Pectus carinatum: Difference between revisions

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{{Short description|Chest wall deformity characterized by outward protrusion of the sternum}}
{{Infobox medical condition (new)
{{Infobox medical condition (new)
| name            = Pectus carinatum
| name            = Pectus carinatum
Line 4: Line 5:
| caption        = Severe case of pectus carinatum
| caption        = Severe case of pectus carinatum
| pronounce      =  
| pronounce      =  
| field          = [[Orthopedics]]
| field          = [[Orthopedics]], [[Pediatrics]]
| synonyms        = Pigeon chest, pectus cavernatum, bird chest, convex chest
| synonyms        = Pigeon chest, pectus cavernatum, bird chest, convex chest
| symptoms        =  
| symptoms        = Outward protrusion of the chest wall, shortness of breath, fatigue
| complications  =  
| complications  = Respiratory difficulty, self-esteem issues, scoliosis, mitral valve prolapse
| onset          =  
| onset          = Typically in adolescence
| duration        =  
| duration        = Lifelong if untreated
| types          =  
| types          = Symmetrical and asymmetrical; includes ''pectus arcuatum''
| causes          =  
| causes          = Overgrowth of costal cartilage, genetic syndromes, rickets, post-surgical
| risks          =  
| risks          = Family history, connective tissue disorders, vitamin D deficiency
| diagnosis      =  
| diagnosis      = Clinical examination, [[CT scan]], [[X-ray]]
| differential    =  
| differential    = [[Pectus excavatum]], thoracic scoliosis
| prevention      =  
| prevention      = Not preventable (often congenital)
| treatment      =  
| treatment      = Orthotic bracing, surgery
| medication      =  
| medication      = Not applicable
| prognosis      =  
| prognosis      = Generally good with treatment
| frequency      =  
| frequency      = Relatively rare
| deaths          =  
| deaths          = None directly attributed
}}
}}
 
'''Pectus carinatum''', also called '''pigeon chest''', is a congenital or developmental deformity of the [[chest wall]] characterized by an outward protrusion of the [[sternum]] and adjacent [[costal cartilage]]. It is less common than its counterpart, [[pectus excavatum]], and typically becomes noticeable during the adolescent growth spurt.
'''Pectus carinatum''', also called '''pigeon chest''', is a malformation of the chest characterized by a protrusion of the [[Human sternum|sternum]] and [[ribs]]. It is distinct from the related malformation [[pectus excavatum]].


==Signs and symptoms==
==Signs and symptoms==
People with pectus carinatum usually develop normal hearts and lungs, but the malformation may prevent these from functioning optimally. In moderate to severe cases of pectus carinatum, the chest wall is rigidly held in an outward position. Thus, respirations are inefficient and the individual needs to use the accessory muscles for respiration, rather than normal chest muscles, during strenuous exercise. This negatively affects gas exchange and causes a decrease in stamina. Children with pectus malformations often tire sooner than their peers, due to shortness of breath and fatigue. Commonly concurrent is mild to moderate [[asthma]].
Individuals with pectus carinatum may present with the following features:


Some children with pectus carinatum also have [[scoliosis]] (i.e., curvature of the spine). Some have [[mitral valve prolapse]], a condition in which the heart mitral valve functions abnormally. Connective tissue disorders involving structural abnormalities of the major blood vessels and heart valves are also seen. Although rarely seen, some children have other connective tissue disorders, including arthritis, visual impairment and healing impairment.
* Prominent, outward bowing of the chest wall
* Shortness of breath, particularly during exercise
* Fatigue and reduced stamina
* Use of [[accessory muscles of respiration]] due to inefficient breathing
* Mild to moderate [[asthma]] symptoms
* [[Scoliosis]] (curvature of the spine)
* [[Mitral valve prolapse]]
* Discomfort or tenderness over the chest


Apart from the possible physiologic consequences, pectus malformations can have a significant psychologic impact. Some people, especially those with milder cases, live happily with pectus carinatum. For others, though, the shape of the chest can damage their self-image and confidence, possibly disrupting social connections and causing them to feel uncomfortable throughout adolescence and adulthood. As the child grows older, bodybuilding techniques may be useful for balancing visual impact.
While the condition does not typically affect [[heart]] or [[lung]] development, the shape of the chest may impede optimal respiratory function in severe cases. Children may tire easily during physical activities. In many cases, pectus carinatum is also associated with psychological and emotional challenges related to body image and self-confidence.


