Pectus Excavatum is a congenital chest wall deformity in which several ribs and the sternum grow abnormally, producing a concave, or caved-in, appearance in the anterior chest wall; it is often referred to as sunken or funnel chest. The image below illustrates the typical appearance of this deformity in a 16-year-old boy.
Pectus Excavatum is the most common type of congenital chest wall abnormality (accounting for 90% of chest deformity’s), followed by Pectus Carinatum (5-7% of chest deformity’s), cleft sternum, pentalogy of Cantrell, asphyxiating thoracic dystrophy, and spondylothoracic dysplasia. Pectus Excavatum occurs in approximately 1 in 300-400 child births, with a male predominance (a male-to-female ratio of 3:1). The condition is typically noticed at birth, and more than 90% of cases are diagnosed within the child’s first year. However, the worsening of the chest?s appearance and the onset of symptoms are typically only reported during the rapid bone growth which occurs in the patients early adolescent years. Many patients are not brought to the attention of a pediatric surgeon until the patient and the family notice such changes.
Nevertheless, the appearance of the chest can be very disturbing to many young teenagers. It is often associated with low self-esteem problems and body image perception issues, which are frequently reported in teenaged patients. Similarly, Psychologic disturbances also common in older patients. In girls, the deformity is of particular concern because of the medial displacement of the breast, resulting in significant asymmetry of the breasts and nipples (cross-eyed appearance of the nipples).
In Pectus Excavatum, the growth of bone and cartilage in the anterior chest wall is abnormal, typically affecting 4-5 ribs on each side of the sternum. The appearance of the defect widely varies, from mild to very severe cases, and some patients present with significant asymmetry between the right and left sides. The exact mechanism involved in this abnormal bone and cartilage overgrowth is unknown, and, to date, no known genetic defect is directly responsible for the development of Pectus Excavatum. Despite the lack of an identifiable genetic marker, the familial occurrence of Pectus deformity’s is reported in roughly 35% of cases. Moreover, the condition is partially associated with Marfan syndrome and Poland syndrome.
As previously alluded to, Pectus Excavatum occurs in an estimated 1 in 300-400 births, with male predominance (male-to-female ratio of 3:1). Pectus Excavatum comprises approximately 90% of all chest wall deformities. However, in certain countries (eg, Argentina), Pectus Carinatum is more common than Pectus Excavatum.
Many patients with Pectus Excavatum are asymptomatic from a functional standpoint. The degree of cardiopulmonary impairment caused by lung compression and the level of cardiac displacement that results from the caved-in chest are subjects of controversy. Exercise tolerance is frequently reported as abnormal, and a restrictive pattern in pulmonary function test can be identified in severe cases. Cardiac function is usually normal, but mitral valve prolapse has been reported in 20-60% of cases. Echocardiography typically reveals some degree of atrial compression and cardiac displacement. Rarely, it may reveal mitral or tricuspid regurgitation. Echocardiographic analysis has demonstrated improved cardiac index upon exertion after operative repair of the deformity. The long-term health risks of patients who are managed without surgery are however not known.
Pectus Excavatum appears to be most prevalent in Caucasians. However, unfortunately, no specific data are available regarding racial distribution; however, clinical observation indicates that treating Pectus Excavatum in African Americans is unusual.
As previously alluded to, the male-to-female ratio is 3:1. Despite such observation, no known genetic factor linked to the X or Y chromosome has been reported.
Most cases of severe Pectus Excavatum are noticed at birth, with progressive worsening of the child’s growth and development. More than 80% of all cases are identified within the first 1-2 years. The condition typically becomes much more pronounced at puberty, during the time of rapid bone and cartilage growth. Most patients are brought to medical attention during their teenage years because of the significant change in the appearance of their chest.
Some patients with Pectus Excavatum experience chest and back pain that is typically musculoskeletal in origin. The exact cause of the pain is not really understood. Pectus Excavatum and Pectus Carinatum are frequently associated with Scoliosis. Although such association is probably coincidental, the poor posture noted in many patients with pectus deformities may be a key factor in the development of pain.
