The two most common chest wall problems that cause concern for children or their caregivers are pectus excavatum and pectus carinatum. Pectus excavatum is more common in boys and is caused by an abnormality of the cartilage that attaches the ribs to the sternum (or breastbone). The result is that the sternum is pushed backward, and so has a sunken appearance. Some patients are quite concerned by the appearance of the chest wall and will not participate in activities where other children may be able to see their chest. The initial assessment of the child with this abnormality is a complete history and physical with particular attention to the presence of heart murmurs since these may be due to compression of the heart by the sternum. Patients then undergo a CT scan of the chest, echocardiogram, and pulmonary function tests. The CT scan allows for the development of a measure of the severity of the condition. The echocardiogram and pulmonary function tests are done to see if the chest wall is compressing the heart or lungs. Surgical correction may be necessary if there is evidence that the condition is affecting the heart or lungs and if it is causing social or psychological distress for the patient. Surgical correction is recommended for patients when they become teenagers because the skeleton is more mature, and they can more readily participate in the decision-making process. Current surgical correction involves positioning metal bars under the sternum using thoracoscopic guidance. Most patients will have considerable pain after the procedure since the shape of the skeleton is rapidly changed although this has been improved using recently developed protocols and pain relief techniques. Finally, the bars must be removed after approximately two years, and the depression of the chest wall may recur although this is less likely in adolescents.
Pectus carinatum is the other common chest wall abnormality, and the abnormal growth of the cartilage attaching the ribs to the sternum are also thought to be the cause of this condition. The final appearance is marked by the protruding of the sternum forward. There are instances where this condition is treated with the surgical excision of the cartilage. However, most of these children can be treated with bracing, which works on the cartilage as it does on teeth. The brace applies steady pressure to the sternum that results in a gradual reduction of the protrusion. There is an advantage to having the brace created by a company that has experience with this specific problem and convincing the child to wear it for eight hours a day for six months can be a considerable challenge.
The appearance of chest wall deformities can cause families and children considerable distress and there are instances where pectus excavatum can cause physical changes that limit the ability of the child to play and participate in sports. Whatever the concern, it is advisable to discuss whether or not the condition should be treated with your pediatrician. It may be that the deformity can just be observed or treated without surgery. Surgical therapy is still a big step, has improved considerably in the last few years, and can result in substantial improvements with a much shorter recovery period than was the case only a few years ago.