A less common variant of pectus carinatum is ''pectus arcuatum'' (also called type 2 pectus excavatum, chondromanubrial malformation or Currarino–Silverman syndrome or pouter pigeon malformation), which produces a [[Sternum#Manubrium|manubrial]] and upper sternal protrusion.
==Types==
* '''Symmetrical pectus carinatum''': Equal protrusion of the sternum across both sides of the chest.
* '''Asymmetrical pectus carinatum''': One side of the sternum protrudes more than the other.
* '''Pectus arcuatum''' (Currarino–Silverman syndrome): A rarer variant with upward bowing of the upper sternum.


==Causes==
==Causes==
{{refimprove section|date=December 2016}}
The exact cause of pectus carinatum is often unknown but may involve:
Pectus carinatum is an overgrowth of [[costal cartilage]] causing the sternum to protrude forward. It primarily occurs among four different patient groups, and males are more frequently affected than females.  Most commonly, pectus carinatum develops in 11-to-14-year-old pubertal males undergoing a [[Adolescence#Growth spurt|growth spurt]]. Some parents report that their child's pectus carinatum seemingly popped up overnight. Second most common is the presence of pectus carinatum at or shortly after birth. The condition may be evident in newborns as a rounded anterior chest wall. As the child reaches age 2 or 3 years of age, the outward sternal protrusion becomes more pronounced. Pectus carinatum can also be caused by [[vitamin D deficiency]] in children ([[Rickets]]) due to deposition of unmineralized [[osteoid]]. Least common is a pectus carinatum malformation following [[open-heart surgery]] or in children with poorly controlled bronchial [[asthma]].


Pectus carinatum is generally a solitary, non-syndromic abnormality. However, the condition may be present in association with other syndromes: [[Turner syndrome]], [[Noonan syndrome]], [[Loeys–Dietz syndrome]], [[Marfan syndrome]], [[Ehlers–Danlos syndrome]], [[Morquio syndrome]], [[trisomy 18]], [[trisomy 21]], [[homocystinuria]], [[osteogenesis imperfecta]], [[multiple lentigines syndrome]] (LEOPARD syndrome), [[Sly syndrome]] ([[mucopolysaccharidosis]] type VII), and [[scoliosis]].
* Overgrowth of [[costal cartilage]]
 
* Genetic predisposition – a family history is noted in ~25% of cases
In about 25% of cases of pectus carinatum, the patient has a family member with the condition.
* Syndromic associations:
** [[Marfan syndrome]]
** [[Ehlers–Danlos syndrome]]
** [[Noonan syndrome]]
** [[Turner syndrome]]
** [[Morquio syndrome]]
** [[Loeys–Dietz syndrome]]
** [[Homocystinuria]]
** [[Multiple lentigines syndrome]]
** [[Osteogenesis imperfecta]]
* [[Vitamin D deficiency]] leading to [[rickets]]
* Complications after [[open-heart surgery]]
* Chronic respiratory disorders such as poorly controlled [[bronchial asthma]]


==Diagnosis==
==Diagnosis==
The pectus carinatum can be easily diagnosed by certain tests like a [[CT scan]] (2D and 3D). It may then be found out that the rib cage is in normal structure. If there is more than average growth of sternum than pectus carinatum protrudes. Also it is of two types, as pectus carinatum is symmetrical or unsymmetrical. On the basis of that further treatment is given to the patient.
Diagnosis is typically made based on:
 
==Treatment==
===External bracing technique===
The use of [[orthotics|orthotic]] bracing, pioneered by [[Sydney Haje]] as of 1977, is finding increasing acceptance as an alternative to surgery in select cases of pectus carinatum.


In children, teenagers, and young adults who have pectus carinatum and are motivated to avoid surgery, the use of a customized chest-wall brace that applies direct pressure on the protruding area of the chest produces excellent outcomes. Willingness to wear the brace as required is essential for the success of this treatment approach. The brace works in much the same way as [[orthodontic]]s (braces that correct the alignment of teeth). The brace consists of front and back compression plates that are anchored to aluminum bars. These bars are bound together by a tightening mechanism which varies from brace to brace. This device is easily hidden under clothing and must be worn from 14 to 24 hours a day. The wearing time varies with each brace manufacturer and the managing physicians protocol, which could be based on the severity of the carinatum malformation (mild moderate severe) and if it is symmetric or asymmetric.
* [[Physical examination]] by a physician
* [[Chest X-ray]] or [[CT scan]] – to evaluate chest wall anatomy
* 3D imaging may be used to assess the severity and guide treatment
* Differentiation from similar conditions such as [[pectus excavatum]]


Depending on the manufacturer and/or the patient's preference, the brace may be worn on the skin or it may be worn over a body 'sock' or sleeve called a Bracemate, specifically designed to be worn under braces. A physician or orthotist or brace manufacturer's representative can show how to check to see if the brace is in correct position on the chest.
Severity is determined based on the degree of protrusion and the impact on respiratory function or psychological health.


