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Chest wall deformities (pectus excavatum, pectus carinatum and Poland syndrome)
Pectus excavatum (sunken chest) is the common chest wall deformity, and when it is severe — Haller index above 3.25 with symptoms or cardiopulmonary compromise — it is corrected by the Nuss procedure in adolescence; pectus carinatum (pigeon chest) is first treated with a compression brace.
Why it matters in the exam
The exam asks about work-up, the Haller index, the best age for surgery, first-line treatment of pectus carinatum and associated conditions. The Haller index is measured on CT or MRI as the internal transverse diameter of the chest divided by the shortest distance between the sternum and the vertebra; a normal value is about 2.5, and a value above 3.25 is considered severe. Work-up also includes an echocardiogram (mitral valve prolapse, right ventricular compression), pulmonary function tests and sometimes exercise testing.
Pectus excavatum is more common in boys, usually appears at birth or in early childhood and worsens in the adolescent growth spurt. It is linked with Marfan and Ehlers-Danlos syndromes and with scoliosis, so signs of connective tissue disease are sought. Symptoms: exertional dyspnoea, reduced endurance, chest pain and palpitations, along with psychological distress about appearance.
The Nuss procedure (minimally invasive repair) passes a curved metal bar beneath the sternum through lateral incisions under thoracoscopic guidance, flips it and raises the sternum; the bar stays for about 2–3 years and is removed. The preferred age is early adolescence, while the chest is still flexible. Complications: bar displacement, pneumothorax, pain and, rarely, cardiac injury. The open Ravitch operation is kept for complex cases. For a mild deformity a vacuum bell can be tried. In pectus carinatum a dynamic compression brace works while the chest is flexible, and surgery is kept for failure. Poland syndrome includes absence of the sternal head of pectoralis major, hypoplasia of the breast and nipple and sometimes hand anomalies on the same side (syndactyly).
Key points
- Pectus excavatum is the common deformity.
- Haller above 3.25 — severe.
- Nuss in early adolescence; the bar stays 2–3 years.
- Pectus carinatum — compression brace.
- Look for Marfan, Ehlers-Danlos and scoliosis.
Summary table
| Deformity | Feature | Work-up | Treatment |
|---|---|---|---|
| Mild pectus excavatum | Mild depression, no symptoms | Physical examination | Follow-up, exercises, vacuum bell |
| Severe pectus excavatum | Haller above 3.25, symptoms, cardiac compression | CT or MRI, echo, pulmonary function | Nuss procedure in early adolescence |
| Pectus carinatum | Protruding sternum | Physical examination | Compression brace; surgery if it fails |
| Poland syndrome | Absent pectoralis major, hand anomalies | Examination and imaging as needed | Reconstruction as needed |
| Associated conditions | Marfan, Ehlers-Danlos, scoliosis | Echo, eye and spine examination | Treat the associated condition |
A free exam question
מה נכון לגבי תיקון חזה( סנדלרים PECTUS EXCAVATUM ?) (the question as examined, in Hebrew)
- א. שימוש בשני מוטות Bars ) אינו מומלץ בשל הכפלת הסיבוכים ותועלת שולית
- ב. MIRPE מתאים גם למטופלים מעל גיל 19-20
- ג. במום בדרגה קלה ובינונית הניתוח המוצע הוא MIRPE ובדרגה חמורה תיקון פתוח
- ד. בתיקון מסוג MIRPE יש להשאיר את ה - bar לתקופה של 6-12 חודשים
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Sources
- Holcomb and Ashcraft's Pediatric Surgery, 7th edition (2019) — Congenital Chest Wall Deformities
- APSA Position statement: Pectus excavatum evaluation and treatment, 2019 — Indications for surgical repair
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.