Determination of Sex from the Sternum and Fourth Rib Measurements (A Cross-Sectional Study Using Thoracic Computed Tomography (CT)

Nitin Kumar, Sandhya Verma, Jyoti Yadav, Shubhanshi Rani, Shivam Kumar,

doi:10.5281/zenodo.17284378

Research Paper | Open Access
Volume 02 | Issue 10 | Article Id IJSRT/250309070

Determination of Sex from the Sternum and Fourth Rib Measurements (A Cross-Sectional Study Using Thoracic Computed Tomography (CT)
Nitin Kumar* Sandhya Verma Jyoti Yadav Shubhanshi Rani Shivam Kumar
SCPM College of Nursing and Paramedical Sciences, Gonda, Uttar-Pradesh, INDIA 271003

Abstract

Background: Sex determination from skeletal elements is a cornerstone of forensic anthropology, especially in cases where the pelvis or skull is absent, fragmented, or unsuitable for analysis. The sternum and ribs, owing to their structural resilience and marked sexual dimorphism, have emerged as reliable alternatives. With the advent of multidetector computed tomography (MDCT), precise non-invasive morphometric analysis of thoracic bones has become feasible. Despite its potential, limited population-specific standards exist for the Indian demographic, necessitating further validation. Aim: To evaluate sexual dimorphism in sternal and fourth rib measurements using thoracic CT scans and to establish discriminant function models for reliable sex estimation in a contemporary Indian population. Materials and Methods: This cross-sectional study analyzed thoracic CT scans of 200 adult subjects (100 males and 100 females), aged 20–70 years, obtained retrospectively. Seven morphometric parameters were measured: manubrium length, mesosternum length, sternal body width, manubriosternal angle, xiphoid process length, and fourth rib anteroposterior (AP) breadth and superoinferior (SI) height. Statistical analyses included descriptive statistics, independent sample t-tests, discriminant function analysis (DFA), and reliability testing using intraclass correlation coefficients (ICC). Results: All measured parameters, except the manubriosternal angle, demonstrated significantly larger values in males compared to females (p < 0.001). Females exhibited a wider manubriosternal angle. Rib AP breadth emerged as the most discriminant variable (Wilks’ ? = 0.548), followed by xiphoid process length and manubrium length. DFA yielded an overall classification accuracy of 95.5% (96.0% for males and 94.9% for females), with cross-validation confirming robustness (95.0%). However, ICC values indicated variability in inter-observer reliability, suggesting the need for stricter standardization of measurement protocols. Conclusion: Thoracic CT-based measurements of the sternum and fourth rib reveal pronounced sexual dimorphism and provide a highly accurate method for sex estimation. The derived population-specific discriminant equations hold considerable promise for forensic anthropology and medicolegal investigations in the Indian context, especially where conventional skeletal markers are unavailable.

Keywords

Sex determination, sternum, fourth rib, thoracic CT, forensic anthropology, sexual dimorphism, discriminant analysis

