AMEI’s Current Trends in Diagnosis & Treatment
Volume 7 | Issue 1 | Year 2023

Morphological Study of Attachment of Costoclavicular Ligament on the Dry Human Clavicles in North Indian Population

Priyanka Sharma1, Anupama Mahajan2, Poonam Verma3

1–3Department of Anatomy, Sri Guru Ram Das Institute of Medical Sciences & Research, Amritsar, Punjab, India

Corresponding Author: Poonam Verma, Department of Anatomy, Sri Guru Ram Das Institute of Medical Sciences & Research, Amritsar, Punjab, India, Phone: +91 8283816579, e-mail:

How to cite this article: Sharma P, Mahajan A, Verma P. Morphological Study of Attachment of Costoclavicular Ligament on the Dry Human Clavicles in North Indian Population. AMEI’s Curr Trends Diagn Treat 2023;7(1):3–6.

Source of support: Nil

Conflict of interest: Dr Anupama Mahajan is associated as the National Editorial Board member of this journal and this manuscript was subjected to this journal’s standard review procedures, with this peer review handled independently of this editorial board member and her research group.

Received on: 25 February 2023; Accepted on: 17 April 2023; Published on: 20 July 2023


Background: The clavicle bone performs a significant role in the movements of the upper limb. Clavicle is a long horizontal bone bearing two ends, i.e., asternal end, an acromial end, and a shaft. The sternal end bears an impression on its lower surface that may be in the form of a tubercle, fossae, or a depression called a costoclavicular area or rhomboid impression. This costoclavicular groove provides the attachment of the costoclavicular ligament. The mostly rough and elevated type was seen. Morphology of this area is clinically vital for the determination of age and sex and also for radiological and orthopedical points of view.

Materials and methods: This study was conducted on 100 dry clavicles, out of which 50 were of the right and 50 were of the left side with unknown sex and age. In this study, rhomboid impressions were observed with variations, photographed, and compared with literature. Bones were taken from a department in a tertiary care medical institute in Punjab.

Result: In this study 100 clavicles comprising 50 right and 50 left were taken and impressions were noticed, i.e., flat and smooth (FS), rough and elevated (RE), depressed and rough (DR), flat and rough (FR), and no impression. We found 18 (18%) flat and smooth (FS), 33 (33%) rough and elevated (RE), 13 (13%) depressed and rough (DR), and 19 (19%) flat and rough (FR) impressions on the clavicle. Out of 100 clavicles, 17 of them had no impressions.

Conclusion: A mostly rough and elevated pattern was observed on the rhomboid impression of the clavicle bone. Knowledge of the costoclavicular impression area is clinically useful for orthopedical, radiological, and also for forensic as well as anthropological points of view.

Keywords: Diagnosis, Radiologists, Surgical procedures.


The costoclavicular ligament of the sternoclavicular region plays a significant role to deliver strength as well as movements of the pectoral girdle.1,2 The costoclavicular ligament provides stability to the sternoclavicular joint.3,4 This ligament ranges from the 1st costal cartilage and the contiguous part of the first rib to the lower surface of the medial part of the shaft of the clavicle.5 This ligament presents in various shapes as anteroposteriorly i.e., flattened, cone shape, inverted, truncated cone. The impressive part of the costoclavicular ligament on the clavicle bears an impression in the form of a rough impression, tubercle rough oval, or depressed area which is also called a rhomboid fossa.68 This ligament is susceptible to damage in Craftsmen, painters, and mariners.911 This ligament can comprise hyperostotic variations on the medial end of the clavicle.11 The rhomboid fossa is the very helpful morphological attribute to estimate age and sex.12 Remnants of some bones such as the skull, pelvis, bones of an upper and lower limb, sternum, and patella are used for estimation of sex and age. But clavicle also has been used for the identification of unknown individuals as it is relatively resistant to environmental degradation so it is more reliable for the determination of sex.13 The usual morphological variants of the attachment region of the costoclavicular ligament on the clavicle may be misjudged as pathological situations by an inexpert viewer.14 Rhomboid impression also acts as a landmark for determining the extent of resection of the medial end of the clavicle bone.15 The subclavian vein which lies posterior to the costoclavicular ligament plays a vital role during procedures like venous catheterization.1618


To study the morphology of rhomboid impression or the area of attachment of the costoclavicular ligament on the clavicle, the bones were obtained from the Anatomy Department of Sri Guru Ramdas Institute of Health and Sciences, Amritsar. Total of 100 clavicle bones were studied, out of which 50 were on the right side and 50 were on the left side. The various patterns of the impression were observed.

