Chest Wall Congenital Deformities

Fritz J. Baumgartner

The congenital deformities of the chest wall include pectus excavatum and pectus carinatum. The most common congenital deformity is the excavatum variety in which the sternum is displaced posteriorly. Asymmetry is common and almost always involves deeper depression of the right costal cartilage with rotation of the sternum to the right. Most patients are asymptomatic, however, some patients have symptoms including chest pain, dyspnea, poor feeding, broncho-spasm and arrhythmias. Most of these symptoms are relieved by operative correction. It is controversial whether or not there is actual impairment in exercise cardiac function. The data at present show no impairment in exercise cardiac function before or after pectus repair. It has been shown, however, that left ventricular end diastolic volume and stroke volume increase at rest after surgery and there is a marked increase in resting right ventricular end diastolic volume. This suggests that some degree of cardiac compression was relieved by repair. Most surgeons recommend operative correction before the age of five, but not before age one and a half. A submammary incision is performed. All deformed costal cartilages are excised subperichondrially. The xiphoid sternal joint is disarticulated and a transverse sternal osteotomy is performed above the point of depression. The sternum is brought forward and a steel bar is placed retrosternally and anchored at the ribs.

Although it is difficult to evaluate, in general pulmonary function tests and stroke volume in patients with pectus excavatum are decreased compared to controls and are improved by surgery, although the clinical relevance is unknown at this time.

Pectus carinatum is much less common than excavatum and is an outpouching deformity of the chest of several varieties. The two types are the chicken breast with a deep depression of the costal cartilage on either side of the sternum. Asymmetry is common usually on the right. Another deformity is the Pouter-pigeon variety which involves a double angle in the sternum with a depression created in the lower sternum resembling a pectus excavatum. Again a submammary incision is performed and a subperichondrial resection of deformed cartilage is made. The excess length of perichondrial bed is plicated and the sternum transsected transversally with an osteotomy if necessary.

Suggested Reading

1. Ravitch MM. Congenital deformities of the chest wall and their operative correction. Philadelphia: WB Saunders, 1977.

2. Robicsek F, Dougherty HK, Mullen DC et al. Technical considerations in the management of pectus excavatum and carinatum. Ann Thorac Surg 1974; 18:549-564.

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