Chest Wall Disorder: Pectus Carinatum (for Parents)

en español: Trastorno de la pared torácica: Pectus carinatum

Reviewed by: Adela T. Casas-Melley, MD

Chest Wall Disorders Program at Nemours Children’s Health

What Is Pectus Carinatum?

Pectus carinatum is when the ribs and the breastbone (sternum) grow outward and make the chest jut out. This gives the chest a birdlike appearance. That’s why the condition is sometimes called pigeon breast or pigeon chest.

What Causes Pectus Carinatum?

Doctors don’t know exactly what causes pectus carinatum (PEK-tus kair-ih-NOT-um). In some cases, it runs in families.

Kids who have it may have another health condition, such as:

• scoliosis
• Down syndrome
• Edwards
  syndrome, which causes babies to have poor growth, congenital defects, and slowed development
• Marfan syndrome
• homocystinuria, a disorder that involves a problem with an amino acid that the body uses to make protein and build tissues
• Morquio syndrome
• osteogenesis imperfecta (brittle bone disease)

What Are the Signs & Symptoms of Pectus Carinatum?

Kids with pectus carinatum have a chest that juts out. This usually doesn’t appear until a child is age 11 or older.

The chest wall surrounds and protects the heart and lungs. So kids and teens with pectus carinatum may:

• feel short of breath, especially during exercise
• have a fast heartbeat
• feel tired
• have chest pain

Some can develop asthma or get a lot of respiratory infections.

Pectus carinatum can affect one side of the chest more than the other. Sometimes, kids have pectus carinatum on one side of the chest, and a different chest wall disorder — pectus excavatum — on the other side. Pectus excavatum makes the chest look sunken.

The condition gets worse as kids grow, and affects boys more often than girls.

How Is Pectus Carinatum Diagnosed?

Health care providers diagnose pectus carinatum based on an exam. If needed, they might also order tests such as:

• chest X-ray to check the severity of the condition
• imaging scans like computed tomography (CT) or magnetic resonance imaging (MRI)
• electrocardiogram to see how the heart is working
• pulmonary function tests to check the lungs
• genetic testing to look for related syndromes

How Is Pectus Carinatum Treated?

Kids and teens with mild pectus carinatum who aren’t bothered by their appearance and don’t have breathing problems typically don’t need treatment.

If treatment is needed, a chest brace or surgery can help.

Kids whose bones are still growing can wear a chest brace. Much like how braces realign teeth, a chest brace will push the breastbone back to a normal position. Kids need to wear a brace for 6 months to a year. They can remove it for sports, showering, and other activities, but usually must wear it for 8 hours a day or longer.

In some cases, surgery can treat pectus carinatum. In the Ravitch procedure, a surgeon:

• repairs or reshapes the sternum (breastbone)
• places a bar (or bars) in the chest wall to hold it in the proper position

The surgeon removes the bar in a later surgery, usually after about 6 months. The Ravitch procedure is most often used for patients 13 to 22 years old.

Doctors also might recommend physical therapy and exercises to strengthen weak chest muscles.

What Else Should I Know?

Mild pectus carinatum won’t need treatment if doesn’t affect how the lungs or heart work. But when the condition is very noticeable, it can affect a person’s self-image. Severe pectus carinatum can make it hard to exercise or play sports, and cause other health problems. In those cases, treatment can improve a child’s emotional and physical well-being.

Most kids and teens who wear a brace or have surgery do very well and are happy with the results.

Reviewed by: Adela T. Casas-Melley, MD

Date reviewed: May 2023

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Uneven Rib Cage: Causes & Treatments

Uneven rib cage

An uneven rib cage can be the result of trauma, a birth defect, or another condition. If your rib cage is only slightly uneven, you may be able to improve your condition with repeated stretching and exercise.

More serious cases of rib cage unevenness may need to be fixed surgically. Sometimes a custom brace can correct your rib cage. Learn more about the potential causes of your uneven rib cage and what exercises may help.

An uneven rib cage can cause problems with your breathing, posture and possibly your body confidence. Some causes of an uneven rib cage include:

Trauma

If you’ve had a trauma to your ribs such as a break or sprain, you may have an uneven rib cage. If time has passed since the incident, your ribs may require surgery to regain symmetry. If your injury occurred a short time ago, consider talking to a medical specialist to assess your rib injuries and promote symmetrical healing.

Birth defects

If you’ve had an uneven rib cage from birth, it may be from a birth defect. You may be missing a rib or your rib cage may be naturally flared. If your rib cage is causing you distress or pain, you should speak to your doctor.

