What is the recommended treatment for an 11-year-old female patient with pectus carinatum?

Treatment of Pectus Carinatum in an 11-Year-Old Female

Orthotic bracing is the first-line treatment for an 11-year-old female with pectus carinatum, as this age represents an ideal window for non-surgical correction with excellent outcomes. 1, 2, 3

Initial Management Approach

Specialist Referral

• Refer immediately to a pediatric surgeon, as the American Academy of Pediatrics recommends that all patients 5 years or younger requiring surgical care must be cared for by a pediatric surgeon, and for children older than 5 years, the decision depends on complexity of the surgical condition. 4
• Pectus carinatum falls under the scope of pediatric general surgery, making a pediatric surgeon the appropriate specialist for evaluation and management. 4
• If a pediatric surgeon is not locally available, contact a pediatric surgeon at a regional pediatric surgical center to discuss whether consultation is necessary, as outcomes are significantly better when children are operated on by surgeons who preferentially treat pediatric patients. 4

Evaluation by Specialist

• The pediatric surgeon will assess the severity and type of deformity (symmetric, asymmetric, or mixed), as this determines treatment approach. 5
• Screen for associated conditions including Marfan syndrome, scoliosis (present in 23% of cases), and other musculoskeletal abnormalities, as these occur in approximately 34% of patients with pectus carinatum. 6, 5
• Evaluate psychosocial impact, as children with pectus carinatum have documented disturbed body image and reduced quality of life that improves with treatment. 2

Treatment Algorithm

First-Line: Orthotic Bracing

• Orthotic bracing should be the initial treatment for this 11-year-old patient, as a growing body of literature supports its use as a nonoperative alternative in select patients. 2, 3
• Age 11 is within the optimal window for bracing, as the chest wall remains sufficiently flexible for non-surgical correction. 1, 3
• Bracing protocols have demonstrated reasonable results in appropriately selected patients with pectus carinatum. 1

Indications for Surgical Correction

• Surgery is reserved for patients who fail bracing, have severe rigid deformities not amenable to bracing, or present after skeletal maturity when bracing is less effective. 3
• Surgical options include the traditional Ravitch technique (bilateral resection of third through seventh costal cartilages with sternal osteotomy) or minimally invasive approaches. 5, 3
• Surgical correction has a low complication rate (3.9%) and provides satisfactory results in essentially all patients. 5

Critical Pitfalls to Avoid

• Do not delay referral, as earlier intervention with bracing during the growth period provides better outcomes than waiting until skeletal maturity. 2, 3
• Do not dismiss the psychosocial impact, as recent evidence confirms that children with pectus carinatum have disturbed body image and reduced quality of life that warrants treatment. 2
• Do not refer to a general surgeon without pediatric training, as outcomes are significantly better when children are operated on by surgeons who preferentially treat pediatric patients. 4
• Do not assume surgery is the only option, as historical undertreatment of pectus carinatum was partly due to lack of awareness about effective non-surgical bracing protocols. 2

Expected Outcomes

• Treatment (whether bracing or surgery) has been shown to improve psychosocial outcomes in these patients. 2
• Surgical correction, when needed, provides satisfactory cosmetic results with minimal complications. 5
• The key is early specialist evaluation to determine the optimal treatment approach based on deformity characteristics, patient age, and flexibility of the chest wall. 3