Pectus Carinatum (pigeon chest ): Difference between revisions

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== Clinically Relevant Anatomy  ==
== Introduction ==
[[File:PC.jpg|thumb|Pectus Carinatum<ref>Shamberger RC, Welch KJ. Surgical correction of pectus carinatum. Journal of pediatric surgery. 1987 Jan 1;22(1):48-53.</ref>]]
[[File:PC.jpg|thumb|Pectus Carinatum<ref>Shamberger RC, Welch KJ. Surgical correction of pectus carinatum. Journal of pediatric surgery. 1987 Jan 1;22(1):48-53.</ref>]]Pectus carinatum (pigeon chest) refers to a chest wall deformity in which the [[sternum]] protrudes anteriorly. It is less common than pectus excavatum. It affects nearly 1 in 1000 teens, and early identification allows for more noninvasive treatment options.<ref name=":0">McHam B, Winkler L. Pectus Carinatum (Pigeon Chest). Available:https://www.ncbi.nlm.nih.gov/books/NBK541121/ (accessed 27.9.2022)</ref>  
Pectus carinatum is a term used to describe a spectrum of protrusion abnormalities of the anterior chest wall. The deformity may be classified as either chondrogladiolar or chondromanubrial, depending on the site of greatest prominence.<ref name=":0">Croitoru D, Nuss D. Chest wall anomalies: pectus excavatum and pectus carinatum. Adolesc Med. 2004;15:455-71.</ref> Lateral deformities are also possible.


Hippocrates described the carinatum deformity as a "sharply pointed chest" and reported that patients became "affected with difficulty breathing." Symptomatic patients report dyspnea and decreased endurance. Some develop rigidity of the chest wall with decreased lung compliance, progressive emphysema, and increased frequency of respiratory tract infections. Many affected patients have no physical complaints; however, concerns about body image have been associated with low self-esteem and a decreased mental quality of life. Cosmetic concerns can be significant factors in opting for correction.Barrel chest deformities with increased anteroposterior (AP) chest diameters can be seen in obstructive forms of chronic pulmonary disease, such as cystic fibrosis and untreated or poorly controlled asthma.<ref name=":0" /><br>
== Etiology ==
The precise etiology of pectus carinatum is unknown, however most consider both pectus carinatum and pectus excavatum to be due to defective elongated growth of the [[Ribs|costal cartilage]].  A [[Genetics and Health|genetic]] element is suggested by the significant portion of patients with a family history of a chest wall defect or deformity. In about 25% of cases of pectus carinatum, the patient has a family member with the condition.<ref name=":0" /><ref name=":1">Radiopedia Pectus Carinatum Available:https://radiopaedia.org/articles/pectus-carinatum (accessed 27.9.2022)</ref>


==  Pathology  ==
Pectus carinatum is generally a solitary, non-syndromic abnormality. However, the condition may be present in association with other syndromes: 


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 growth spurt<ref name=":0" />. 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 deformity following open-heart surgery or in children with poorly controlled bronchial asthma.
* [[Scoliosis]] (common)
 
* Cyanotic [[Congenital Heart Disease|congenital heart disease]] (uncommon)
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.<ref name=":0" />
* [[Marfan Syndrome|Marfan syndrome]].<ref name=":1" />
 
In about 25% of cases of pectus carinatum, the patient has a family member with the condition.


== Clinical Presentation  ==
== Clinical Presentation  ==
 
Patients may present with [[dyspnoea]] and [[Physical Activity and Exercise Prescription|exercise]] intolerance. Some studies have shown an association with [[asthma]] or [[Chronic Bronchitis|chronic bronchitis]] in up to 16.4% of patients.<ref name=":0" /><ref name=":1" />
People with pectus carinatum usually develop normal hearts and lungs, but the deformity may prevent these from functioning optimally. In moderate to severe cases of pectus carinatum, the chest wall is rigidly held in an outward position.<ref name=":1">Shamberger RC. Congenital chest wall deformities. Current problems in surgery. 1996 Jun 1;33(6):469-542.</ref> 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 deformities often tire sooner than their peers, due to shortness of breath and fatigue. Commonly concurrent is mild to moderate asthma.<ref name=":0" /><ref name=":1" />
 
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.
 
Apart from the possible physiologic consequences, pectus deformities 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.
 