Many physicians attribute the symptomatic impairment in Pectus Excavatum to a decrease in intrathoracic volume secondary to the sunken chest. However, this relationship is difficult to prove due to the wide range of pulmonary function among healthy individuals and the correlation of pulmonary function with physical training and body habitus. There has been scientific evidence reported that demonstrates shortness of breath upon exertion in patients with pectus excavatum, primarily due to the decrease in pulmonary reserve.
Clinicians have observed that many patients with Pectus Excavatum tend to become symptomatic during their teenage years or early in adult life. Patients younger than 10 years who have Pectus Excavatum do not typically experience symptoms associated with shortness of breath. Studies of pulmonary function in patients with Pectus Excavatum have provided the following information:
Posterior displacement of the sternum in Pectus Excavatum can produce a heart deformity, with anterior indentation of the right ventricle. Early pathologic studies demonstrated this finding, and a series of early case reports included cardiac evaluations for patients with severe symptoms. Angiographic studies have demonstrated the sternal imprint on the anterior wall of the right ventricle.
Several studies have demonstrated limitation of cardiac stroke volume in patients with Pectus Excavatum, particularly in the sitting, or upright, position. When patients with pectus remain in the supine position (lying flat), no significant impairment to cardiac function is apparent. Further evidence has suggested that operative repair of pectus results in normalization of the cardiac function. One study assessed cardiac workload in 13 patients with Pectus Excavatum. The patients were assessed in an upright position on a bicycle ergometer. Findings suggested that, following surgery, most patients could more easily reach the target heart rate during exercise without becoming symptomatic. Many use this observation as substantial evidence that operative repair for Pectus Excavatum results in improved cardiac function. However, the role of conditioning and subjective response to surgery is very difficult to assess.
The hallmark of Pectus Excavatum is the caved-in appearance of the anterior chest. As mentioned above, the severity of the defect and the asymmetry of the chest widely vary. Patients may present with a very mild form of Pectus Excavatum or their sternum may be almost touching the spine. Typically, the lower third of the sternum is more involved, and the upper third may appear fairly normal. A compensatory anterior flaring of the lower ribs at each costal margin is also common. Many patients have associated scoliosis, but this is not directly related to the presence of Pectus Excavatum.
The precise causes of Pectus Excavatum are not known. It probably originates from a genetic defect that results in abnormal musculoskeletal growth. The cartilaginous portion of the rib is very likely the main source of this abnormal growth pattern. Abnormalities of rib morphogenesis and growth are the most likely causes of Pectus Excavatum and Pectus Carinatum. In Pectus Excavatum, the sternum is thought to be pushed in by abnormal growth at the articulation with the ribs and cartilage. Again, the exact mechanism that results in this abnormal growth pattern is not known. Increased work of breathing, as is observed in young patients during exercise or play activity, may contribute to the progression of the pectus deformity, particularly during early the teenage years. However, no scientific evidence supports such a theory.
Conditions associated with Pectus Excavatum include Marfan syndrome, Poland syndrome, and Pouter pigeon breast.
No specific laboratory study is necessary in the workup of patients with Pectus Excavatum. Most children with this condition are otherwise healthy.
Imaging studies are important in the initial assessment of any patient with Pectus Excavatum.
The operative procedure for correction of Pectus Excavatum is discussed within this article in the Surgical Care section and in the surgical treatment page. Additionally, non surgical medical procedures are discussed on the non-surgical treatment page
Histologic assessment of the affected ribs, cartilage, and sternum typically does not reveal any abnormal findings other than the unusual shape of the deformed ribs.
No effective nonoperative management strategies can correct of severe Pectus Excavatum, but they can be used in minor cases of the disorder. Several exercise programs have been suggested. However, they are only effective in achieving anatomical correction in minor severity cases.
External braces have also been used in the nonoperative management of Pectus Excavatum, but no experience with this approach in the treatment of chest wall deformities in North America has been reported. Pectus Carinatum is more likely to improve with the consistent use of an external brace because the exogenous compression of the sternum and anterior ribs by the brace may, over time, result in some degree of correction of the deformity. Good results are unlikely to be achieved with external bracing techniques in the correction of severe Pectus Excavatum. For more information on this subject, please consult this website for the Orthopaedic Conservative Method and Information on Pectus Deformities.