Rib cartilage deformities

Deformities such as pectus carinatum and pectus excavatum affect roughly 1 in 1,500 children. These deformities cause the chest to bow outwards or inwards. Many cases of rib deformities are corrected with a brace, but some may require surgery.

Muscle weakness

If your rib cage is slightly uneven or protruding, it may be due to a muscle weakness. Your abdominal muscles play a large role in holding your rib cage in place. If your muscles on one side of your body are weaker, it may be causing one side of your rib cage to stick out or sit unevenly.

Scoliosis

If you have scoliosis, you may also have uneven ribs. Due to your spine’s abnormal curve, other parts of your body may adjust to accommodate the curvature.

In cases of slightly uneven ribs, your doctor or physician may suggest exercises to help your muscles hold your rib cage in place.

Strengthening your back and abdominal muscles can help align your rib cage and improve breathing. If your uneven side is weaker, adding extra exercise repetitions to your weaker side can help you build a more even appearance.

Some recommended exercises often include:

• yoga for posture
• abdominal crunches
• ab rollouts
• breathing exercises
• pectoral lifts

Your doctor or physical therapist may have more exercises to help your rib cage appear straighter. Consult your doctor before beginning any new workout. Make sure you’re performing the exercises correctly to ensure you don’t injure yourself.

If your rib cage is slightly uneven and not causing any serious health concerns, your doctor may suggest exercises or physical therapy to correct the issue. If the unevenness is severe, you may need surgery or a corrective brace.

If your uneven rib cage is due to serious trauma, contact a medical professional immediately.

Chest deformity – health articles

11/10/2022

Chest deformities in children – congenital or early acquired curvature of the sternum and ribs articulating with it. Chest deformities in children are manifested by a visible cosmetic defect, disorders of the respiratory and cardiovascular systems (shortness of breath, frequent respiratory diseases, fatigue).

Causes

Most chest deformities in children are genetic. In other words, there is already a program in the genes that triggers the wrong growth and development of chest cartilage. Quite often, parents tend to blame themselves for the appearance of any deformities in the baby. But, for the most part, chest deformity is a genetic congenital defect, which, fortunately, can be corrected.

If the deformity is congenital, then in such situations the shape of the anterior part of the chest is changed. Such violations are accompanied by underdevelopment of the ribs or their absence, underdevelopment of the muscles and sternum.

The causes of acquired deformities include various diseases (rickets, scoliosis, chronic lung diseases, bone tuberculosis), injuries, burns that occur in the chest area.

When the formation of bone structures is disturbed, the most severe forms of deformities can occur.

Symptoms

External changes. In most cases (92% of all congenital deformities), children have a funnel-shaped pathology of the sternum, which is characterized by inadequate development of the costal cartilages, resulting in a depression in the lower or middle zone of the chest. The sternum is considerably enlarged in the transverse direction.

As the child’s body grows and develops, the disease becomes more pronounced. As the ribs grow, the chest cavity clearly decreases, which, in turn, irreversibly leads to a curvature of the spine and disruption of the cardiovascular system and lungs.

In newborn babies, this pathology has a mild character and becomes more pronounced at the age of three. When inhaling, periodic retraction of the ribs is noted, and paradoxical breathing intensifies, which leads to the development of respiratory failure.

Compared to their peers, children lag behind in their physical development, are prone to colds and vegetative disorders, and get tired quickly when playing sports or physical activity.

In case of deformation of the upper or middle part of the chest, a navicular depression is noted, in which motor functions may be impaired.

Diagnostics

The development of deformity is easily determined by a specialist in many external signs.

Instrumental diagnostics includes methods such as radiography, which allows you to identify the type of pathology and the degree of its development.

Computed tomography reveals bone defects, compression of the lungs, mediastinal displacement, and the degree of development of the disease.

And with the help of magnetic resonance imaging, extensive information can be obtained regarding abnormalities in soft and bone tissues.

If there is a suspicion of a violation in the functioning of the lungs and heart, then echocardiography, cardiac monitoring by the Holter method, x-ray of the lungs and other studies are performed.

Treatment

Treatment of chest deformity in a child is carried out under the strict supervision of an orthopedist. The keeled pathology of the sternum does not require specific therapy, since it does not interfere with the full functioning of the internal organs. In this case, children may experience only slight fatigue and shortness of breath. The defect is easily eliminated by thoracoplasty.