Bracing is becoming more popular over surgery for pectus carinatum, mostly because it eliminates the risks that accompany surgery. The prescribing of bracing as a treatment for pectus carinatum has 'trickled down' from both paediatric and thoracic surgeons to the family physician and pediatricians again due to its lower risks and well-documented very high success results. The pectus carinatum guideline of 2012 of the American Pediatric Surgical Association has stated: "As reconstructive therapy for the compliant pectus [carinatum] malformation, nonoperative compressive orthotic bracing is usually an appropriate [[Therapy#Lines of therapy|first line of therapy]] as it does not preclude the operative option. For appropriate candidates, orthotic bracing of chest wall malformations can reasonably be expected to prevent worsening of the malformation and often results in a lasting correction of the malformation. Orthotic bracing is often successful in prepubertal children whose chest wall is compliant. Expert opinion suggests that the noncompliant chest wall malformation or significant asymmetry of the pectus carinatum malformation caused by a concomitant excavatum-type malformation may not respond to orthotic bracing.
==Treatment==
===Orthotic bracing===
Orthotic bracing is the first-line treatment in most adolescents with flexible chest walls. It involves wearing a custom-fitted chest brace that applies pressure to correct the protrusion over time.


Regular supervision during the bracing period is required for optimal results. Adjustments may be needed to the brace as the child grows and the pectus improves.
* Non-surgical
* Worn for several hours per day (usually 14–16 hours)
* Best results when started before the chest wall hardens (usually before age 18)
* Requires long-term compliance and follow-up


===Surgical===
===Surgical intervention===
For patients with severe pectus carinatum, surgery may be necessary. However bracing could and may still be the first line of treatment. Some severe cases treated with bracing may result in just enough improvement that patient is happy with the outcome and may not want surgery afterwards.
Surgery may be considered in severe or rigid cases, or when bracing is unsuccessful.


If bracing should fail for whatever reason then surgery would be the next step. The two most common procedures are the [[Ravitch technique]] and the Reverse Nuss procedure.
* '''Ravitch procedure''': Traditional surgical correction involving resection of abnormal cartilage and sternal realignment.
* '''Minimally invasive techniques''': Still under investigation for pectus carinatum.


A modified Ravitch technique uses bioabsorbable material and postoperative bracing, and in some cases a diced rib cartilage graft technique.
===Supportive management===
 
* Breathing exercises and physical therapy
The Nuss was developed by [[Donald Nuss]] at the Children's Hospital of the King's Daughters in Norfolk, Va. The Nuss is primarily used for Pectus Excavatum, but has recently been revised for use in some cases of PC, primarily when the malformation is symmetrical.
* Psychological counseling for self-esteem issues
 
* Management of associated conditions like scoliosis or asthma
===Other options===
After adolescence, some men and women use bodybuilding as a means to hide their malformation. Some women find that their breasts, if large enough, serve the same purpose. Some plastic surgeons perform breast augmentation to disguise mild to moderate cases in women. Bodybuilding is suggested for people with symmetrical pectus carinatum.


==Prognosis==
==Prognosis==
Pectus malformations usually become more severe during adolescent growth years and may worsen throughout adult life. The secondary effects, such as scoliosis and cardiovascular and pulmonary conditions, may worsen with advancing age.
With appropriate treatment, especially early bracing, most individuals achieve excellent cosmetic and functional results. Surgery is effective but involves greater risk and recovery time.


Body building exercises (often attempted to cover the defect with pectoral muscles) will not alter the ribs and cartilage of the chest wall, and are generally considered not harmful.
Untreated severe cases may persist into adulthood, potentially affecting posture, respiratory efficiency, and self-image.
 
Most insurance companies no longer consider chest wall malformations like pectus carinatum to be purely cosmetic conditions. While the psychologic impact of any malformation is real and must be addressed, the physiological concerns must take precedence. The possibility of lifelong cardiopulmonary difficulties is serious enough to warrant a visit to a thoracic surgeon.
 
==Epidemiology==
Pectus malformations are common; about 1 in 400 people have a pectus disorder.


