Cheat wall deformity

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Cheat wall deformity

Introduction

Chest wall: The thoracic wall or chest wall is the boundary of the thoracic cavity. The bony portion is known as the thoracic cage. However the wall also includes muscles, Skin & fascia.
Chest wall deformity: Chest wall deformities are fairly common structural deformity in the chest wall.
Types: There are two basic kinds of chest wall deformity:
1.      Pectus excavatum
2.      Pectus carinatum
Pectus excavatum
Definition
Pectus excavatum is a condition in which a person's breastbone is sunken into his or her chest. The chest bows inward instead of outward. In severe cases, pectus excavatum can look as if the center of the chest has been scooped out, leaving a deep dent.
While the sunken breastbone is often noticeable shortly after birth, the severity of pectus excavatum typically worsens during the adolescent growth spurt.


Also called funnel chest, pectus excavatum is more common in boys than in girls. Severe cases of pectus excavatum can eventually interfere with the function of the heart and lungs. But even mild cases of pectus excavatum can make children feel self-conscious about their appearance. Surgery can correct the deformity.
·         Also known as sunken or funnel chest. It is the most congenital abnormality of the chest wall.
·         When the bone caves into the chest forming a depression or cup like structure is called pectus excavatum. It occurs in 1 out of 500 children and occurs mostly in girls.

Pathophysiology

Because the heart is located behind the sternum, and because individuals with pectus excavatum have been shown to have visible deformities of the heart (seen both on radiological imaging and after autopsies), it has been hypothesized that there is impairment of function of the cardiovascular system in individuals with pectus excavatum. While some studies have demonstrated decreased cardiovascular function in pectus excavatum, there has been no consensus reached based on newer physiological tests (such as echocardiography) of the presence or degree of impairment in cardiovascular function in people with pectus excavatum. Similarly, there is no consensus on the degree of functional improvement after corrective surgery.

Symptoms

For many people with pectus excavatum, their only sign or symptom is a slight indentation in their chests. In some people, the depth of the indentation worsens in early adolescence and can continue to worsen into adulthood.
In severe cases of pectus excavatum, the breastbone may compress the lungs and heart. Signs and symptoms may include:
  • Decreased exercise tolerance
  • Rapid heartbeat or heart palpitations
  • Recurrent respiratory infections
  • Wheezing or coughing
  • Chest pain
  • Heart murmur
  • Fatigue
Causes

While the exact cause of pectus excavatum is unknown, it may be an inherited condition because it sometimes runs in families.
Pectus excavatum can occur in conjunction with other medical conditions, such as:
  • Marfan syndrome. This hereditary condition affects the connective tissue, often resulting in limbs and fingers that are especially long and thin.
  • Scoliosis. An abnormal curvature of the spine, scoliosis usually occurs in pre-adolescent girls.
  • Mitral valve prolapse. The mitral valve separates the two chambers of the left side of the heart. Defects in the mitral valve may reduce the heart's efficiency in pumping blood.
Risk factors

Pectus excavatum is more common in boys than in girls.

Complications

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Severe cases of pectus excavatum can compress the lungs and push the heart over to one side. Even mild cases of pectus excavatum can result in self-image problems.
Heart and lung problems
If the depth of the breastbone indentation is severe, it may reduce the amount of room the lungs have to expand. This compression can also squeeze the heart, pushing it into the left side of the chest and reducing its ability to pump efficiently.
Self-image problems
Children who have pectus excavatum also tend to have a hunched-forward posture, with flared ribs and shoulder blades. Many are so self-conscious about their appearance that they avoid activities, such as swimming, where the indentation in their chests is more difficult to camouflage with clothing