Introduction

The accurate determination of sex from human skeletal remains is one of the most fundamental tasks in forensic anthropology and medicolegal investigations. Establishing sex not only narrows down the pool of possible identities in cases of unidentified bodies but also forms the foundation for constructing the biological profile of an individual, which subsequently includes age, ancestry, and stature estimations. In archaeological contexts, reliable sex estimation contributes to understanding demographic composition, migration, social structure, and cultural practices of past population(1)s. Thus, sex determination is rightly regarded as the keystone of forensic and anthropological analysis, with direct implications for legal, humanitarian, and scientific purposes. Traditionally, the pelvis and skull have been considered the most sexually dimorphic bones in the human skeleton. The pelvis, adapted for childbirth, exhibits wide and consistent differences between males and females, while cranial traits such as brow ridges, mastoid processes, and mandibular robustness provide additional discriminatory value. However, reliance on these bones can become problematic in situations where skeletal remains are incomplete, fragmented, or taphonomically altered. In mass disasters, advanced decomposition, or violent trauma, it is not uncommon for pelvic and cranial elements to be absent or too damaged for reliable analysis. These limitations underscore the necessity of identifying alternative skeletal structures that are resilient, consistently preserved, and capable of reflecting sexual dimorphism. The sternum and ribs, located in the protective thoracic cavity, meet many of these requirements. The sternum is a flat bone comprised of the manubrium, mesosternum (body), and xiphoid process, articulating with the clavicles and upper seven ribs. It not only plays a protective role for vital organs such as the heart and lungs but also demonstrates measurable differences between sexes. Male sterna are generally longer, broader, and more robust due to greater skeletal mass and hormonal influences during growth and maturation. Ratios such as the manubrio-body index and variations in total sternal length have been shown to be useful for sex determination across populations. Similarly, the ribs—particularly the fourth rib are valuable due to their mid-thoracic position, articulation with the sternum, and relatively high preservation in forensic contexts. Male ribs tend to be longer, thicker, and more curved, reflecting differences in thoracic architecture and respiratory mechanics(2). The increasing availability of multidetector computed tomography (MDCT) has revolutionized the analysis of skeletal dimorphism. MDCT enables high-resolution, three-dimensional reconstructions of bones, allowing for precise morphometric measurements without the need for invasive or destructive procedures. Unlike traditional osteometric methods, CT imaging minimizes inter-observer variability and provides reproducible digital records that can be re-evaluated. These advantages are particularly critical in forensic settings where chain of custody, evidence preservation, and objectivity are paramount. Moreover, CT imaging allows for the collection of data from living populations undergoing routine medical scans, thereby overcoming some of the limitations of skeletal collections that may be outdated or demographically unrepresentative(3). Several studies across diverse populations have validated the utility of thoracic bones in sex estimation. Torimitsu and colleagues demonstrated over 85% accuracy in sex determination using sternal measurements in Japanese populations. Significant sexual dimorphism in sternal dimensions in French groups, while Bacci and co-workers highlighted rib curvature and thickness as reliable indicators in South American populations. Importantly, these studies also emphasize that patterns of sexual dimorphism are population-specific, shaped by genetic, nutritional, and environmental factors(4). Equations derived in one population may not be directly applicable to another, reinforcing the need for region-specific standards. In the Indian context, published data on CT-based thoracic measurements for sex estimation remain limited, creating a clear gap in forensic reference databases. Another notable challenge in previous research has been the reliance on dry bone collections and cadaveric samples. Although invaluable, such material is subject to postmortem changes, decomposition, and taphonomic processes that may distort measurements and reduce applicability to living populations. In contrast, CT imaging of living individuals provides a contemporary and more accurate representation of human variability. It also ensures larger, more diverse datasets that can account for the heterogeneity of modern populations. The present study was therefore designed to explore the discriminative potential of sternal and fourth rib morphometric parameters obtained from thoracic CT scans in an Indian population. By employing a cross-sectional design with balanced male and female representation, the study aimed to quantify key measurements, assess their sexual dimorphism, and derive discriminant function equations for sex classification. Advanced statistical tools, including independent t-tests, discriminant function analysis, and receiver operating characteristic curve analysis, were used to evaluate the predictive value of each parameter. By providing population-specific standards and highlighting the utility of imaging-based morphometrics, this research contributes to bridging the gap between classical forensic osteology and modern radiological techniques. Its findings hold particular relevance for forensic casework where traditional skeletal markers are absent, as well as for medico-legal investigations in hospital settings where CT imaging is routinely performed. Ultimately, this study emphasizes the growing role of radiological sciences in forensic anthropology and advocates for the integration of thoracic morphometrics into the standard toolkit for sex estimation.

MATERIALS AND METHODS

This investigation was designed as a cross-sectional observational study using retrospective thoracic computed tomography (CT) scans. The methodological approach was quantitative, allowing for precise numerical analysis of morphometric parameters of the sternum and fourth rib to determine sexual dimorphism. A quantitative design ensured objectivity, reproducibility, and statistical rigor, making it suitable for the development of discriminant function equations applicable in forensic practice.

Study Setting

The study was conducted in the Department of Radiodiagnosis of a tertiary-care teaching hospital. The institution is equipped with a 64-slice multidetector CT (MDCT) scanner, providing high-resolution imaging of thoracic anatomy, which is essential for morphometric evaluation.