Until the mid 1990s, the operative treatment of Pectus Excavatum had been fairly well standardized and was based on the open operation originally described by Ravitch in 1949.6 Few variations to his original description have been added, and the operation became almost universally accepted by pediatric surgeons as the standard for treatment of this condition.
Several published series demonstrated excellent results with low complication rates despite the fairly radical nature of the Ravitch operation, which required anterior chest wall exposure, creation of muscle and skin flaps, extensive cartilage resection, and sternal osteotomy. The procedure involves the surgical exposure of the anterior chest wall, creation of skin and muscle flaps, and resection of the affected cartilages and sternal osteotomy are visible.
In 1987, during the early stages of laparoscopic and minimally invasive surgery, the creative mind of a pediatric surgeon from Virginia, Donald Nuss, MD, challenged the surgical dogma.7 Nuss performed the first minimally invasive operation for the correction of Pectus Excavatum. Not until May of 1997 was this new and innovative technique introduced to the American Pediatric Surgical Association and, subsequently, published in the Journal of Pediatric Surgery. Because of the excellent results obtained with this new technique and because of the less radical nature of the operation, the popularity of this technique has grown dramatically.
Operative correction should be considered in patients who present with Pectus Excavatum and cardiopulmonary impairment. The most common goal in operative repair of pectus excavatum is to correct the chest deformity. This is particularly important in teenagers, in whom the appearance of the chest can result in significant problems related to body image and self-esteem. Thus, the desire to improve the appearance of the chest is considered an appropriate medical indication for surgery.
Other indications include exercise and physical activity limitations, evidence of cardiac or pulmonary dysfunction, chest pain, psychological distress, and potential future need for sternotomy (open-heart surgery). Adult patients with Pectus Excavatum who undergo open-heart surgery typically have significant displacement and rotation of the heart to the left chest. This can make the operative approach to the heart at the time of open-heart surgery difficult and challenging. With this in mind, elective repair of the pectus deformity prior to open-heart surgery may be indicated in selected cases.
The clinical observations that provided the rationale for developing a less invasive operation that would allow for the anatomical correction of Pectus Excavatum deformity are written below.
First, children have a very soft and malleable chest. Second, the phenomenon of chest remodeling is well known in adult patients with emphysema who develop a barrel-shaped chest. If the chest wall in older adults can be reconfigured, the same should be possible in children and teenagers because of the increased malleability of their anterior chest wall. Third, the use of braces and internal fixating devices has allowed orthopedic surgeons and orthodontists to correct skeletal anomalies such as scoliosis, club foot, and maxillomandibular malocclusion. The anterior chest wall, which is quite malleable, is ideal for this type of correction. Such observations resulted in a technique in which a convex stainless-steel bar is placed under the sternum through a small lateral thoracic incision to correct the condition known as funnel chest. Thus, the minimally invasive repair of pectus excavatum (MIRPE), also known as the Nuss technique, was born.9
Prior to surgery, the chest is measured from the midaxillary line to midaxillary line to determine the approximate length of the bar required, and the correct length is typically obtained by subtracting 1 cm from that initial measurement. A mild bowel preparation 1 day before surgery may be helpful in decreasing problems related to postoperative constipation. Administer a first-generation cephalosporin antibiotic (cefazolin) approximately 1 hour prior to surgery and continue for at least 48 hours or until the patient is afebrile. As a rule, patients can be admitted on the same day of surgery.
The combination of general endotracheal anesthesia and a thoracic epidural is considered ideal. The epidural catheter is left in place for up to 3 days following the operation, providing excellent adjuvant therapy to pain management techniques. Patients and families must understand that, although the technique is considered minimally invasive, postoperative pain and discomfort can be significant because of the forceful bending of the sternum and cartilages. An indwelling Foley catheter is placed because urinary retention is common with thoracic epidurals. Orogastric tube decompression of the stomach is recommended only during the operation. Hemodynamic monitoring by the anesthesiologist does not necessitate central venous or arterial lines.