A less common variant of pectus carinatum is ''pectus arcuatum'' (also called type 2 pectus excavatum, chondromanubrial deformity or Currarino–Silverman syndrome or pouter pigeon deformity), which produces a manubrial and upper sternal protrusion, particularly also at the sternal angle.<ref name=":0" /> Pectus arcuatum is often confused with a combination of pectus carinatum and pectus excavatum, but in pectus arcuatum the visual appearance is characterized by a protrusion of the costal cartilages and there is no depression of the sternum.
 
== Causes ==
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 growth spurt.<ref name=":1" /> 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 deformity 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.
 
In about 25% of cases of pectus carinatum, the patient has a family member with the condition.


== Diagnostic Procedures  ==
== Diagnostic Procedures  ==


Pectus deformities 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.
Diagnosis of pectus carinatum is made by visual inspection, with further details offered by lateral chest [[X-Rays|Xray]] or computed tomography ([[CT Scans|CT]]).<ref name=":0" />
 
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.
 
Most insurance companies no longer consider chest wall deformities like pectus carinatum to be purely cosmetic conditions. While the psychologic impact of any deformity 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.


== Management / Interventions  ==
== Management / Interventions  ==
[[File:Brace.png|thumb|External brace for treatment of Pectus Carinatum<ref>Shamberger RC, Welch KJ. Surgical correction of pectus carinatum. Journal of pediatric surgery. 1987 Jan 1;22(1):48-53.</ref>]]Treatment of pectus carinatum falls into three categories: non-surgical bracing, surgical correction, or cosmetic concealment.  Orthotic braces are the first option for treatment as acceptable results are often achievable.<ref name=":0" />


=== External bracing technique ===
'''External bracing technique'''
[[File:Brace.png|thumb|External brace for treatment of Pectus Carinatum<ref>Shamberger RC, Welch KJ. Surgical correction of pectus carinatum. Journal of pediatric surgery. 1987 Jan 1;22(1):48-53.</ref>]]
The use of orthotic bracing, pioneered by Sydney Haje as of 1977, is finding increasing acceptance as an alternative to surgery in select cases of pectus carinatum.<ref name=":2">Frey AS, Garcia VF, Brown RL, Inge TH, Ryckman FC, Cohen AP, Durrett G, Azizkhan RG. Nonoperative management of pectus carinatum. Journal of pediatric surgery. 2006 Jan 1;41(1):40-5.</ref> 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 orthodontics (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 deformity (mild moderate severe) and if it is symmetric or asymmetric.<ref>Kravarusic D, Dicken BJ, Dewar R, Harder J, Poncet P, Schneider M, Sigalet DL. The Calgary protocol for bracing of pectus carinatum: a preliminary report. Journal of pediatric surgery. 2006 May 1;41(5):923-6.</ref>
 
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.<ref name=":2" />
 
Bracing is becoming more popular over surgery for pectus carinatum, mostly because it eliminates the risks that accompany surgery.<ref>Lee SY, Lee SJ, Jeon CW, Lee CS, Lee KR. Effect of the compressive brace in pectus carinatum. European Journal of Cardio-Thoracic Surgery. 2008 Jul 1;34(1):146-9.</ref> 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] deformity, nonoperative compressive orthotic bracing is usually an appropriate first line of therapy as it does not preclude the operative option. For appropriate candidates, orthotic bracing of chest wall deformities can reasonably be expected to prevent worsening of the deformity and often results in a lasting correction of the deformity. Orthotic bracing is often successful in prepubertal children whose chest wall is compliant. Expert opinion suggests that the noncompliant chest wall deformity or significant asymmetry of the pectus carinatum deformity caused by a concomitant excavatum-type deformity may not respond to orthotic bracing."<ref name=":2" />
 
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.


=== Surgical ===
Braces are worn either under/over the patient’s clothing for between 14 and 24 hours per day, depending on the manufacturer and the severity of the chest wall protrusion.  Braces are most effective when applied before the patient’s growth spurt and less effective after age 19 due to changes in the flexibility of the chest wall. Unfortunately due to the lengthy treatment period (often months to years) and slow progression of the correction, many patients do not like this option.<ref name=":0" />
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.<ref>Robicsek F, Watts LT, Fokin AA. Surgical repair of pectus excavatum and carinatum. InSeminars in thoracic and cardiovascular surgery 2009 Mar 1 (Vol. 21, No. 1, pp. 64-75). WB Saunders.</ref>