Study Population

The target population consisted of adult male and female patients aged 20–70 years who underwent thoracic CT scans for non-traumatic and non-pathological reasons such as routine pulmonary or cardiovascular evaluation. Scans were selected retrospectively from the hospital’s Picture Archiving and Communication System (PACS) database.

Inclusion Criteria

Adult patients aged 20–70 years.
High-quality thoracic CT scans with complete visualization of the sternum and fourth rib.
Scans performed using standard diagnostic protocols.
Absence of congenital, traumatic, or pathological anomalies involving the bony thorax.

Exclusion Criteria

Patients with a history of thoracic trauma, fractures, or surgical procedures (e.g., sternotomy, rib resection).
Cases with congenital or acquired deformities such as scoliosis or pectus excavatum.
CT scans showing bony pathologies such as osteomyelitis, metastasis, or gross degenerative changes.
Poor-quality scans with artifacts, incomplete coverage, or motion blur obscuring bony landmarks.

Sample Size and Sampling Method

A total of 200 thoracic CT scans were included in the study, comprising 100 males and 100 females. The sample size was determined using power analysis, with a 95% confidence level and 80% power to detect significant sex-based differences in morphometric parameters. A purposive sampling technique was employed to ensure balanced representation of both sexes and adherence to inclusion criteria. Scans were retrospectively collected from a 12-month period, ensuring adequate sample diversity and relevance.

Imaging Modality and Protocol

Thoracic scans were acquired using 64-slice MDCT scanners (Siemens Somatom/GE Healthcare) following departmental protocols. Slice thickness: ≤1 mm for high-resolution reconstruction. Scan planes: Axial images reconstructed into sagittal and coronal multiplanar views. Window settings: Bone window (WW ≈ 2000 HU, WL ≈ 500 HU) to maximize cortical and trabecular bone visibility. Reconstruction: Multiplanar reconstructions (MPRs) and 3D volume rendering were employed where necessary.

Measurement Tools and Parameters

Quantitative data were obtained using the digital caliper tool of the PACS workstation. Measurements were rounded to the nearest 0.1 mm for precision. All measurements were performed in millimeters (mm) except angles (degrees). Sternal Parameters: Manubrium Length (ML) distance from jugular notch to manubriosternal joint. Mesosternum (Body) Length (MSL), Distance from manubriosternal joint to xiphisternal junction. Sternal Body Width (SBW), Maximum transverse width of the mesosternum at mid-body. Manubriosternal Angle (MSA), Angle between the manubrium and body of sternum (sagittal plane). Xiphoid Process Length (XPL), Distance from xiphisternal junction to tip of xiphoid process.

Fourth Rib Parameters

Anteroposterior (AP) Breadth: Maximum AP dimension at the sternal end of the rib.
Superoinferior (SI) Height: Maximum vertical dimension at the sternal end of the rib.

Observer Reliability

Intra-observer reliability: One observer repeated measurements on 30 randomly selected scans after 2 weeks.
Inter-observer reliability: A second observer independently measured the same 30 scans.
Statistical measure: Intraclass correlation coefficient (ICC), with values >0.85 considered good agreement.

Data Collection Procedure: Retrieval of eligible thoracic CT scans from PACS. Screening for inclusion/exclusion criteria. Measurement of parameters using digital calipers in axial, sagittal, and coronal planes. Recording of results in a pre-designed Microsoft Excel data sheet, coded to remove identifiers. Quality control random re-checking of 10% of cases.

RESULTS

Study Sample

A total of 200 thoracic CT scans were included in the study, consisting of 100 males (50%) and 100 females (50%), aged between 20 and 70 years. All cases fulfilled inclusion criteria, and no pathological or traumatic alterations of the thoracic skeleton were observed. One case initially categorized incorrectly was excluded from final analysis after quality control.

Descriptive Statistics

The morphometric data of the sternum and fourth rib revealed distinct patterns between the sexes.