The surgical technique is as follows:
Pain management typically requires keeping the patient well sedated for the first 1-3 days to prevent bar displacement. Medications and therapies depend on the patient’s response to pain and may include an epidural catheter, intravenous narcotics for breakthrough pain, patient-controlled analgesia (PCA), and nonsteroidal anti-inflammatory drugs (NSAIDs). In the first postoperative day, the patient is kept flat, with a straight thoracic spine, and is allowed only a small pillow. Mobilization is permitted on the second postoperative day by flexing the bed at the hip level and keeping the back straight. Do not permit waist bending, twisting, and log rolling. Avoid allowing the patient to sit in bed with the thoracic spine flexed. The patient needs assistance when getting out of bed the first few times.
The epidural catheter is generally removed on the third postoperative day, and the patient should be fully ambulatory after that point. The patient is discharged home when able to walk unassisted. The average length of stay is 4-7 days. Good posture with a straight back is very important, even after discharge. Again, bending at the hip and slouching are not allowed in the first month. Regular activity is permitted as pain reduces and mobility increases. Heavy lifting is not permitted for one month following surgery, and contact sports are to be avoided for at least 3 months. The bar generally remains implanted for 2 years and is removed in an outpatient procedure under anesthesia.
To date, only 2 large series that examine complications and outcomes of this new technique have been reported.10,11 In those reports, patient and family satisfaction were found to be very good, with excellent and good results reported at 93% and 96%, respectively. However, the only multi-institutional study, which reviewed 251 cases of MIRPE, demonstrated a significant rate of complications (the overall incidence rate of complications was almost 20%).11 By far, the most common complication requiring reoperation was displacement of the retrosternal stainless steel support bar (initially reported to occur in 9.5% of all patients). Such displacement can include a 90? rotation, a 180? rotation, or a lateral migration. Teenaged patients are at higher risk for complications, particularly pectus bar displacement, probably because of the increased pressure on the bar generated by a larger chest and more rigid chest cage.
Since the introduction of thoracoscopy and lateral stabilizers, as well as the third point of fixation technique, bar displacement has become quite unlikely, with an estimated incidence of less than 2.5% (prospective studies are currently underway to analyze outcomes of surgery).
The acceptance and popularity of MIRPE developed quickly since its introduction in 1997. The principal advantages of this new technique are based on the fact that incising the anterior chest wall, raising the pectoralis muscle flaps, resecting the rib cartilages, and performing a sternal osteotomy are not needed. This leads to a much shorter operating time, minimal blood loss, and early return to full activity because the stability and strength of the chest wall is not compromised. The apparent simplicity of the technique, combined with the early good results reported, contributed to the enthusiastic widespread use of this operation by many pediatric surgeons.
Unfortunately, a relatively high rate of complications was reported when many different surgeons performed the operation, probably reflecting the learning curve associated with the introduction of this new technique. Since the first MIRPE was performed, the bar has been modified 4 times and is now strong enough to withstand the pressure of even the most severe deformity. The poor results likely occurred early in the reported series because the bar was too soft, was removed too soon, or was not stabilized adequately. Experience has shown that stabilization of the bar is absolutely essential for success, and the use of a lateral stabilizing bar and the third point of fixation (when appropriate) minimizes the occurrence of bar displacement.
Fortunately, most factors that may lead to complications and poor results were related to early inexperience, and these factors have been corrected. Moreover, the introduction of thoracoscopy when performing MIRPE has significantly enhanced the surgeon’s ability to pass the bar precisely behind the sternum, avoiding the risk of cardiac or vascular injury. Reassuringly, one reported case of cardiac perforation occurred prior to the routine use of thoracoscopy.
Another significant advantage of MIRPE over the open surgical procedure is that the dreaded complication of “thoracic constriction” (Jeune syndrome) does not seem to occur with this new technique. Chest wall constriction has been described in a few patients following extensive open pectus excavatum operations. Apparently, the bone growth center can be affected, which results in restriction of chest wall growth with marked limitation of ventilatory function. Such patients are very symptomatic and cannot compete in running games. The forced vital capacity and forced expiratory volume in one second is typically decreased by more than 50% of predicted reference range levels. With the MIRPE, because no resection or incision is made on ribs or cartilages, such a complication does not appear to be a problem. Once the cartilage and bony structures are remodeled, normal or improved pulmonary function is established and the flexibility and malleability of the chest remains unaffected.