Conservative therapy for sunken chest. The course of treatment depends entirely on the degree of retraction of the sternum. Grade 1 and 2 require therapeutic exercises, with the emphasis on the sternum: the patient learns to do push-ups, spread the dumbbells to the sides, and pull themselves up. Also, the child is shown to engage in sports such as rowing and volleyball – the loads resulting from these exercises prevent further retraction of the sternum. The result is a quality massage.

In severe cases, a surgical operation is prescribed, but it can be performed no earlier than the child reaches 7 years of age. The fact is that at this age the pathology ceases to form. During the operation, the doctor makes an incision in the child’s chest and inserts a magnetic plate there. After the operation, a special belt with a magnet is put on the outside of the chest. They begin to attract each other, a gradual healing effect occurs – usually a sunken chest changes after 2 years of wearing magnetic plates.

If the chest defect is caused by heredity, then initially the child is examined for possible pathologies that could cause this deformity, and then treatment is carried out – conservative or surgical, depending on the underlying cause of the disease.

Keeled chest. What is a keeled chest?

IMPORTANT
The information in this section should not be used for self-diagnosis or self-treatment. In case of pain or other exacerbation of the disease, only the attending physician should prescribe diagnostic tests. For diagnosis and proper treatment, you should contact your doctor.

Keeled chest is a pathology in which the front of the chest protrudes, acquiring the shape of a boat keel. It is a congenital anomaly, inherited, manifests itself as the patient grows. It is manifested by a visible deformation of the anterior part of the chest (ribs and sternum). By itself, it does not adversely affect the functioning of internal organs, but it may be accompanied by a narrowing of the chest. To clarify the diagnosis, determine the type and degree of deformity, radiography and CT are performed. Conservative treatment is ineffective. To eliminate a cosmetic defect, surgical operations are performed.

ICD-10

Q67.7 Keeled chest

• Causes
• Pathogenesis
• Classification
• Symptoms
• Diagnostics
• Treatment of keeled chest
• Prices for treatment

General

Keeled chest (keeled chest deformity, chicken breast, KHDK) is the second most common congenital deformity of the chest after funnel chest. It makes up about 7% of the total number of violations of the shape of the anterior chest wall. Men are affected 4 times more often than women. In 26%, a hereditary predisposition is revealed, in 15% there is a combination with Marfan’s syndrome, congenital heart defects, scoliosis and other connective tissue diseases. Treatment of keeled deformity of the chest is carried out by thoracic surgeons, and in small settlements that do not have thoracic centers – traumatologists and orthopedists.

Keeled chest

Causes

Keeled chest is a hereditary congenital malformation. In some cases, the joint inheritance of the keeled and funnel chest is revealed, so some researchers suggest a common nature and mechanism for the development of these anomalies. In addition, the relationship between the presence of CDGC, the physique of patients and the state of their connective tissue has been reliably established. In most cases, patients with keeled chest deformity are tall and asthenic.

In some patients, chest pathology is combined with Marfan syndrome, a systemic disease caused by connective tissue pathology and including dolichostenomyelia (tall growth), arachnodactyly (elongated spider fingers), underdevelopment of fatty tissue, joint hypermobility, disorders of the cardiovascular system and organs of vision. It is also possible to combine with congenital heart defects and scoliotic deformity of the spine.

Pathogenesis

At the birth of a child, the anomaly of the chest is usually subtle, but as it grows, the deformity progresses, and over time, a cosmetic defect is formed, the severity of which can vary greatly. Functional disorders of the respiratory and circulatory organs in the first years of life are not expressed. Some older children complain of shortness of breath, fatigue and palpitations during intense physical exertion. At the same time, objective disorders can be detected: an increase in the minute volume of breathing, a decrease in the oxygen consumption coefficient and vital capacity of the lungs.

The listed violations, as a rule, are caused not by the deformation itself, but by the accompanying features (asthenic body type, narrowed chest, congenital heart defects). Currently, most experts believe that the keeled chest itself does not entail negative consequences in the form of disruption of the heart and lungs and is a purely cosmetic defect.

Classification

There are a large number of classifications of KDGK, but the most complete and practically significant is the version of Fokin and Bairov:

• Costal type. The curvature of the sternum is absent or mild and has a rotational character. The deformity is formed by bending the costal cartilages anteriorly.
• Manubriocostal type. The handle of the sternum, together with 2-3 articulating costal cartilages, is curved anteriorly, and the body of the sternum with the xiphoid process is displaced posteriorly.
• Corpocostal type. There are two options. First – the sternum is arched forward in the lower and middle third, the costal cartilages are curved inwards. The second – the sternum is directed obliquely forward and downward and protrudes as much as possible in the lower third.