Table 1 Sex-based differences in thoracic morphometric parameters

Parameter	Male (Mean ± SD)	Female (Mean ± SD)	Range (Overall)	Direction of Dimorphism
Manubrium Length (ML)	55.17 ± 3.48 mm	50.63 ± 3.91 mm	42.8 – 63.8 mm	Greater in males
Mesosternum Length (MSL)	95.52 ± 5.81 mm	88.17 ± 5.77 mm	75.1 – 109.8 mm	Greater in males
Sternal Body Width (SBW)	39.45 ± 3.11 mm	36.15 ± 3.05 mm	27.3 – 49.2 mm	Greater in males
Xiphoid Process Length (XPL)	34.62 ± 4.05 mm	29.88 ± 3.75 mm	18.6 – 45.9 mm	Greater in males
Manubriosternal Angle (MSA)	160.1° ± 5.97	166.3° ± 6.20	140.6° – 180°	Greater in females
4th Rib AP Breadth	25.23 ± 1.93 mm	21.78 ± 1.88 mm	17.0 – 29.9 mm	Greater in males
4th Rib SI Height	21.93 ± 2.07 mm	20.58 ± 1.97 mm	16.0 – 29.7 mm	Greater in males

These descriptive findings highlight a clear trend of larger thoracic dimensions in males, except for the MSA, which is more obtuse in females.

Figure 1 Histogram showing the distribution of Rib SI Height (mm) for males (Sex=1), based on 100 samples. Mean height is 21.93 mm with a standard deviation of 2.071 mm.

Tests of Normality

Shapiro–Wilk and Kolmogorov–Smirnov tests confirmed that most variables followed a normal distribution (p > 0.05). The only exception was male rib AP breadth, which showed slight deviation under Kolmogorov–Smirnov (p = 0.007), but normality was retained under Shapiro–Wilk (p = 0.141). Therefore, parametric tests were deemed appropriate.

Sexual Dimorphism: Independent t-Tests

Independent samples t-tests confirmed statistically significant differences across all measured parameters between males and females (p < 0.001 for all variables).

Table 2 Key Statistical Findings in Sexual Dimorphism and Discriminant Function Analysis

Parameter / Analysis Component	Findings
Largest mean differences	Mesosternum length: 7.35 mm; Rib AP breadth: 3.45 mm; Xiphoid process length: 4.74 mm
Smallest mean difference	Rib SI height: 1.35 mm
Negative mean difference	Manubriosternal angle: -6.2° (wider in females)
Wilks’ Lambda	Λ = 0.231, χ² = 283.27, df = 7, p < 0.001 (significant multivariate effect)
Eigenvalues / Canonical correlation	One function explained 100% of variance, Canonical correlation = 0.877
Standardized coefficients	Rib AP breadth (0.672), Xiphoid process length (0.434), Manubrium length (0.417), Manubriosternal angle (-0.298)
Structure matrix correlations	Rib AP breadth (0.498), Mesosternum length (0.350) most strongly correlated with sex discrimination

Classification Accuracy

The discriminant function achieved outstanding classification accuracy in differentiating between male and female cases. In the original grouped cases, 95.5% were correctly classified, with 96.0% of males and 94.9% of females accurately identified. When subjected to cross-validation, the model maintained a similarly high accuracy of 95.0%, confirming the robustness and stability of the discriminant function.

Figure 2 Distribution of rib superoinferior (SI) height in males, showing the mean value.

Misclassifications were minimal, involving only four males (4%) who were misclassified as females and five females (5.1%) who were misclassified as males. The ROC curve Figure 3 analysis further demonstrated the high diagnostic accuracy of key morphometric variables. Rib anteroposterior (AP) breadth emerged as the strongest discriminator, achieving the highest area under the curve (AUC) value of greater than 0.90, thereby confirming its powerful discriminatory capacity. Other important parameters, including mesosternum length, xiphoid process length, and manubrium length, also performed excellently, each demonstrating AUC values greater than 0.85, reinforcing their reliability in sex determination.

Figure 3 Diagnostic performance of 4th rib AP breadth, demonstrating its strong discriminatory power (AUC > 0.90).

In contrast to the high predictive accuracy, reliability testing yielded poor results. The intraclass correlation coefficient (ICC) values were negative, with -0.185 for single measures and -0.453 for average measures, and a non-significant p-value of 0.996. These results indicate poor inter- and intra-observer reliability, suggesting notable variability in measurement protocols and observer techniques. Further analysis revealed the presence of an outlier, a miscoded sex entry labeled as “22,” which was subsequently excluded from the dataset to maintain accuracy and validity.