Critics of the MIRPE claim that the Nuss procedure is too invasive, risky, and not pain free. Proponents argue that this new approach, compared with the open surgery (modified Ravitch operation), eliminates the need for a large anterior chest wall incision with creation of pectoralis muscle flaps, resection of several ribs and cartilages, and sternal osteotomies. The MIRPE allows for a much shorter operating time, minimal blood loss, and minimal anterior chest wall scar. Moreover, the stability and strength of the chest wall is not compromised as it is with the open repair. For a more detailed review of the pros and cons of both approaches, please refer to the article “To Nuss or Not to Nuss? Two Opposing Views” in the Spring 2009 edition of Seminars of Thoracic and Cardiovascular Surgery.12
The current recommendations support the use of MIRPE in patients aged 5-20 years. The ideal age for undergoing this operation is 8-12 years because the chest wall is still very malleable, stabilization of the bar is easily achieved, thoracic epidural can be safely placed, and the child is mature enough to understand the operation and postoperative instructions, particularly incentive spirometry, which is essential for minimizing pulmonary problems after surgery.
Of note, one should not view operative correction of pectus excavatum as an operation limited exclusively to pediatric patients. Indeed, the open technique has been used in adult patients with excellent results. However, experience with the MIRPE in adult patients has been limited to a few cases, reported in anecdotes. Early results seem to indicate that similar principles apply and that operative correction using MIRPE can be achieved in adult patients. Limiting factors include a larger chest wall and poor malleability of the ribs, cartilage, and sternum. A surgeon experienced in the field of chest wall malformations must carefully evaluate adult patients to determine which operation would best correct the anatomical deformity.
An interesting observation has been that complications, mainly bar displacement, have appeared to be more common in teenaged patients. Initially, the MIRPE was limited to the younger prepubertal patients (aged 3-12 y), which probably accounted for the rare occurrence of bar displacement in the first report by Nuss.7 Older patients were offered the procedure because of the success of the procedure in young patients. Only later was the importance of proper stabilization of the bar identified and the lateral stabilizing bar was introduced (in 1998), followed by the addition of the third point of fixation technique (in 2000) to provide additional support and stability for the bar. The results seemed to have improved so much that the operation is now considered in adult patients with pectus excavatum.
A consultation with a cardiologist and pulmonologist are not mandatory and are obtained only if indicated based on the medical history and physical examination findings. However, many physicians and insurance companies believe that such an assessment is important prior to surgery. Experience has shown that, unless medically indicated by the presence of cardiopulmonary symptoms or abnormal physical findings, routine preoperative consultation with such specialists is of little benefit in the clinical evaluation and outcome of patients with pectus excavatum. However, their input can be helpful in cases in which insurance companies deny coverage of the procedure.
A consultation with a physical therapist before or after operative repair of pectus excavatum is considered an important factor in good recovery from surgery. The physical therapist assists and instructs patients on appropriate stretching techniques and exercises that aid the patient in the recovery phase. Continue such therapy for at least one month after surgery, when most patients are free of any significant discomfort with routine activities of daily life. Moreover, the physical therapist can assist patients in establishing proper posture, an important factor for a good functional and cosmetic outcome after surgery.
Dietary restrictions are not indicated. Note that constipation is common after operative repair of pectus excavatum, probably because of the use of narcotics for postoperative pain management. Thus, a high-fiber diet and use of laxatives is recommended early after surgical repair. Normal bowel function should resume after discontinuation of all pain medications.
Good posture with a straight back (ie, the military posture) is very important following surgery. Patients are also instructed to avoid any bending at the hip and to not slouch for the first month. Regular activity is permitted as pain reduces and mobility increases. Heavy lifting is not permitted for one month following surgery (patients are not allowed to carry heavy book bags for at least 4 wk), and contact sports are to be avoided for at least 3 months. After 3 months, most patients return to normal activities, including sports (eg, baseball, basketball, running, swimming, tennis, jumping). Following bar removal (typically performed in the outpatient setting at 2-3 years after the repair of pectus excavatum), patients are not to be restricted from any activities, except for 5-7 days after this minor procedure.
As previously mentioned, no effective drug therapy is available for the treatment of pectus excavatum. See Surgical Care.