Both symmetric and asymmetric deformation can be observed. In the second case, due to the incorrect development of the ribs, the sternum is curved along the axis.

Symptoms

The shape of the chest is broken due to the protruding sternum, the front of the chest will stand forward. In most patients, the cartilaginous parts of the IV-VIII ribs sink down on one or both sides. Usually a characteristic turn of the edges of the costal arches is revealed. The chest is significantly enlarged in the anteroposterior direction, changes in the anteroposterior size during respiratory excursions are reduced compared to the norm or are practically absent. From the side it looks as if the chest is constantly in a state of inhalation.

Diagnostics

The diagnosis is made by a thoracic surgeon based on the examination data; to clarify the type of deformity and the severity of the changes, a chest x-ray in a lateral projection and computed tomography are prescribed. If a pathology of the heart and lungs is suspected, the necessary studies are carried out: spirography, ECG, Echo-KG, etc., consultations with a cardiologist and pulmonologist are prescribed. With Marfan’s syndrome, a comprehensive examination is indicated, which includes consultations with an orthopedist, cardiologist, pulmonologist, ophthalmologist and neurologist.

Treatment of keeled chest

Among people far from medicine, it is widely believed that keeled chest deformity can be corrected with the help of physiotherapy exercises, breathing exercises and physical exercises. Unfortunately, experts are of a different opinion – it is possible to restore the normal shape of the chest only using surgical techniques. All other methods only improve the physical form of the patient (which is also important, especially with severe asthenia, the presence of connective tissue diseases and the pathology of the cardiovascular system).

Based on the foregoing, and also from the fact that the keeled chest is for the most part a purely cosmetic defect, it is clear that the optimal result in the treatment of this pathology can be achieved only by determining the priorities that are most important for a particular patient. With the same type and degree of deformity, for one patient it will be more important to restore a normal psychological background and self-esteem by performing an operation, for another – to improve the general condition of the body by prescribing a course of exercise therapy and restorative treatment.

Since, unlike funnel-shaped, keeled deformity of the chest does not have a clear negative effect on the functioning of the patient’s organs and systems, the only indication for surgical correction is the patient’s urgent need to eliminate a cosmetic defect. At the same time, doctors recommend resorting to surgical treatment only in extreme cases. There are two main surgical methods for the treatment of keeled breasts: a minimally invasive intervention according to the Abramson method and an open access operation according to the Mark Ravic method.

During Ravich surgery, the doctor performs a transverse incision under the mammary glands / pectoral muscles and cuts off the pectoral muscles and rectus abdominis muscles from the attachment sites. Then the costal cartilage is resected and the remaining perichondrium is sutured, reducing the intercostal spaces and bringing the sternum into a physiological position. With severe deformity, a wedge-shaped sternotomy is additionally performed.

Rarely used are open surgical interventions according to the Kondrashin method (transverse sternotomy with resection of the deformity and relocation of the ribs), as well as metallosternochondroplasty according to Timoshchenko. Currently, along with the listed traditional methods, the minimally invasive Abramson operation is becoming increasingly popular. When using this technique, the doctor makes two incisions 3-4 cm long on the sides, hems the plates to the ribs and attaches another one to these plates – straightening. Metal structures are removed after a few years, after complete correction of the keeled deformity and reshaping of the chest.

If there are contraindications to surgery, as well as in cases where the patient is dissatisfied with the appearance of his chest, but does not agree to the listed surgical interventions, methods are offered to correct the aesthetic perception of the body without correcting the shape of the chest. Men are recommended to pump up the pectoral muscles, and women are recommended to install silicone implants of the mammary glands. This does not eliminate the deformation, but makes it less noticeable.

In recent years, a number of domestic thoracic surgeons offer patients non-surgical correction using the Ferre compression system. This technique can only be used at an early age, when the bones and cartilage are still quite flexible, and involves wearing a special apparatus.

It should be noted that this system has not yet been certified in Russia, and devices have to be ordered abroad. Another disadvantage of this method is the need to wear the apparatus for several years. Children are quite difficult to tolerate the procedure, and only half of the patients “reach” the completion of the course of treatment. In addition, due to prolonged pressure, the skin in the sternum area can become thinner and become overly pigmented.

You can share your medical history, what helped you in the treatment of keeled chest.