Morphology of rhomboid impression or costoclavicular ligament were observed for the following features:


The sternal end of the clavicle bone showed an impression of its inferior aspect. This area was reflected in different patterns of impression. In this study, 100 dry human clavicles of unknown age and sex were studied out of which 50 right and 50 left sides were taken and different patterns of impressions were perceived. Out of 100 bones, only 83 bones were comprised of diverse impressions, the remaining 17 bones out of which eight of right side and nine of left side impression was found to be absent (Table 1). The different patterns of impression were observed mentioned in (Table 2). Flat and smooth (FS): Found in 18 bones (18%) (Fig. 1). Flat and rough (FR): Found in 19 bones (19%) (Fig. 2). Elevated and rough (FR): Were present in 33 bones (33%) (Fig. 3). Depressed and rough (DR) present in 13 bones (13%) (Fig. 4). No impression found in 17 bones (17%) (Fig. 5). In our study, Chi-square test is applied in Table 1 and the (p = 0.789) value found is not statistically highly significant. In Table 2, value (p = 0.978) found which was also not statistically significant (Table 3).

Fig. 1: Clavicle showing flat and smooth impression

Fig. 2: Bone showing flat and rough impression

Fig. 3: Bone showing elevated and rough impression

Fig. 4: Bone showing depressed and rough on

Fig. 5: Clavicle bone showing no impression contain nutrient foramina instead of impression

Table 1: Represent the rhomboid impression on clavicle bones
Rhomboid impression Right (50) Left (50) Total (100)
Present 42 41 83
Absent 8 9 17

χ2: 0.071; df: 1; p = 0.789

Table 2: Represent the type of rhomboid impression in bones
Type of impression Right (50) Left (50) Total (100)
Flat and smooth 8 (16%) 10 (20%) 18 (18%)
Flat and rough 10 (20%) 9 (18%) 19 (19%)
Elevated and rough 17 (34%) 16 (32%) 33 (33%)
Depressed and rough 7 (14%) 6 (12%) 13 (13%)
No impression 8 (16%) 9 (18%) 17 (17%)

χ2: 0.441; df: 4; p = 0.978

Table 3: Showing comparison of various studies by researchers on rhomboid impression
Type of impression Flat and smooth Flat and rough Elevated and rough Depressed and rough No impression
Cave AJE (1961)1 29% 31% 8.5% 18%
Anita Rani et al. (2011)21 6.19% 28.32% 9.73% 30.97% 3.54%
Trupti et al. (2012)28 54% 64% 24% 30%
Rai R and Shrestha S (2014)24 22.8% 40% 2.9% 20%  
Bhat S et al. (2015)12 30.6% 7.32% 61%
Rathnakar P et al. (2018)23 7.6% 7.6% 48.7% 29.5%
Vani PC et al. (2018)26 16% 26% 34% 24%
Devi KVS and Sakthivel (2020)25 15% 20% 28.5% 29% 2.5%
Dyotimoy Datta and Chhitji Anand (2021)27 22.8% 40% 2.8% 20%
Present study (2023) 18% 19% 33% 13% 17%


On the undersurface of the clavicle towards its sternal end, a rough oval impression is usually present for the attachment of the costoclavicular ligament called a rhomboid impression. According to Williams et al., rarely, this area is smooth or even raised and may form a synovial joint with the first rib.8

There are various patterns for the attachment area of the costoclavicular ligament, i.e., elevated and rough, flat and rough, flat and smooth, and depressed and rough. A deficiency of knowledge of the differences in the attachment area of the costoclavicular ligament can lead to diagnostic errors. Depressed and rough area on the rhomboid fossa may lead to the misapprehension of chronic osteomyelitis.1

Cave studied a flat and rough, flat and smooth, elevated and rough and depressed and rough impression for costoclavicular ligament, i.e., 31, 29.1, 8.5, and 18%, respectively.1 On the other side, Paraskevas et al. in their radiological study observed that the various morphological patterns as mentioned above are 58.12, 26.88, and 15%, respectively.19

According to Flournoy et al.,20 diverse characters detected on the costoclavicular ligament of the clavicle in the North American population and defined them as rough impressions, tubercles, and grooves like fossa called rhomboid fossa, occasionally there is no impression.

In a study carried out at Lucknow by Anita Rani and her coworkers, rhomboid fossa was the most common outcome in clavicles of Indian origin.21 Even the absence of costoclavicular ligament has been described by Tubbs et al.2228

In our present study following findings were observed in 100 clavicles 50 on the right side and 50 on the left side with unknown age and sex. In our study, we reported flat and smooth in 18 bones (18%), flat and rough in 19 bones (19%), elevated and rough in 33 bones (33%), and depressed and rough in 13 bones (13%). Even in 17 bones (17%) impressions were absent.


The most common morphological pattern of the rhomboid fossa is elevated and rough. A rhomboid fossa is very useful to determine the age of an unknown individual. This fossa is playing a vital role in sex determination. The knowledge of the costoclavicular impression area is clinically beneficial for orthopaedical, radiological, and also for forensic as well as anthropological points of view.


The author would like to gratitude to all the faculty members of Department of Anatomy for their assistance during my research work.

Contribution of Authors

Priyanka Sharma – Data collection, data curation. Dr. Anupama Mahajan – Conceptualization, Supervision. Dr. Poonam Verma – Design of study, interpretation of data, revision of manuscript.


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