During the patient’s hospital stay following corrective surgery for pectus excavatum, the author strongly recommends consultation with the anesthesia pain team. With intravenous narcotics and epidural analgesia, the pain that follows surgery can be controlled fairly well.
Typically, the thoracic epidural is removed 3-4 days after surgery, and most patients are discharged after 5-7 days. At the time of discharge, pain should be controlled with oral narcotics. NSAIDs, such as ibuprofen or ketorolac tromethamine (Toradol), are frequently added to the postoperative drug regimen. When using NSAIDs, consider adding histamine 2 (H2) blockers to prevent ulcer-related complications.
The typical follow-up postoperative repair of pectus excavatum involves outpatient visits with the pediatric surgeon 2-3 weeks after surgery and at regular intervals after that for the next 2 years. Monitoring patients at least every 3-6 months is recommended to ensure that they are not developing an anterior protrusion of the chest due to too much pressure from the pectus bar. Pectus carinatum as a sequela of MIRPE has been reported.
Refer patients with pectus excavatum to a pediatric surgeon experienced in the field of congenital chest wall deformities.
Physical fitness and development of strong anterior chest musculature may improve the appearance of pectus excavatum. However, clinical experience has demonstrated that only mild cases of pectus may benefit from this technique. The deformity worsens in most patients with moderate or severe pectus excavatum, particularly during the physiologic rapid growth of puberty.
The prognosis of Pectus Excavatum, with treatment, is excellent. Patients with mild pectus excavatum who do not undergo operative correction also have an excellent prognosis. Patients with moderate-to-severe pectus excavatum may experience problems related to cardiopulmonary impairment, decreased exercise tolerance, decreased stamina, and adjustment disorders related to the impact of this deformity on body image and coping mechanisms. Mortality is not associated with the condition.
Because of the recent advances in the operative repair of pectus excavatum, education of medical professionals and the public is important. Again, patients with pectus excavatum should be referred to a surgeon experienced in the field of congenital chest wall malformations. Early assessment and follow-up is essential to maximize good outcomes.
After operative repair of the pectus excavatum, instruct patients on correct posture to eliminate musculoskeletal pain and to prevent worsening of the spinal deformity. Emphasize that repair of the pectus in itself does not result in correction of any associated spinal deformity or problems related to poor posture.
An association between anterior chest wall deformities and scoliosis is described in the literature but is poorly defined. Apparently, only 4-5% of patients with severe anterior chest wall deformities have scoliosis of sufficient magnitude to warrant evaluation and observation by a spinal deformity physician. The relationship between anterior chest wall deformity and scoliosis is most clear in patients with Marfan syndrome. Patients with Marfan syndrome who have scoliosis are at high risk for progression of the deformity to unacceptable levels and have not historically responded well to brace therapy. Because of the association between pectus deformities and scoliosis, carefully examine patients with anterior chest wall deformities for signs of scoliosis and perform radiography if indicated. Patients younger than 5 years who present with spinal deformity are at risk for adverse cardiopulmonary sequelae related to the scoliosis. The management of scoliosis in patients with anterior chest wall deformities follows the treatment principles outlined for patients with idiopathic scoliosis.
This condition represents a rare congenital deformity of the chest characterized by a protrusion of the manubriosternal junction and adjacent costal cartilages, as well as premature sternal ossification. One third of patients with Pouter pigeon breast have concomitant depression of the lower sternum (pectus excavatum). Several cardiovascular abnormalities have been associated with premature sternal ossification, the most common being ventricular septal defect. Surgical correction includes the wide wedge transverse sternotomy at the angle of Louis and subperichondrial resection of the adjacent costal cartilages. Long-term outcomes are encouraging.
This syndrome is characterized by pectus excavatum, hypoplasia or absence of the breast or nipple, hypoplasia of subcutaneous tissue, absence of the costosternal portion of the pectoralis major muscle, absence of the pectoralis minor muscle, syndactyly or bony abnormalities of the forearm, and absence of costal cartilages or ribs (typically ribs 2-4 or 3-5). Clinical manifestations of Poland syndrome widely vary, and all features rarely affect a single individual.
