What is Pectus Carinatum?
Pectus carinatum (or also called pigeon chest) is a condition that is not life-threatening. The breastbone is abnormally protruded outward, because of the rapid cartilage growth that is forcing the chest cavity outward. Mainly, the first symptoms are shown in the 11 or 12 years, and that this condition is diagnosed. But, also that doesn’t mean that the first symptoms can’t be shown earlier. Sometimes, they may be present from birth or in the early childhood.
It is more often to appear in boys, and also there is a possible heredity component. For most children, it is not dangerous. But sometimes it may cause few symptoms like difficulty breathing, asthma or some respiratory infections.
What causes pectus carinatum?
The exact cause of this condition is not known. Many doctors believe that is it caused by an issue that occurs between the connection of the ribs and the breastbone. They are guessing that the cartilage is growing faster than the bones. Due to this, the breastbone is pushed outward. Still, there are researches done in order to determinate the reason for the rapid growth of the cartilage.
What are the symptoms of pectus carinatum?
Most commonly this disorder is asymptomatic. This means that there are not any symptoms that may be noticeable and that may reveal the condition.
But in some cases, there might be some symptoms like
- Increased frequency of respiratory tract infections.
- Difficulty breathing during physical activity
- Rigidity of the chest wall with decreased lung compliance
- Progressive emphysema
Types of Pectus Carinatum
This deformity can be classified in two ways:
- Chondrogladiolar prominence (CG) and
- Chondromanubrial prominence (CM).
The chondrogladiolar prominence pectus carinatum is more common, whether the other one – chondromanubrial prominence is really rear and difficult to treat.
People that are affected by chondrogladiolar prominence are having their middle and lower areas of the rib cage arch forward. It is easier to correct the ribs that are longer because they are more flexible. If the ribs are shorter, they are less flexible and harder to correct.
Chondromanubrial prominence pectus carinatus – CM is typically symmetrical and affects the upper rib. It is harder to fix this type of pectus carinatum because the ribs that are affected are shorter and less flexible.
Another type of classification of pectus carinatum is done by the cause and the time of onset. These kinds of classifications are:
- Post-surgical – occurs when the sternum is operated and it doesn’t heal properly after the surgery or chest trauma
- Congenital – the premature fusion of the chest cavity is present at birth
- Idiopathic – this is the most common type of pectus carinatum, that mainly appears between the ages 11 and 15
When does the pectus carinatum become noticeable?
Pectus carinatum is diagnosed in roughly 1 per 1500 children. It happens more often in boys than it happens in girls. Usually, nothing is seen before the 11th or the 12th year. This doesn’t mean that is not occurring in younger kids, only the percentage of younger children is smaller.
The conditions get worse is the adolescence stage, when most of the symptoms are noticeable.
Are there any risk factors, and are there another medical complications that are related to pectus carinatum?
If there is a family history of this disorder or some other chest wall deformity, that increase the risk of getting pectus carinatum. Also, another factor that increases the risk is a connective tissue disorder like Marfan’s syndrome.
When diagnosed in infancy, it may also be seen with premature breastbone fusion and congenital heart disease. Pectus carinatum is also much more common in Caucasians than people of other races.
What is the long-term viewpoint?
Pectus carinatum is non-life-threatening. The majority of children who are diagnosed are having the ability to live normal lives. If the case is mild to moderate, there’s the possibility that no medical treatment will be necessary. For children who do require medical intervention, results can usually be visible within a short period of time.
How can be pectus carinatum diagnosed?
Pectus carinatum is mainly diagnosed by a physical examination. For further confirmation, a front and side chest X-ray is needed as part of the workup for this condition. Also, a CT scan and MRI scan may be asked in some cases.
If you are experiencing an irregular heartbeat, the doctor will ask you to do an electrocardiogram (EKG) or echocardiogram.
How is this deformity treated?
In the past years, some researchers are done about the exercise being a potential treatment for pectus carinatum. These exercises target the muscles surrounding the protruding area and decrease the appearance of the outward chest cavity.
