Introduction

Pectus carinatum is a chest wall disorder characterised by an outward-shaped sternum  (breastbone) and ribs. This condition results in an abnormal chest shape, with the sternum pushing forward, giving the chest a protruding or "pigeon-like" appearance; pectus carinatum is also known as “pigeon chest”. This condition commonly affects boys more than girls and may occur in approximately 1 out of 1,000 children, with evidence showing worsening during puberty.¹ Apart from the appearance of the chest, most kids do not have any symptoms, however, children may find this psychologically challenging due to them not liking how their chest looks.

Diagnosis and treatment of pectus carinatum are essential for addressing both physical and emotional aspects of the condition. Early identification and intervention can help prevent complications and improve long-term outcomes for patients.

In this article, we will explore various aspects of pectus carinatum, including its diagnosis, treatment options, and post-treatment care. This article aims to equip our readers with the knowledge they need to understand about pectus carinatum.

Diagnosis of pectus carinatum

Diagnosing pectus carinatum typically involves a comprehensive evaluation by a healthcare professional to assess the severity of the chest wall deformity and its impact on respiratory function and overall health.

Medical history and physical examination

The initial step in diagnosing pectus carinatum involves obtaining a thorough and detailed medical history. They may also further investigate and assess for any associated symptoms such as respiratory difficulties or exercise intolerance. It is crucial to identify any underlying conditions or factors that may contribute to the development of pectus carinatum. Healthcare professionals may particularly focus on the following information to diagnose pectus carinatum and possible syndromes, and genetic testing may also apply. The following questions may be asked concerning this condition:

• When was the onset and progression of symptoms?
• Is there any family history of chest wall deformities?
• Have you had any previous treatments or surgeries?

Another important assessment that follows the medical history is the physical examination.  During this, the healthcare provider will visually inspect the appearance of the chest wall, have a feel around your chest wall, listen to your chest and assess movements and sensations for pain.^{1, 2, 3}

Imaging studies

Imaging studies such as X-rays, CT and magnetic resonance imaging (MRI) scans play an important role in identifying orthopaedic conditions. These technologies are commonly used to visualise the chest wall structures and confirm the diagnosis of pectus carinatum.³ X-rays provide two-dimensional images of the chest, allowing healthcare providers to inspect abnormal curvature of the sternum and ribs. CT or MRI scans offer more precise images and can help identify the severity of deformity and any associated abnormalities. Imaging studies consistently are required during assessment in monitoring and managing disease progression.  

Pulmonary function tests

Pectus carinatum rarely causes any serious or dangerous respiratory problems.⁴ But in some cases, Pulmonary Function Tests (PFTs) may be warranted to assess lung function and respiratory capacity in individuals with pectus carinatum.⁵ These tests measure parameters such as lung volume, airflow, and gas exchange to evaluate the impact of the chest wall deformity on respiratory function. PFTs can help determine the need for intervention and guide treatment decisions.

Differential diagnosis

During the diagnostic process, healthcare providers will consider other conditions that may present with similar clinical features to pectus carinatum, such as scoliosis, Marfan syndrome, pectus excavatum (sunken chest), or other skeletal disorders.⁶ Differential diagnosis approach contributes to a more accurate final diagnosis and identifies possible complications, guiding appropriate treatment decisions and optimising patient outcomes.

By conducting a comprehensive physical evaluation, healthcare professionals can accurately diagnose the severity of the condition and develop a personalised treatment plan tailored to the needs of each patient. In the following section, we will explore various treatment options available for managing pectus carinatum and improving patient outcomes.

Treatment options for pectus carinatum

Pectus carinatum is not a life-threatening disease and hardly causes any serious physical problems, for most mild cases no need for further treatment. Usually, if the appearance of this condition causes significant emotional distress, treatment may be offered for cosmetic reasons.¹ There are two main treatment options to address the chest wall deformity and associated symptoms: bracing or surgery. The choice of treatment depends on factors such as the severity of the condition, the patient's age, and individual preferences.

Non-surgical treatment

Non-surgical approaches are often recommended as the initial management strategy for moderate to severe cases of pectus carinatum.