Tests and diagnosis

Pectus excavatum can usually be diagnosed simply by examining the chest. But your doctor may suggest several different types of tests to check for associated problems with the heart and lungs. These tests may include:
  • Chest X-ray. This test can visualize the dip in the breastbone and often shows the heart being displaced into the left side of the chest. X-rays are painless and take only a few minutes to complete.
  • Computerized tomography (CT). A CT scan may be used to help determine the severity of the pectus excavatum and whether the heart or lungs are being compressed. CT scans take many X-rays from a variety of angles to produce cross-sectional images of the body's internal structure.
  • Electrocardiogram. An electrocardiogram can show whether the heart's rhythm is normal or irregular, and if the electrical signals that control the heartbeat are timed properly. This test is painless and involves the placement of more than a dozen electrical leads, which are attached to the body with a sticky adhesive.
  • Echocardiogram. An echocardiogram is a sonogram of the heart. It can show real-time images of how well the heart and its valves are working. The images are produced by transmitting sound waves via a wand pressed against the chest.
  • Lung function tests. These types of tests measure the amount of air your lungs can hold and how quickly you can empty your lungs. In some cases, these tests are performed while the person is exercising on a treadmill.
  • Exercise test. This test monitors how well your heart and lungs function while you exercise, usually on a treadmill.
Treatments and drugs

Pectus excavatum can be surgically repaired, but surgery is usually reserved for people who have moderate to severe signs and symptoms. People who have mild signs and symptoms may be helped by physical therapy. Certain exercises can improve posture and increase the degree to which the chest can expand.
If you have mild pectus excavatum, your doctor may want to re-evaluate you every six to 24 months, to make sure your symptoms haven't worsened.

Types of surgery

If you have moderate to severe pectus excavatum, your doctor may suggest surgery. The two most common types of surgeries used to correct pectus excavatum differ by the size of the incisions used:
  • Larger incision. The larger, center-of-the-chest incision used in the Ravitch technique allows the surgeon to view the breastbone directly. The abnormal cartilage attaching the ribs to the lower breastbone is removed and the breastbone is fixed into a more normal position with surgical hardware, such as a metal strut or mesh supports. These supports are removed in nine to 12 months.
  • Smaller incisions. In the minimally invasive Nuss procedure, small incisions are placed on each side of the chest, under each arm. Long-handled tools and a narrow fiber-optic camera are inserted through the incisions. A curved metal bar is threaded under the depressed breastbone, to raise it into a more normal position. In some cases, more than one bar is used. The bars are removed after two years.
Comparable risks and outcomes
Both the Ravitch and Nuss procedures have been revised and improved over the years. While the Ravitch technique takes longer to complete, the Nuss procedure typically results in a longer hospital stay. Success rates are higher at hospitals that perform more of these types of surgeries.
Most people who undergo surgery to correct pectus excavatum are happy with the change in how their chests look, no matter which procedure is used. Either procedure also improves heart function. Best results are achieved when the surgery is performed after the age of 8 and before the end of adolescence, but adults also have benefitted from these types of surgeries.

Pectus Carinatum

Pectus carinatum, (L carīnātus, equiv. to carīn(a) keel), also called pigeon chest, is a deformity of the chest characterized by a protrusion of the sternum and ribs. It is the opposite of pectus excavatum.
It also known as pigeon chest. When the bone pushes outward forming a moud like structure characterized by protution of sternum & ribs. Occurs in 1 out of 1500 children and occure mostly in boys.

Can cause scoliosis. It is the opposite of pectus excavatum.

Pathogenesis: No specific cause is identified but there is an association with other skeletal abnormalities. Such as scoliosis suggesting that connective tissue disease in some cases may play a role in its pathogenesis.

Common Causes
Clinical presentation:
1.      May patient with this defect area. Asumptomatic.
2.      Patient with severe anomalies may complain of pain wher lying in the prone position.

Epidemiology

Pectus deformities are common; about 1 in 400 people have a pectus disorder.
Pectus carinatum is rarer than pectus excavatum, another pectus disorder, occurring in only about 20% of people with pectus deformities. About four out of five patients are males.