==See also==
==See also==
* [[Pectus excavatum]]
* [[Pectus excavatum]]
* [[Costal cartilage]]
* [[Sternum]]
* [[Chest wall deformities]]
* [[Marfan syndrome]]
* [[Rickets]]


==References==
==External links==
{{reflist}}
* [https://www.chop.edu/conditions-diseases/pectus-carinatum Pectus Carinatum – Children's Hospital of Philadelphia]
* [https://www.ncbi.nlm.nih.gov/books/NBK558948/ Pectus Carinatum – NCBI Bookshelf]


== External links ==
[[Category:Congenital disorders]]
{{Medical resources
[[Category:Orthopedic problems]]
|  DiseasesDB      = 29402 
[[Category:Musculoskeletal disorders]]
|  ICD10          = {{ICD10|Q|67|7|q|65}} 
[[Category:Pediatric diseases]]
|  ICD9            = {{ICD9|754.82}} 
[[Category:Chest wall deformities]]
|  ICDO            = 
|  OMIM            = 
|  MedlinePlus    = 003321 
|  eMedicineSubj  = ped 
|  eMedicineTopic  = 1803 
|  MeshID          =
}}
{{Congenital malformations and deformations of musculoskeletal system}}
{{Congenital malformations and deformations of musculoskeletal system}}
 
{{nt}}
[[Category:Congenital disorders of musculoskeletal system]]
[[Category:Congenital disorders of musculoskeletal system]]

Latest revision as of 03:30, 30 March 2025

Chest wall deformity characterized by outward protrusion of the sternum


Pectus carinatum
File:Ben Fraser pectus carinatum.jpg
Synonyms Pigeon chest, pectus cavernatum, bird chest, convex chest
Pronounce
Field Orthopedics, Pediatrics
Symptoms Outward protrusion of the chest wall, shortness of breath, fatigue
Complications Respiratory difficulty, self-esteem issues, scoliosis, mitral valve prolapse
Onset Typically in adolescence
Duration Lifelong if untreated
Types Symmetrical and asymmetrical; includes pectus arcuatum
Causes Overgrowth of costal cartilage, genetic syndromes, rickets, post-surgical
Risks Family history, connective tissue disorders, vitamin D deficiency
Diagnosis Clinical examination, CT scan, X-ray
Differential diagnosis Pectus excavatum, thoracic scoliosis
Prevention Not preventable (often congenital)
Treatment Orthotic bracing, surgery
Medication Not applicable
Prognosis Generally good with treatment
Frequency Relatively rare
Deaths None directly attributed


Pectus carinatum, also called pigeon chest, is a congenital or developmental deformity of the chest wall characterized by an outward protrusion of the sternum and adjacent costal cartilage. It is less common than its counterpart, pectus excavatum, and typically becomes noticeable during the adolescent growth spurt.

Signs and symptoms[edit]

Individuals with pectus carinatum may present with the following features:

While the condition does not typically affect heart or lung development, the shape of the chest may impede optimal respiratory function in severe cases. Children may tire easily during physical activities. In many cases, pectus carinatum is also associated with psychological and emotional challenges related to body image and self-confidence.

Types[edit]

  • Symmetrical pectus carinatum: Equal protrusion of the sternum across both sides of the chest.
  • Asymmetrical pectus carinatum: One side of the sternum protrudes more than the other.
  • Pectus arcuatum (Currarino–Silverman syndrome): A rarer variant with upward bowing of the upper sternum.

Causes[edit]

The exact cause of pectus carinatum is often unknown but may involve:

Diagnosis[edit]

Diagnosis is typically made based on:

Severity is determined based on the degree of protrusion and the impact on respiratory function or psychological health.

Treatment[edit]

Orthotic bracing[edit]

Orthotic bracing is the first-line treatment in most adolescents with flexible chest walls. It involves wearing a custom-fitted chest brace that applies pressure to correct the protrusion over time.

  • Non-surgical
  • Worn for several hours per day (usually 14–16 hours)
  • Best results when started before the chest wall hardens (usually before age 18)
  • Requires long-term compliance and follow-up

Surgical intervention[edit]

Surgery may be considered in severe or rigid cases, or when bracing is unsuccessful.

  • Ravitch procedure: Traditional surgical correction involving resection of abnormal cartilage and sternal realignment.
  • Minimally invasive techniques: Still under investigation for pectus carinatum.

Supportive management[edit]

  • Breathing exercises and physical therapy
  • Psychological counseling for self-esteem issues
  • Management of associated conditions like scoliosis or asthma

Prognosis[edit]

With appropriate treatment, especially early bracing, most individuals achieve excellent cosmetic and functional results. Surgery is effective but involves greater risk and recovery time.

Untreated severe cases may persist into adulthood, potentially affecting posture, respiratory efficiency, and self-image.

See also[edit]

External links[edit]

Congenital malformations and deformations of musculoskeletal system / musculoskeletal abnormality
Appendicular
limb / dysmelia
Axial
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