Still, the solution hasn’t been found yet. Before choosing this type of method is really important to speak firstly with your doctor.
Brace treatment does not require general anesthesia and surgery and does not leave an operative scar. The treatment is performed at an outpatient clinic. For the most accident of pectus carinatum, treatment may not be a necessity. The most frequent approach for mild to moderate cases that need to be treated is done with the usage of braces of the chest wall. This is done by custom fitting a circumferential external brace that puts sustained force on the most prominent portion of the sternum or cartilages in order to cause regression or flattening of the chest wall. You’ll need to wear the brace for at least eight hours in a day during a minimum period of six months. This semi-padded brace corrects the outward presence of the chest over time through consistent pressure to the cartilage. This constant pressure causes the cartilage to gradually reshape. This steadfast pressure suits the gristle to gradually refashion. The best result is obtained if you wear the brace for a minimum one year and if you are braced through adolescence. Success rates of 65-80 % and long-term outcomes with orthotic bracing alone are encouraging.
Prior to a brace being used, a doctor regulates the amount of pressure that will be prescribed to fix the issue on a case-by-case basis. Results are mainly noticeable within the first few months.
The improvement of pectus carinatum is documented by using a chest CT scan. However, considering that most patients are concerned about the cosmetic results, satisfaction can be a better tool to measure the clinical outcome.
For older patients that are experiencing more advanced level of pectus carinatum, bracing may not be effective and the next thing to be considered is the surgery.
The patients who have completed the treatment protocol, which the medical staff has recommended, showed satisfaction scores superior to that of those who did not complete the treatment.
- Some of the most common questions about bracing that parents are asking:
What is pectus carinatum brace?
It’s a lightweight brace that’s custom-made for every child personally. It wraps around the chest and puts pressure on the front part of the chest that sticks out.
How does a pectus carinatum brace work?
It works similar to the teeth braces, a chest brace will push the breastbone back to the normal position that has to be obtained. Your child’s health care provider will see your child regularly and adjust the pressure of the brace so it can work but still be comfortable.
How long do kids need to wear a brace?
Most of the kids are wearing the brace for 6 months minimum to a year, though some need to wear it longer, depending on the degree of the deformity. They usually can remove it for sports, showering, and other activities, but usually must wear it for 8 hours a day or even longer (it is better to wear it as much longer as they are able to). You must your child wear the brace exactly as recommended by your healthcare provider. This will help your child get the best results from it.
Are there any problems with wearing the brace?
Usually, wearing the brace causes no problems. Occasionally, the skin under it can get a little red and irritated. This usually goes away on its own, but call your health care provider’s office if :
-The redness doesn’t go away within 30 minutes after taking off the brace. -Your child develops blisters, sores, or a rash under the brace.
Is bracing painful?
Some kids can experience a slight discomfort after having the brace pressure adjusted. If your child is uncomfortable and your health care provider says it’s OK, you can give acetaminophen (such as Tylenol® or a store brand) or ibuprofen (for example Advil®, Motrin®, or a store brand) as directed.
What if my kid is not feeling comfortable and won’t wear the brace?
Most kids are feeling comfortable with wearing their brace. Usually, the brace can’t be noticed under the shirt. But if your child feels uncomfortable, please try to understand it and help him with that. Be all the time together, work and speak together, exercise together to come up with solutions and incentives to get your child to wear the brace. And agree on the occasional “night off” for important events, like a dance or beach day.
Your care team is a resource — for you and your child. The doctors and the whole team are there to answer any questions that you have and help you and your child get through the challenges of bracing and achieve the best result. You must understand that wearing the braces is essential for your child. You may feel sorry, but be strong and make your child yo wear it every day.
What expectations should we have regarding the bracing treatment?
Recovery and success rates for both traditional methods of treatment, bracing and surgery, range from good to excellent. Bracing is the least invasive treatment and poses the smallest risk. The main side effect of using a brace is skin irritation. The success rate of the bracing method is higher at the children who are aged from 11-14 years. Older people are most likely to be exposed to have a surgery.
