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Pectus excavatum and pectus carinatum
Pectus excavatum is the commonest chest wall deformity; a Haller index above 3.25 on CT, together with symptoms, cardiac compression or respiratory impairment, is an indication for repair — usually by the minimally invasive Nuss procedure in adolescence; pectus carinatum is first treated with a compression brace, and surgery is kept for failure.
Why it matters in the exam
Pectus excavatum is more common in boys and usually worsens during the adolescent growth spurt. It may be part of a connective tissue syndrome — Marfan or Ehlers-Danlos — so in a patient with suggestive features echocardiography is done to look for mitral valve prolapse and aortic root aneurysm. The Haller index is calculated on CT or MRI: the internal transverse diameter of the chest divided by the shortest distance between the sternum and the vertebra; the normal value is about 2.5, and a value above 3.25 is considered significant. Indications for surgery are a combination of a significant deformity with cardiac displacement, impaired lung function (restrictive pattern), arrhythmias, documented progression or significant psychological distress; in every case the patient and parents share the decision.
The Nuss procedure is the accepted approach today: a curved metal bar is passed under the sternum through lateral incisions, guided by thoracoscopy so as not to injure the heart, and is removed after 2–3 years. The preferred age is adolescence, when the chest is still flexible. Complications: bar displacement, pneumothorax, infection, and rarely cardiac injury; postoperative pain is significant and is now also treated with cryoablation of intercostal nerves. The open Ravitch operation — resection of deformed cartilages and fixation of the sternum — is used mainly in adults, asymmetric deformity and redo surgery. Pectus carinatum is first treated with a dynamic compression brace, which works while the chest is flexible, and a Ravitch-type operation is kept for failure. Know also Poland syndrome — absence of the pectoralis major with hand anomalies on the same side.
In mild pectus excavatum a vacuum bell can be tried as non-surgical treatment.
Key points
- Pectus excavatum is the commonest deformity.
- Haller above 3.25 is significant.
- Nuss in adolescence.
- Pectus carinatum — compression brace.
- Marfan — echocardiography.
Summary table
| Condition | Assessment | Treatment |
|---|---|---|
| Mild pectus excavatum | Haller up to 3.25, no symptoms | Observation, exercise, vacuum bell |
| Significant pectus excavatum | Haller above 3.25, cardiac displacement, restrictive pattern | Nuss procedure in adolescence |
| Pectus excavatum in an adult or asymmetric | CT, lung function, echo | Ravitch or Nuss case by case |
| Pectus carinatum | Clinical assessment | Compression brace; Ravitch if it fails |
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Sources
- Nuss et al., J Pediatr Surg, 1998 — A 10-year review of a minimally invasive technique for the correction of pectus excavatum
- Coran: Pediatric Surgery, 8th edition (2023) — Congenital chest wall deformities
- Shields' General Thoracic Surgery, 8th edition (2019) — Pectus excavatum and carinatum
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.