Symptoms

People with pectus carinatum usually develop normal hearts and lungs, but the deformity may prevent these from functioning optimally. In moderate to severe cases of pectus carinatum, the chest wall is rigidly held in an outward position. Thus, respirations are inefficient and the individual needs to use the accessory muscles for respiration, rather than normal chest muscles, during strenuous exercise. This negatively affects gas exchange and causes a decrease in stamina. Children with pectus deformities often tire sooner than their peers, due to shortness of breath and fatigue. Commonly concurrent is mild to moderate asthma.
Some children with pectus carinatum also have scoliosis (curvature of the spine). Some have mitral valve prolapse, a condition in which the heart mitral valve functions abnormally. Connective tissue disorders involving structural abnormalities of the major blood vessels and heart valves are also seen. Although rarely seen, some children have other connective tissue disorders, including arthritis, visual impairment and healing impairment.
Apart from the possible physiologic consequences, pectus deformities can have a significant psychologic impact. Some people, especially those with milder cases, live happily with pectus carinatum. For others, though, the shape of the chest can damage their self-image and confidence, possibly disrupting social connections and causing them to feel uncomfortable throughout adolescence and adulthood. As the child grows older, especially if male, bodybuilding techniques may be useful for balancing visual impact.

Prognosis

Pectus deformities usually become more severe during adolescent growth years and may worsen throughout adult life. The secondary effects, such as scoliosis and cardiovascular and pulmonary conditions, may worsen with advancing age.
Body building exercises (often attempted to cover the defect with pectoral muscles) will not alter the ribs and cartilage of the chest wall, and are generally considered not harmful.
Most insurance companies no longer consider chest wall deformities like pectus carinatum to be purely cosmetic conditions. While the psychologic impact of any deformity is real and must be addressed, the physiological concerns must take precedence. The possibility of lifelong cardiopulmonary difficulties is serious enough to warrant a visit to a thoracic surgeon.

Treatment

External bracing technique

In children, teenagers, and young adults who have pectus carinatum and are motivated to avoid surgery, the use of a customized chest-wall brace that applies direct pressure on the protruding area of the chest produces excellent outcomes. Willingness to wear the brace as required is essential for the success of this treatment approach. The brace works in much the same way as orthodontics (braces that correct the alignment of teeth). The brace consists of front and back compression plates that are anchored to aluminum bars. These bars are bound together by a tightening mechanism which varies from brace to brace. This device is easily hidden under clothing and must be worn from 14 to 24 hours a day. The wearing time varies with each brace manufacturer and the managing physicians protocol, which could be based on the severity of the carinatum deformity (mild moderate severe) and if it is symmetric or asymmetric.
Depending on the manufacturer and/or the patient's preference, the brace may be worn on the skin or it may be worn over a body 'sock' or sleeve called a Bracemate, specifically designed to be worn under braces. A physician or orthotist or brace manufacturer's representative can show how to check to see if the brace is in correct position on the chest.
Bracing is becoming more popular over surgery for pectus carinatum, mostly because it eliminates the risks that accompany surgery. The prescribing of bracing as a treatment for pectus carinatum has 'trickled down' from both paediatric and thoracic surgeons to the family physician and pediatricians again due to its lower risks and well-documented very high success results.
Regular supervision during the bracing period is required for optimal results. Adjustments may be needed to the brace as the child grows and the pectus improves.
If the person with PC is not treated with a brace by the end of puberty, the brace technique is not an option, as the shape of the ribcage and sternum are set for the rest of their lives.

Surgical

For patients with severe pectus carinatum, surgery may be necessary. However bracing could and may still be the first line of treatment. Some severe cases treated with bracing may result in just enough improvement that patient is happy with the outcome and may not want surgery afterwards.
If bracing should fail for whatever reason then surgery would be the next step. The two most common procedures are the Ravitch technique and the Reverse Nuss procedure.
The Nuss was developed by Donald Nuss at the Children's Hospital of the King's Daughters in Norfolk, Va. The Nuss is primarily used for Pectus Excavatum, but has recently been revised for use in some cases of PC, primarily when the deformity is symmetrical.

Other options

After adolescence, some men and women use bodybuilding as a means to hide their deformity. Some women find that their breasts, if large enough, serve the same purpose. Some plastic surgeons perform breast augmentation to disguise mild to moderate cases in women. Bodybuilding is suggested for people with symmetrical pectus carinatum.


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