If the bracing treatment is not able to correct the deformity, what is the next thing to do?
The surgical treatment was used as a second-line treatment in patients who were noncompliant to the brace treatment. Surgery is only offered if the bracing is not giving the desired correction or if the patient has passed his puberty and the skeleton cannot respond to the bracing method. Surgical repair (or also called Ravitch procedure) is done through a horizontal chest incision across the mid-chest. The abnormal costal cartilages are removed, preserving the lining that covers the outside of the cartilage, allowing the sternum to be pushed downward in a more normal position. The whole procedure is done in several hours.
In certain patients, a break in the sternum is done in order to allow the sternum to be positioned downward. Additionally, this is also done to keep the sternum in the desired position after the cartilages have been removed and the osteotomy (the break), a temporary metal chest strut (bar) may need to be placed.
What is the care in the hospital following surgery?
The surgical repair of the pectus carinatum is a procedure that s really painful. How long will you have to stay in the hospital is determinate by the level of the pain that you will be experiencing.
- Anesthesia– Local anesthesia is used and given through an epidural catheter that is placed in the child’s back during the surgery. The catheter might stay in place for few days after the surgery. Also, a urinary catheter will be placed in order to drain the urine from the bladder. Another catheter – intravenous will be placed and fluid and medications will be given through it. When the doctor will assume that all of these catheters are not needed anymore, they will all be taken away.
- The day after the surgery– Getting from bad is usually required the day after the surgery. The patient will need to practice deep breathing as well, in order to keep the lungs healthy and to prevent pneumonia.
- Constipation– This is one of the most common things that children on medications are experiencing.
- Leaving the hospital– Once when the children are feeling comfortable, and they are able to eat and walk on their own, they will be released from the hospital. Also, their infection and fever must be gone away. The drain may still stay, but the family will be taught how to manage it at home.
- Homecare– Children must do controls in the first year after the surgery. The chest strut is expected to stay in place for 2-3 years.
- A shower can be taken 5 days after surgery. Have your child take the film dressing off before the shower and leave the tape strips in place. These will fall off on their own.
- There are no stitches to be removed. These are under the skin and dissolvable.
- Narcotic pain management may be required for up to one month after surgery.
- Constipation is a common problem, and daily use of laxatives while on narcotics is recommended.
- Redness or swelling of the incision(s) should be reported as soon as noted.
- If your child is discharged with a drain in place, it will be removed in the surgical office when the draining had stopped.
- Sports may be resumed as soon as the surgeon determines this is safe.
What type of activity is obligatory after the surgery?
Postoperative patients may report decreased exercise tolerance and exceptional dyspnea that may be the main factor to lower the activity tolerance. The improvement of these symptoms will begin to be noticeable between the third and the sixth month after the surgery. In the meantime, some postoperative activities are recommended, such as:
- Use incentive spirometer and further periodic deep breaths.
- Limit the twisting movements of the chest for at least 4 months after the surgery.
- Skip some rapid elevation of the arms overhead for at least 4 months postoperatively.
- Encourage lower extremity exercise (may begin within the second week after surgery).
- Lightweights may be used to strengthen biceps and deltoids; the use of chest and abdominal muscles may be increased later (after the third to fourth week).
- Gym classes are not recommended for 5 months after surgery in school-aged children.
- Long-term recommendations include stretching exercises that involve pulling the shoulder blades posterior to improve posture.
- Sources used:
- Egan JC, DuBois JJ, Morphy M, Samples TL, Lindell B. Compressive orthotics in the treatment of asymmetric pectus carinatum: a preliminary report with an objective radiographic marker. J Pediatr Surg. 2000;35:1183–1186. [PubMed]
- Robicsek F, Watts LT, Fokin AA. Surgical repair of pectus excavatum and carinatum. Semin Thorac Cardiovasc Surg. 2009;21:64–75.