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Other Common Problems

Background

Both pectus excavatum and carinatum are associated with other skeletal problems and what can be regarded as a 'pectus syndrome', a cluster of symptoms and signs that occur together and characterize a condition. Such a syndrome is often described by patients or their family as 'poor posture'. It is common and in our experience affects 1 in 3 patients with pectus deformities. It often overlooked by non-specialist pectus health care professionals.

Spine

Along with recognized spinal conditions such as scheuermann's syndrome (or juvenile kyphosis) causing excessive outward curvature of the spine, kyphosis of upper spine and neck is often seen in pectus patients as well as excessive curvature or lordosis of the lower spine and scoliosis or abnormal, sideways curvature of the spine. Such spinal issues seem to be most noticeable in asymmetric pectus deformities, either carinatum or excavatum and may be caused by uneven pressures applied to the rib cage and tilting of the sternum.

Stooped shoulders
Stooped shoulders with thoracic kyphosis and lateral rotation of the scapula

Head and Neck

Commonly the head appears to be pushed forward and the neck excessively flexed. This could be caused by an altered centre of gravity caused by the pectus condition, particularly in protruding pectus carinatum patients. He believes a pectus brace may allow realignment of the body's centre of gravity leading to improvement of this strikingly common problem.

Head pushed forwards
Head pushed forwards with the neck excessively flexed

Shoulders

The shoulders often appear to be uneven particularly in the more asymmetric pectus cases and may be caused a similar problem seen with the spine with excessive and uneven pressures applied to the rib cage and tilting of the sternum. Protruding shoulder blades is sometimes also noted and is caused by lateral rotation of the shoulder, and in the most extreme examples are called by doctors as scapular (shoulder) winging.

Shoulders

Shoulders
Uneven shoulders noted in a young man with asymmetric pectus excavatum

Shoulders

Shoulders
Shoulder tilt with lateral rotation of the scapula in a patient with severe pectus carinatum

Abdomen and Pelvis

The abdomen or belly can sometimes appear to be excessively protruding as if the patient has a 'pop' belly despite not being overweight. It may be exaggerated by the lower ribcage appearing to stick out (see rib flaring) and anterior pelvic tilt. It appears to be associated with poor muscle tone and pelvic tone and often responses to specific core muscle exercises.

Abdomen and Pelvis
Young boy with a symmetric pectus carinatum deformity and umber lordosis with anterior pelvic tilt and protruding abdomen

Rib flaring and flattening

One of the most common aspects of pectus deformity is abnormality of the associated ribcage. This typically affects the lower ribs and the lower edge of the ribcage (the costal margin). In both pectus excavatum and carinatum as well as mixed deformities the lower ribs can be flared where the ribs and the costal margin either on one or both sides are pulled upwards and stick out (see picture). Often Rib flaring can often appear to be the most significant deformity associated with otherwise a minor pectus excavatum or carinatum deformity. Rib flaring can also appear to be isolated without any other obvious abnormality.

Rib flaring and pectus excavatum. There is a lot of discussion amongst doctors about the best treatment for significant rib flaring as the standard surgical treatment for a pectus excavatum, a NUSS procedure (see Surgery) may not improve rib flaring and some reports have suggested it may even make it more pronounced though once the pectus is corrected over time the flaring may become less apparent. Open (Ravitch or modified Ravitch) procedures in experienced surgical hands may improve the appearance but rib flaring remains a difficult area for the surgeon to tackle. Specific exercise regimes to target and develop core muscle groups particularly the oblique muscles (see picture) may offer the best chance of improving rib flaring but requires dedication and hard work.

Isolated minor left sided rib-flaring
Isolated minor left sided rib-flaring in a patient with an otherwise normal chest

Rib flaring and pectus carinatum. In young patients bracing remains for many experienced pectus doctors the procedure of choice but like surgical options for pectus excavatum, bracing may not improve significantly prominent rib flaring, though some advocate the use of a specific brace to tackle the rib flaring directly in addition to a pectus brace.

Bilateral rib flaring
Bilateral rib flaring in a patient lying flat with a severe asymmetric right sided pectus carinatum deformity

Rib flattening, either one-sided and opposite the asymmetric pectus or bilateral particularly with pectus carinatum can also be striking and difficult to correct. Like rib flaring specific exercise regimes to target and develop core muscle groups may improve rib flattening.

3D model bilateral rib flattening
3D model used to assess and measure severity of pectus deformity demonstrating bilateral rib flattening in a severe symmetric pectus carinatum deformity

Low-esteem, Anxiety and depression

Probably the most common symptom seen in patients with pectus deformity is an unhappiness about how the pectus deformity appears. How unhappy they feel about their chest appearance will of course but very variable and in many people with pectus deformity it will not affect their lives and confidence significantly. However, it can affect self-esteem often at a vulnerable period in a young person life. A previously out-going confident teenager may start to avoid the swimming pool and school trips, cover up in baggy clothes even in summer weather and become increasingly withdrawn and avoid relationships. Low esteem due to concerns about physical appearance can in a few cases lead to increasing anxiety and even clinical depression.

Low-esteem, Anxiety and depression