Bracing 

Orthotic bracing is suitable for young children and adolescents, as their chest bones are still soft and flexible, wearing customised bracing can help to reshape and improve the protruding sternum and rib features. This involves the use of custom-made chest braces based on the measurement parameters and the shape of the chest. Orthotic devices allow pressures to apply to the protruding breastbone and cartilage, gradually reshaping the chest wall over time.¹

Bracing is typically worn for several hours (8 to 12 hours) each day and when sleeping overnight. The treatment process may vary depending on the severity of the deformity and the patient's response.² Lack of adherence or insufficient time of wearing may result in inefficacy to the treatment.

Physical therapy exercises

Alternatively, management with physical therapy may also benefit the patient.  Nonetheless, there was not enough scientific evidence to prove its efficacy in managing disease development. Therapeutic exercises may include stretching, core strengthening, and breathing exercises aimed at enhancing chest wall flexibility and respiratory function.

Surgical treatment

Surgical intervention may be considered for severe or refractory cases of pectus carinatum that do not respond to the treatment with bracing.

The Ravitch procedure is a minimally invasive surgical technique, which involves making small incisions in the chest wall and using specialised instruments to reposition the sternum and ribs into normal alignment. This procedure may be performed under general anaesthesia and typically results in less postoperative pain and faster recovery times compared to traditional open surgery.^{1, 2}

Considerations for patient age and severity of condition

When determining the most appropriate treatment approach for pectus carinatum, healthcare providers consider factors such as patient age, overall health, and the severity of the chest wall deformity. Treatment plans are specialised to meet the unique needs and preferences of each patient, to improve chest wall features and overall quality of life.

Post-treatment care and follow-up

Sternum orthotic treatment for pectus carinatum patients requires ongoing care and monitoring to ensure optimal recovery and long-term outcomes.

Considerations during the recovery stage

The recovery period following surgical or non-surgical treatment for pectus carinatum varies depending on the type of intervention, the patient’s response, and individual factors such as age and severity. Patients undergoing surgical correction may experience discomfort and restricted activity initially. Non-surgical treatments such as bracing may also require high patient adherence to achieve desired results.

Monitoring for complications

Most children with pectus carinatum do not have any other medical problems. However, the sternum is connected to the ribs which are connected to the spine, and therefore any deformity of the breastbone potentially may affect the spine. Up to 1 in 10 children with pectus carinatum or sternal conditions may develop scoliosis.⁷ Children with pectus carinatum may also have an increased risk of connective tissue disorders such as Marfan syndrome and Ehlers-Danlos syndrome.¹

Regular follow-up appointments with healthcare professionals are essential to monitor for any potential complications or adverse effects following the management of pectus carinatum. If there are any unusual symptoms or pain, the patient or children’s parent should report to the healthcare team promptly.

Imaging studies such as X-rays or CT scans may be performed during follow-up visits to assess treatment outcomes and identify any signs of complications. Early detection and intervention can help mitigate the impact of complications and ensure optimal recovery.

Long-term outcomes and quality of life improvements

Long-term outcomes following treatment for pectus carinatum are generally favourable, with many individuals experiencing significant improvements in chest wall aesthetics and overall quality of life. Surgical correction can result in a more symmetrical chest appearance and improved lung growth and airway function, leading to enhanced respiratory efficiency and physical performance.⁴ 

Non-surgical treatments may also have positive outcomes, particularly when initiated early during adolescence. Patient satisfaction rates are generally high, with many individuals reporting increased self-confidence and improved body image following successful treatment. Long-term follow-up care focuses on maintaining treatment outcomes, addressing any residual symptoms or concerns, and supporting patients in achieving their optimal health and well-being.

Summary

Pectus carinatum is a chest wall problem in which the sternum and ribs are pushed outward to give a “pigeon-like” appearance. This chest bone disorder particularly worsens during adolescence and affects boys more than girls. Most children with pectus carinatum do not have any additional symptoms and rarely impact respiratory function. However, it may primarily be a cosmetic concern, and the unusual appearance of chest bone may cause negative feelings and affect quality of life.

Diagnosis typically involves physical examination, imaging studies, and pulmonary function tests to assess the severity of the deformity and its impact on lung function.

There are two main treatment options for pectus carinatum: bracing or Ravitch procedure. Non-surgical approaches such as bracing are generally used for young children whose chest bones are still flexible and developing. Bracing may have less effect on completely formed sternums and ribs. Ravitch procedure technology may be put into treatment if response failures to bracing.

Post-treatment care and follow-up are essential to ensure optimal recovery and monitor for any complications. Overall, early diagnosis and appropriate treatment are essential for managing pectus carinatum effectively and improving patient outcomes.