Referral for Pectus Abnormalities
Patients with pectus abnormalities should be referred to a pediatric orthopedist at the time of diagnosis, with subsequent consideration for cardiothoracic surgery or plastic surgery depending on the severity and type of deformity. 1
Primary Referral Pathway
Initial Specialist Referral
- Refer to a pediatric orthopedist at diagnosis for all patients with pectus deformities (excavatum, carinatum, or mixed), as this specialist manages the musculoskeletal aspects and coordinates further care 1
- The orthopedist will assess for associated conditions including scoliosis, joint contractures, hip dysplasia, and other skeletal abnormalities that commonly accompany pectus deformities 1
Surgical Specialist Referral
- Cardiothoracic surgeons are the guideline-recommended specialists for surgical correction of pectus abnormalities, particularly for moderate to severe cases requiring procedures like the Nuss procedure (minimally invasive repair) or Ravitch procedure 2
- Plastic surgeons may be appropriate for mild cosmetic cases or when considering pectus implants and aesthetic correction techniques 2, 3
Assessment Considerations Before Referral
Physiological Impact Evaluation
- Obtain baseline imaging to assess cardiac compression, particularly right ventricular compression which can cause dyspnea and chest pain with exertion 4
- Consider echocardiography to evaluate for extrinsic compression of the right ventricle, using modified apical four-chamber views to visualize compression through the abnormal anterior chest wall 4
- MRI using rapid 2-D FIESTA acquisition can measure the Haller index (severity metric) without radiation exposure, making it preferable to CT scanning in pediatric patients 5
Psychological Impact Assessment
- Evaluate for psychological harm including low self-esteem, depression, and social withdrawal from activities like swimming or dating, as these effects occur during crucial developmental periods 2
- Recognize that psychological impact does not correlate directly with deformity severity—even mild defects can cause significant distress 2, 6
Timing and Urgency of Referral
- Non-urgent referral is appropriate for most cases, as the majority of pectus defects are mild and well-tolerated 2
- Urgent referral is warranted when there is evidence of cardiopulmonary impairment (symptoms at rest, life-threatening compression of major vessels or organs) 2
- Radiographic assessment should include thoracolumbar spine imaging and lateral cervical spine films depending on clinical findings 1
Common Pitfalls to Avoid
- Do not assume that mild-appearing deformities lack clinical significance—psychological impact can be severe regardless of physical severity 2, 6
- Avoid delaying orthopedic referral even when the deformity appears purely cosmetic, as associated skeletal abnormalities require monitoring 1
- Do not rely solely on physical examination to determine physiological impact—imaging is essential to assess cardiac compression 4
- For patients with genetic syndromes (Marfan syndrome, cardio-facio-cutaneous syndrome), coordinate care with genetics and cardiology, as pectus deformities are part of broader systemic involvement 1