Treatment Approach for Pectus Carinatum
Bracing therapy is the first-line treatment for pectus carinatum and should be initiated early in adolescence before skeletal maturity for optimal outcomes. 1, 2
Understanding Pectus Carinatum
Pectus carinatum (pigeon chest) is a chest wall deformity characterized by an outward protrusion of the sternum and adjacent costal cartilages. Unlike pectus excavatum (funnel chest), which involves depression of the sternum, pectus carinatum presents as an anterior protrusion.
Types of Pectus Deformities
- Pectus carinatum: Outward protrusion of the sternum
- Pectus excavatum: Inward depression of the sternum
- Pectus arcuatum: Unique form caused by premature obliteration of sternal sutures 3
Diagnostic Evaluation
- Physical examination: Assessment of protrusion severity, chest wall flexibility, and associated skeletal abnormalities
- Imaging:
- Chest radiography (PA and lateral views) to evaluate the degree of protrusion
- CT scan may be used in complex cases or when planning surgical intervention
- MRI provides better characterization of chest wall abnormalities with improved soft-tissue contrast 4
Treatment Algorithm
1. Non-surgical Management (First-line)
Dynamic Compression Bracing:
- Indication: Flexible chest walls in patients who have not reached skeletal maturity (ideally Tanner stage ≤III) 1
- Protocol (Calgary Protocol):
- Correction phase: Continuous brace wear until defect is corrected (typically 4-8 months)
- Maintenance phase: Nighttime wear (8 hours/day) until completion of axial growth 1
- Expected outcomes:
2. Surgical Management
Indications for surgery:
- Failed bracing therapy due to non-compliance or non-response
- Rigid chest wall deformity not amenable to bracing
- Severe psychological distress affecting quality of life
- Cardiopulmonary compromise (rare in pectus carinatum)
Surgical options:
- Ravitch procedure: Open surgical correction involving resection of abnormal costal cartilages and sternal osteotomy
- Minimally invasive techniques: Modified approaches with smaller incisions
Special Considerations
Pectus Arcuatum
- Distinguished from pectus carinatum by premature obliteration of sternal sutures
- Important: Bracing is ineffective for pectus arcuatum 3
- Surgical correction with sternotomy and partial chondro-costal resection is the only effective treatment
Associated Conditions
- Screen for connective tissue disorders (Marfan syndrome, Noonan syndrome)
- Evaluate for scoliosis and other skeletal abnormalities
- Consider echocardiogram if associated with connective tissue disorders 5
Factors Affecting Treatment Success
- Age: Better outcomes in younger patients before skeletal maturity
- Compliance: Direct correlation between daily brace-wearing time and treatment success 2
- Chest wall flexibility: More flexible chest walls respond better to bracing
- Severity of deformity: Extreme protrusions may require longer treatment or surgical intervention
Treatment Pitfalls to Avoid
- Delayed treatment: Starting treatment after skeletal maturity significantly reduces bracing effectiveness
- Inadequate brace-wearing time: Less than 14 hours daily wear correlates with poor outcomes 2
- Premature discontinuation: Stopping maintenance phase before skeletal maturity can lead to recurrence 1
- Misdiagnosis of pectus arcuatum: Attempting bracing for pectus arcuatum is ineffective and wastes time 3
- Neglecting psychological impact: The deformity can cause significant psychological distress that should be addressed alongside physical treatment
By following this treatment algorithm and addressing both the physical and psychological aspects of pectus carinatum, most patients can achieve excellent cosmetic and functional outcomes with appropriate treatment.