incidental finding, affects animal well-being.
Our study had several limitations. First, the retrospective design prohibits adequate
correlation between radiographic findings and clinical signs. For example, it cannot be
reliably determined if sternal dislocation in dogs with severe intersternebral cartilage de-
generation was associated with pain or other clinical signs, because no specific history and
Animals 2023, 13, 1233 10 of 11

physical examination addressing these findings were performed in these cases. Secondly,
the large variety in breeds in combination with the relatively low number of cases for each
disorder impedes drawing firm conclusions on any breed predispositions. Thirdly, the
use of radiography instead of a cross-sectional technique such as computed tomography
results in a lower sensitivity for detection of abnormalities because of the inferior contrast
resolution and problems of superimposition inherent to radiography. Moreover, computed
tomography would allow a better representation of the anatomy. For instance, computed
tomography was reported to be useful for evaluation of thoracic asymmetry and sternal
torsion in cats with pectus excavatum, which cannot be done with radiography [11]. In
addition, the use of intravenous iodinated contrast medium in computed tomography
would allow for better characterization of potential soft tissue abnormalities, such as
inflammation [18].

5. Conclusions
Sternal abnormalities are common incidental findings on thoracic radiographs of
companion animals and were observed on thoracic radiographs of 24% of dogs and of
29% of cats in our study population. Clinically relevant abnormalities, such as severe
degeneration of the intersternebral cartilage space, dislocation, or aggressive bone lesions,
were only recognized in few cases, whilst most animals showed abnormalities that were
unlikely to cause clinical complaints.

Author Contributions: Conceptualization, D.H.N.v.d.B. and S.V.; methodology, D.H.N.v.d.B. and S.V.;
validation, D.H.N.v.d.B., S.V. and M.T.R.; formal analysis, D.H.N.v.d.B.; investigation, D.H.N.v.d.B.,
S.V., S.C.V. and M.T.R.; resources, S.V.; data curation, D.H.N.v.d.B., S.C.V., S.V. and M.T.R.;
writing—original draft preparation, D.H.N.v.d.B.; writing—review and editing, S.C.V., S.V. and
M.T.R.; visualization, D.H.N.v.d.B.; supervision, S.V.; project administration, D.H.N.v.d.B. All authors
have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Ethical review and approval were waived for this study due
to usage of data previously acquired during regular clinical evaluations.
Informed Consent Statement: Written informed consent was obtained from the owner of the animals
and anonymity is preserved.
Data Availability Statement: Data is contained within the article.
Acknowledgments: An abstract on part of the data from this study was presented at the EVDI online
congress, 24 September 2021.
Conflicts of Interest: The authors declare no conflict of interest.

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