During the era of open surgery to repair pectus excavatum, adult patients rarely underwent corrective surgery. However, with the introduction of MIRPE, surgeons have noticed a significant change in the trend for corrective surgery in patients older than 18 years. Although MIRPE can be successfully performed in adult patients, the risk of bar displacement and other complications is increased in that group of patients. In addition, the degree of postoperative pain is more significant and more prolonged.
Steps to improve your Pectus Excavatum
When improving your pectus excavatum through exercises it is important to create an exercise program which targets the following:
The first two areas are to mobilize the articulating joints and to lengthen any tight soft tissue around the chest wall so that less impedance will be encountered during the elevation of depressed chest.
1. Forward arm stretching in pone kneeling
The patient is positioned in an inclined prone kneeling position with hands stretching forward and supported by wall bar (about 2 to 3 feet high from ground) Slowly lower his upper body and press his scapula (are around underarms) towards the floor. Experience the stretch feeling around the underarm and shoulder. Hold 8 seconds (may get a deep breathe and hold to increasingly stretch the chest wall) and release. Repeat for 20 times and 4 sessions per day.
Purpose: Stretch all anterior chest wall muscles especially pectoralis major (main pec muscles) and extend the upper back.
2. Upper trunk rotation – standing
The patient is to stand side on to a wall. The hand closest to the wall is put on the wall a bit higher than the shoulder level. The patient?s pelvis turns to the opposite side while still leaving the hand fixed on the wall. A stretch is felt at the anterior shoulder and upper chest wall.
Hold 8 second, then release and return to the original position. Take a rest and repeat on the other side. Repeat for 20 cycles and 4 sessions per day.
Purpose: Rotation gives the greatest range of movement for thoracic vertebrae (fancy word for spine) allowing stretch to ligaments, muscles and joints around the chest wall in a different direction.
3. Upper trunk side flexion – sitting
The patient is seated on a chair. Side bend to one side with the opposite hand crossing over the head to another side. A stretching feeling is felt on the other side of trunk. Hold 8 seconds (may get a deep breathe and hold to increasingly stretch the chest wall) and then return to the original position. Take a rest and repeat on the other side. Repeat for 20 times and 4 sessions per day.
Purpose: Similar to the 2nd exercise
1. Weight lifting in stretch supine – lying
The patient is positioned in supine with the upper trunk on a small foam roll around 2 to 3 inches in diameter (if patient can?t tolerate, just lie flat). The arms are put in an upward stretched position. The hands should hold on a fixed wall bar or hardly movable weight about 10 inches from the surface of the bed (pillows may be used to support the weight) . Deeply inspire and exert maximal force in lifting the wall bar or weight. Hold 8 seconds and relax. Repeat 10 times as 1 lot. Take rest then and repeat another 2 lots performing a total of 30 repetitions and 4 sessions per day.
Purpose: By the technique of ?reverse origin and insertion?, the arms are being fixed and the anterior chest wall is lifted up mainly by the pectoralis major and minor. Maximal force exertion allows recruitment of surrounding respiratory muscles for training. The foam roll under the upper to middle part of the trunk exerts postero-anterior force to the thoracic spine helping in extension, which mobilizes and corrects any unnatural bends in the back (poor posture related usually). The depressed chest will also be ?opened? up facilitating the elevation of the chest wall. Arms, being in a mid-length muscle range, are capable to exert the greatest force to elevate the depressed chest. Tone of pectorlis major is built up for better posture and outlook.
2. Upper trunk extension in prone – lying
The patient is positioned in prone lying with one or two pillows under the tummy (avoiding the lower anterior chest pressing on the pillow, area where lungs and heart are keep pillow lower down) . The hands are placed behind the head. The feet may be fixed on wall bar. Deeply inspire and extend the upper trunk with arms arching back. Stay and hold 8 seconds and then relax. Repeat 10 times as 1 lot. Take rest then and repeat another 2 lots. Perform a total of 30 repetitions and 4 sessions per day.
Purpose: The strengthened upper back muscles help to balance the improved muscle force of the anterior chest wall muscle. This prevents the development of Poor back posture due to strong anterior muscle pull and keeps a good posture.