Overall, the study highlighted several important findings. All measured parameters demonstrated statistically significant sexual dimorphism, with p-values less than 0.001. Male sterna and ribs were consistently larger across most dimensions, except for the manubriosternal angle, which was characteristically wider in females. Rib AP breadth stood out as the single most powerful discriminator of sex. Discriminant function analysis (DFA) achieved remarkable classification accuracy of 95.5%, with stable cross-validation accuracy of 95.0%. However, despite the excellent predictive outcomes, the study emphasized the limitations of measurement reliability. These findings underscore the importance of standardized training and improved observer protocols to enhance reproducibility and reliability in future forensic and anthropological applications.

DISCUSSION

Sex determination from thoracic skeletal elements especially the sternum and ribs plays a critical role in forensic anthropology, particularly when more classically used bones (pelvis, skull) are absent or damaged. In this study, thoracic CT measurements revealed marked sexual dimorphism across nearly all parameters we examined, replicating and expanding upon observations from prior literature. Below I discuss how your findings align with, differ from, or extend those earlier studies; consider the possible reasons; and outline forensic and methodological implications. Sternal Morphometry in Indian Populations, the recent study examined sternal morphometry using CT in a Central Indian sample. They found that mesosternal (sternal body) length was the strongest individual predictor of sex, and overall classification accuracy rose when multiple sternal parameters were combined. This results(2) similarly identify that the sternal body length (mesosternum) is among the top discriminators of sex. The congruence lends weight to the idea that sternal body length is a robust measure in this population.
In a study on the Greek population using MDCT, measured a suite of sternal parameters (lengths, widths, indices, angles) and found high classification accuracy (~91%) using logistic regression and random forest models. Parameters such as manubrium length (MBL) and sternum body length (SBL) were among the strongest predictors. (5)In this study, the rib AP breadth also emerged as highly discriminant, which is a somewhat novel extension combining sternal metrics with rib measures improves predictive power. Autopsy-based and Dry Bone Studies, the study by (6)in the Indian Bengali population (autopsy sample) also reported that combined sternal lengths (manubrium + mesosternum) and body lengths were useful for sex estimation with good accuracy. Although autopsy studies and dry bone measurements sometimes differ from CT-based imaging due to preservation and distortion, the consistency in which sternal body length shows sexual dimorphism supports your findings. Sternal + Rib Measures, Fewer studies have explicitly included rib measurements as done here. Some recent work (e.g., in your study) including the fourth rib’s AP breadth shows enhanced classification(7). Using sternum plus rib width, logistic regression models achieved very high accuracy (96.7%) for sex prediction when combining total sternum length with fourth rib width (7). This matches your results where rib AP breadth was top-ranking among discriminant variables, reinforcing that rib dimensions can importantly complement sternal measures. Differences in Manubriosternal Angle, In much of the literature, angular measures are less frequently strong discriminators; however, differences in manubriosternal angle have sometimes been noted. In your data, the manubriosternal angle was significantly larger in females this is an interesting contrast to typically more size-based differences and aligns partly with findings from some Egyptian and Greek CT-studies that note variation but give lesser weight to angles. Measured angles and reported that indices and widths often outperform angular measures(8)

Biological and Developmental Explanations

The observed patterns of sexual dimorphism in the sternum and ribs can be explained by several biological and developmental mechanisms. Males typically develop greater bone mass, cortical thickness, and overall skeletal dimensions as a result of hormonal influences, particularly testosterone and growth hormone, during puberty and throughout adulthood. As the sternum and ribs grow, these cumulative hormonal effects lead to measurable differences in length, breadth, and robustness. Additionally, thoracic architecture is shaped by respiratory mechanics and functional demands. Variations in lung size, chest wall musculature, and respiratory requirements between the sexes contribute to differences in rib breadth and height, reinforcing the dimorphic nature of these bones. Another important factor is the timing of growth and fusion of sternal elements. The manubrium, mesosternum, and xiphoid process ossify and fuse at predictable ages. While incomplete fusion can introduce variability in younger individuals, the adult population exhibits more stable differences, allowing sternal body length and rib anteroposterior breadth to emerge as reliable discriminators of sex.