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.<ref>Shamberger RC, Welch KJ. Surgical correction of pectus carinatum. Journal of pediatric surgery. 1987 Jan 1;22(1):48-53.</ref>
'''Surgical:''' 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 the patient is happy with the outcome and may not want surgery afterward.<ref>Robicsek F, Watts LT, Fokin AA. Surgical repair of pectus excavatum and carinatum. Semin Thorac Cardiovasc Surg. 2009;21(1):64-75. doi:10.1053/j.semtcvs.2009.03.002</ref>{{#ev:youtube|v=6iujiHWnQRE|400}}<ref>Maimonides Medical Center. Nuss Procedure for Pectus Excavatum. Available from:https://www.youtube.com/watch?v=6iujiHWnQRE [last accessed 27/8/2020]</ref>


A modified Ravitch technique uses bioabsorbable material and postoperative bracing, and in some cases a diced rib cartilage graft technique.
'''Other options:''' After adolescence, some men and women use bodybuilding as a means to hide their deformity. 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.


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 deformity is symmetrical.<ref>Fonkalsrud EW, Beanes S. Surgical management of pectus carinatom: 30 years’ experience. World journal of surgery. 2001 Jul 1;25(7):898-903.</ref><ref>Sigalet DL, Montgomery M, Harder J, Wong V, Kravarusic D, Alassiri A. Long term cardiopulmonary effects of closed repair of pectus excavatum. Pediatric surgery international. 2007 May 1;23(5):493-7.</ref>
=== Physiotherapy ===
[[File:Yoga DS.jpg|thumb|Yoga]]
Postural correction and strengthening chest and [[Back Muscles|back muscles]] may help with pectus excavatum as bad [[posture]] is implicated in the severity and prominence of the condition.


{{#ev:youtube|v=6iujiHWnQRE|400}}<ref>https://www.youtube.com/watch?v=6iujiHWnQRE</ref>
The aim of exercises in this condition is to:
# Loose and lengthen tight or contractured tissues.
# Improve chest wall and spinal mobility
# [[Strength Training|Strengthen muscles]] needed for chest expansion and elevation
# Restore and maintain normal posture
# Improve and maintain [[Lung Compliance|lung compliance]]
Exercises such as the use of dumbbells to strengthen the [[Latissimus Dorsi Muscle|latissimus dorsi]] and [[rhomboids]] using a pose termed dumbbell rear delt fly, [[Yoga]] poses such as superman (Lie on a mat with your stomach and arms extended and forehead resting on the ground, inhale then lift your head, legs, and arms, hold for 5seconds and then gently relax); seated twist (Sitting straight, engage your core and arms in forward flexion with/without weight in both hands, inhale and as you exhale, perform a lateral rotation to the right, hold for 5seconds and while inhaling relax; do for the other side and repeat for about 10 times); Bow pose for improved chest expansion and deep breathing (Lie on a mat with your stomach with knees flexed, grab your ankles with your hands then inhale and lift your thighs off the floor while your shoulder blades pressing back to open your chest and your gaze forward; hold the pose for 15 seconds and repeat 2 times); Camel pose (In upright kneeling with your shins and the dorsum of your feet pressed to the ground, your hands at the back of your pelvis, lean back, aiming to drop your hands to your heels with your head dropped back and without losing the upright kneeling posture; hold the pose for about 15 seconds and repeat twice)<ref>Bubnis D. Healthline; 2016. Exercises to treat pectus excarvatum and improve strength. Available from:https://www.healthline.com/health/fitness-exercise/pectus-excavatum-exercises (accessed 31 August 2020)</ref>


=== Other options ===
After adolescence, some men and women use bodybuilding as a means to hide their deformity. 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.
== References  ==
== References  ==


<references />
<references />


[[Category:Cardiopulmonary]]
[[Category:Conditions]]
[[Category:Cardiopulmonary]]
[[Category:Cardiopulmonary - Conditions]]
[[Category:Paediatrics]]
[[Category:Paediatrics - Conditions]]

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Introduction[edit | edit source]

Pectus Carinatum[1]

Pectus carinatum (pigeon chest) refers to a chest wall deformity in which the sternum protrudes anteriorly. It is less common than pectus excavatum. It affects nearly 1 in 1000 teens, and early identification allows for more noninvasive treatment options.[2]

Etiology[edit | edit source]

The precise etiology of pectus carinatum is unknown, however most consider both pectus carinatum and pectus excavatum to be due to defective elongated growth of the costal cartilage.  A genetic element is suggested by the significant portion of patients with a family history of a chest wall defect or deformity. In about 25% of cases of pectus carinatum, the patient has a family member with the condition.[2][3]

