What is the treatment for pectus carinatum (Pigeon chest)?

Treatment for Pectus Carinatum (Pigeon Chest)

External bracing is the first-line treatment for pectus carinatum in most patients, with surgical correction reserved for cases that are rigid, severe, or unresponsive to bracing therapy.

Diagnosis and Evaluation

• Pectus carinatum is characterized by an anterior protrusion of the sternum and adjacent costal cartilages
• Often becomes more noticeable during adolescent growth spurts
• May be associated with:
  • Other skeletal abnormalities
  • Connective tissue disorders like Marfan syndrome 1
  • Psychological impact affecting quality of life

Initial Assessment Should Include:

• Evaluation of chest wall flexibility (compressibility of the protrusion)
• Assessment for associated conditions:
  • Marfan syndrome features (using systemic scoring) 1
  • Scoliosis or other skeletal abnormalities
  • Cardiopulmonary symptoms

Treatment Algorithm

1. External Bracing (First-Line Treatment)

• Indications:

  • Flexible chest wall deformities
  • Patients in active growth phase (typically adolescents)
  • Mild to moderate deformities 2, 3

• Protocol:

  • Custom-fitted external compression brace
  • Initial wearing period: 20-23 hours daily until correction achieved
  • Maintenance phase: 8-12 hours daily (typically nighttime wear)
  • Duration: Usually 6-12 months depending on severity and compliance

• Advantages:

  • Non-invasive
  • High success rates (57% of Canadian surgeons report good to excellent results) 3
  • Avoids surgical complications
  • Lower cost than surgery

2. Surgical Correction

• Indications:

  • Rigid chest wall not amenable to bracing
  • Failed bracing therapy after adequate trial
  • Severe deformities causing cardiopulmonary compromise
  • Significant psychological distress affecting quality of life
  • Older patients with completed skeletal growth 4, 2

• Surgical Options:

  1. Minimally Invasive Techniques:

     • Intrathoracic compression using metal bar placement
     • Bar remains implanted for approximately 1 year 4
     • Less invasive than traditional open techniques
     • Maintains chest contour after bar removal

  2. Ravitch Procedure:

     • Traditional open surgical approach
     • Involves resection of abnormal costal cartilages
     • Sternal osteotomy may be required
     • More invasive but may be necessary for severe or rigid deformities 2, 5

  3. Reverse Nuss Procedure:

     • Minimally invasive option for select cases
     • Less commonly used (only 3% of Canadian surgeons reported using this technique) 3

Special Considerations

Timing of Treatment

• Optimal timing is during adolescent growth spurt when the chest wall is most malleable
• Bracing is most effective when started early, before complete ossification of costal cartilages

Associated Conditions

• If pectus carinatum is associated with Marfan syndrome:
  • Cardiovascular evaluation takes precedence over pectus repair 6
  • Delay pectus repair if aortic root dilation is approaching surgical thresholds (≥4.5 cm) 6
  • Regular echocardiographic monitoring is essential

Psychological Impact

• The visible deformity can significantly impact body image and self-esteem
• Treatment decisions should consider psychological effects, particularly in adolescents

Follow-up and Monitoring

• Regular follow-up during bracing treatment to assess:
  • Compliance with brace wear
  • Progress of correction
  • Skin irritation or other complications
• Post-surgical follow-up to monitor for:
  • Recurrence of deformity
  • Hardware complications if bars were placed
  • Wound healing

Treatment Success Rates

• External bracing: 65-80% success rate with good compliance
• Surgical correction: >90% good to excellent results with appropriate patient selection
• Canadian survey data shows 69% of pediatric surgeons prefer bracing as first-line treatment, with 57% reporting good to excellent results 3