3. Push up
The patient is positioned in prone lying and both hands are used to push up his body. The level of difficulty depends on the actual ability of the patients (1st level ? upper trunk pushed up, 2nd level ? whole body pushed up in one piece, 3rd level ? push and clap both hands in mid air). Start with the 1st level and when the patient is able to finish the level easily, he may proceed to next level). Repeat 10 times as 1 lot. Take rest and then repeat another 2 lots performing a total of 30 repetitions and 4 sessions per day.
Purpose: The exercise aims at general strengthening of the chest wall. Moreover, the high intensity but low frequency impacting force may be advantageous to stimulate remodeling and shaping of the chest wall deformity. Bone mineralization may also be enhanced.
4. Hands up and down movement behind and by the sides of body (with theraband or stretchy rope/velcro)
The patient is positioned sitting or standing with both arms in a stretched position. Each hand holds one end of a theraband or a spring (resistance should be set at 10 repetitive maximum, RM, i.e. theresistance that one can perform 10 repetitions but no more). Then stretch the theraband and maintain the elbows straight . Slowly put the hands behind and pass by the sides of body and then down below buttock. After 3 seconds rest, the hands slowly go up and along the same track to the starting position. Repeat 10 times as 1 lot. Take rest and then repeat another 2 lots performing a total 30 repetitions and 4 sessions per day.
Purpose: The exercise is used to strengthen the neck, shoulder, upper back and anterior upper chest muscles. It can be treated as a kind of stabilization exercise to the upper thorax.
1. The first step will be a course of antibiotics at the time of surgery to prevent infection and reduce the development of pneumonia. This surgery is performed under general anesthesia with a muscle relaxant and epidural block for both operation and pain control purposes.
2. The patient is then positioned with both arms extended out sideways to allow better access to chest wall. Padding under the arms will prevent any neurologic injury.
3. The patient is then draped, and the chest is marked and sterilized. The deepest section of the pectus is marked. If the deepest point of the pectus is inferiro to the sternum, then mark the lower end of the sternum. Using this point, establish a horizontal plane across the pectus area. Extend the horizontal plane to the lateral chest wall and mark between the anterior and midaxillary lines for transverse lateral incisions.
4. The preop chest measurements are then double chcked. And the proper bar is then selected for beind into the desired chest wall curvature. A bar will be chosen specifically for your chest that will give you maximum stability and correction.
5. Using the pectus bender, the bar is shaped from the center outward making small gradual bends. It may be necessary to exaggerate the curvature slightly to allow for chest wall pressure downward force on the sternum. Avoid bending the lateral ends of the bar.
6. 2.5cm incisions are then made at the marks previously made. A skin tunnel is raised from both incisions to the top of the pectus ridge at previously selected space. The pectus bar then enters the chest slightly elevated from the pectus ridge.
7. A thoracoscope is used during the procedure to get an idea of where all the surrounding organs are in order not to damage them. The pectus bar is then entered from the patients right side with the proper pectus introducer in order to make a tunnel for the implant. Small introducers are used for patients 4 to 12 years old and the longer one for patients 13 – 20 or older.
8. The introducer is slowly eased in through the side of chest and pushed through to the other side of the chest. From here the surgeons can begin elevating the sternum.
9. The sternum is then lifted into place from both sides. Pressure is applied above and below the sternum to obtain the desired curvature of the sternum. This process may be repeated a few times in order to stretch the connective tissue and correct the deformity prior to inserting the main bar. Two strangs of umbilical tape are then tied through each end of the hole this will be later used to guide the bar through the hole.
The bar is then inserted and flipped into a position that will push the sternum outwards to the desired position.
10. At this point the stability of the bar is checked. Depending on how stable the bar is, will dictate if any stabilization need take place. Patients typically require one bar to achieve correction but some may have 2 or 3 for more severe deformities.
A stabalizer bar is then fitted to each end of the pectus bar. Patients 4 to 13 years have one stabilizer per bar , and 14 to 18 years of age have one or two depending on patients muscular development and activity level (sports , gym e,g)
11. The bar and stabilizer are then secured to each other and to the chest wall and the bar and stabilizer are covered up. The incisions are then closed up and a chest radiograph is obtained postop to check for pneumothorax and is an excellent way to see final bar placement.
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