Pectus carinatum is generally a solitary, non-syndromic abnormality. However, the condition may be present in association with other syndromes: 

Clinical Presentation[edit | edit source]

Patients may present with dyspnoea and exercise intolerance. Some studies have shown an association with asthma or chronic bronchitis in up to 16.4% of patients.[2][3]

Diagnostic Procedures[edit | edit source]

Diagnosis of pectus carinatum is made by visual inspection, with further details offered by lateral chest Xray or computed tomography (CT).[2]

Management / Interventions[edit | edit source]

External brace for treatment of Pectus Carinatum[4]

Treatment of pectus carinatum falls into three categories: non-surgical bracing, surgical correction, or cosmetic concealment.  Orthotic braces are the first option for treatment as acceptable results are often achievable.[2]

External bracing technique

Braces are worn either under/over the patient’s clothing for between 14 and 24 hours per day, depending on the manufacturer and the severity of the chest wall protrusion.  Braces are most effective when applied before the patient’s growth spurt and less effective after age 19 due to changes in the flexibility of the chest wall. Unfortunately due to the lengthy treatment period (often months to years) and slow progression of the correction, many patients do not like this option.[2]

Surgical: 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 the patient is happy with the outcome and may not want surgery afterward.[5]

[6]

Other options: After adolescence, some men and women use bodybuilding as a means to hide their deformity. 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.

Physiotherapy[edit | edit source]

Yoga

Postural correction and strengthening chest and back muscles may help with pectus excavatum as bad posture is implicated in the severity and prominence of the condition.

The aim of exercises in this condition is to:

  1. Loose and lengthen tight or contractured tissues.
  2. Improve chest wall and spinal mobility
  3. Strengthen muscles needed for chest expansion and elevation
  4. Restore and maintain normal posture
  5. Improve and maintain lung compliance

Exercises such as the use of dumbbells to strengthen the latissimus dorsi and rhomboids using a pose termed dumbbell rear delt fly, Yoga poses such as superman (Lie on a mat with your stomach and arms extended and forehead resting on the ground, inhale then lift your head, legs, and arms, hold for 5seconds and then gently relax); seated twist (Sitting straight, engage your core and arms in forward flexion with/without weight in both hands, inhale and as you exhale, perform a lateral rotation to the right, hold for 5seconds and while inhaling relax; do for the other side and repeat for about 10 times); Bow pose for improved chest expansion and deep breathing (Lie on a mat with your stomach with knees flexed, grab your ankles with your hands then inhale and lift your thighs off the floor while your shoulder blades pressing back to open your chest and your gaze forward; hold the pose for 15 seconds and repeat 2 times); Camel pose (In upright kneeling with your shins and the dorsum of your feet pressed to the ground, your hands at the back of your pelvis, lean back, aiming to drop your hands to your heels with your head dropped back and without losing the upright kneeling posture; hold the pose for about 15 seconds and repeat twice)[7]

References[edit | edit source]

  1. ↑ Shamberger RC, Welch KJ. Surgical correction of pectus carinatum. Journal of pediatric surgery. 1987 Jan 1;22(1):48-53.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 McHam B, Winkler L. Pectus Carinatum (Pigeon Chest). Available:https://www.ncbi.nlm.nih.gov/books/NBK541121/ (accessed 27.9.2022)
  3. ↑ 3.0 3.1 3.2 Radiopedia Pectus Carinatum Available:https://radiopaedia.org/articles/pectus-carinatum (accessed 27.9.2022)
  4. ↑ Shamberger RC, Welch KJ. Surgical correction of pectus carinatum. Journal of pediatric surgery. 1987 Jan 1;22(1):48-53.
  5. ↑ Robicsek F, Watts LT, Fokin AA. Surgical repair of pectus excavatum and carinatum. Semin Thorac Cardiovasc Surg. 2009;21(1):64-75. doi:10.1053/j.semtcvs.2009.03.002
  6. ↑ Maimonides Medical Center. Nuss Procedure for Pectus Excavatum. Available from:https://www.youtube.com/watch?v=6iujiHWnQRE [last accessed 27/8/2020]
  7. ↑ Bubnis D. Healthline; 2016. Exercises to treat pectus excarvatum and improve strength. Available from:https://www.healthline.com/health/fitness-exercise/pectus-excavatum-exercises (accessed 31 August 2020)
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