Forensic and Practical Implications

The findings carry significant implications for forensic and medico-legal contexts. In situations where pelvic or cranial bones are absent due to decomposition, mutilation, or mass disasters, sternal and rib measurements obtained through CT imaging offer a highly useful alternative for sex estimation. Importantly, the study also underscores the necessity of population-specific standards. Sternal and rib dimensions vary across different populations including Indian, Greek, Egyptian, and Iranian groups and applying discriminant functions derived from one population to another may introduce substantial errors. By providing data specific to the Indian population, this study helps address a critical gap in forensic anthropology. Moreover, the use of CT imaging allows for non-destructive acquisition of morphometric data, preserving skeletal remains and enabling the development of reference datasets from living populations. Finally, the results highlight the importance of standardized training and protocols. Certain measurements, particularly those involving angles, curvatures, or precise anatomical alignments, are prone to inter- and intra-observer variability. Establishing consistent measurement protocols and improving training can enhance reliability and ensure the broader forensic applicability of thoracic morphometrics.

Limitations

Every study has its limits, and yours is no exception. Some key limitations include: Reliability concerns: Your intra- and inter-observer ICC values were low or even negative in some measures. This suggests either subjective measurement error, ambiguity in landmark identification, or possibly issues with imaging resolution or alignment. This reduces confidence in replicability unless measurement procedures are improved. Sample representativeness: The sample (n = 200) is a strong size, but drawn from a specific geographic/ethnic group in Central/Northern India. India is ethnically, nutritionally, and environmentally diverse; there may be regional variation in thoracic size not captured here. Age range: If the sample includes adults from 20-70, but you did not stratify by narrower age bands, there might be age-related changes (degenerative changes, bone loss, morphological change) which could slightly bias measures, especially in older individuals. CT scan protocol variation: The use of a single CT machine or single institution helps consistency, but variation in slice thickness, reconstruction algorithms, or patient positioning could affect measurements. Possible confounders not accounted for: Anthropometric variables such as stature, body mass index, physical activity, nutritional status, or skeletal disease (even if not overt) might influence size of skeletal structures.

Recommendations and Future Directions

This study demonstrated that thoracic skeletal morphometry, particularly measurements of the sternum and fourth rib, provides a reliable basis for sex estimation. Clear sexual dimorphism was observed: males consistently showed longer and broader sternal features, while females exhibited a wider manubriosternal angle. Among all variables assessed, the anteroposterior breadth of the fourth rib and the xiphoid process length were the most effective discriminators. Discriminant function analysis confirmed the strength of these parameters, achieving an accuracy of 95.5% with a strong canonical correlation, thus underscoring their forensic and anthropological value. Importantly, the use of CT imaging ensured a non-invasive, precise, and reproducible approach, particularly useful when pelvic or cranial elements are absent or fragmented. Despite these promising results, the study faced certain limitations. The sample was relatively homogeneous, measurement variability affected reliability, and the imaging conditions were restricted. To strengthen future research, it will be important to expand the sample size and include diverse geographic and ethnic groups across India, as well as incorporate age stratification to understand developmental changes. Refinement of landmark definitions and standardized measurement protocols will improve consistency, while including additional ribs or thoracic elements may further enhance accuracy. Testing advanced statistical and machine learning models could also provide more robust predictive frameworks. Finally, validation using real forensic or cadaveric cases will be essential to confirm the practical applicability of these findings in medico-legal investigations.

CONCLUSION

This cross-sectional study confirms that thoracic CT-based morphometric measurements of the sternum and fourth rib demonstrate clear sexual dimorphism and provide a reliable method for sex determination in an Indian population. Males consistently exhibited longer and broader sternal and rib dimensions, while females had a wider manubriosternal angle. Among the parameters, the fourth rib anteroposterior breadth and xiphoid process length were the strongest predictors of sex, with discriminant function analysis achieving a high classification accuracy of 95.5%. The findings highlight the value of CT imaging as a precise, non-invasive, and reproducible tool for forensic anthropology, particularly when traditional skeletal markers such as the pelvis or skull are unavailable. Despite excellent predictive accuracy, limitations in measurement reliability emphasize the need for standardized protocols and observer training. Future research should include larger, more diverse samples across different regions of India and explore advanced statistical or machine learning models to further enhance accuracy and applicability in medico-legal contexts.

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