PC (also called pigeon breast) describes a range of chest wall deformities characterized by a convex protrusion of the sternum and the adjacent costal cartilages. The condition is thought to result from the abnormal growth of the costal cartilages resulting in an anterior chest wall protrusion of varying severity. The exact cause of the exaggerated growth is not yet understood. The condition is seen more commonly in families with other thoracic deformities and has also been associated with Marfan syndrome, congenital heart disease, and hand agenesis indicating that there may be a hereditary or congenital origin.
The overall incidence of PC is 0.6%, and the deformity affects males more than females (4:1).1 The deformity often progresses in severity during the accelerated growth seen with puberty. As such, the condition is not typically appreciated until after the first decade of life and most patients present for correction as teenagers.2 Although PC may be associated with significant cardiopulmonary compromise with symptoms such as palpitations, dyspnea, and wheezing because of chest wall rigidity, for most patients it is the significant cosmetic and psychosocial impact that prompts them to seek surgical reconstruction.3
Surgery is the traditional treatment for PC. Although surgical management usually produces good results, these procedures are often very debilitating. For this reason, there has recently been an increasing impetus to explore nonoperative management strategies for PC by taking advantage of the fact that the anterior chest wall is still compliant during puberty. Various different strategies for remodeling the chest wall have been described, but it is clear that some of the most convincing outcomes have been seen with orthotic bracing.
The first case report describing the use of orthotic bracing for the PC deformity was published in 1993. In this report, Mielke and Winter4 describe an excellent result in an 8-year-old girl treated with bracing for about 16 months for a cosmetically objectionable PC deformity. This first report was followed by other reports documenting similar success with orthotic bracing for PC.1,5–7 In this report, we again demonstrate good success with custom-made braces for very noticeable pectus deformities in two motivated teenage boys.
Fabrication of these orthoses is a relatively simple procedure. There are a few prefabricated PC orthoses commercially available, but we choose to custom fabricate each patient due to the asymmetry of the protrusion abnormalities. Custom fabrication most importantly insures a lower profile and more comfortable orthosis with fewer problems associated with skin breakdown. To make a custom brace, first a negative cast is taken of the patient supine using plaster splints. This is then filled and modified slightly building up the most prominent aspect of the protrusion. A rigid material such as high-density polyethylene or copolymer is thermoformed over the protrusion and lined with a soft interface. The anterior and posterior bands made from aluminum are carefully contoured and are then covered with heat shrink tubing leaving adequate clearance for compression. These are connected with ladder buckles on each side to allow adjustment of the compression. The patient can monitor the compression by the position of these buckles and ladder straps and increase it at regular intervals. This keeps a gradual increase of compression on course and provides the clinician with a progress report. Shoulder straps are added to aid with suspension of the orthoses. The completed orthoses is shown in Figure 4.
Once a custom brace has been constructed, the correct application of the brace and diligence with brace wearing on the part of the patient are of paramount importance. Application of bracing in early teenage growth phase (before age 16) seems to be the optimal time for initiating this approach. Patients are typically instructed to wear the brace for 23 hrs a day for 3 to 6 months or until the defect is flattened. After this, the brace should be worn for 16 hours a day for the next 3 to 6 months, which allows the patient to participate in school activities without the brace. After complete subjective improvement is noted, the maintenance phase is initiated with nightly brace wearing until linear growth ceases.7 All patients should undergo re-evaluation every 3 months to ensure proper fit of the orthoses.
This report clearly documents, in a pictorial format, the potential efficacy of orthotic bracing for a child with a disfiguring PC deformity. In addition, we also describe the process of creating a custom pectus orthoses to achieve the best corrective result. Although similar results have been reported previously, there are no convincing imaging data in the literature to support the documented results and there is very little data on the actual construction of a custom orthosis. Here, we provide imaging that clearly demonstrates remarkable improvement in a PC deformity after only 2 to 3 months of bracing in two very motivated teenaged boys. From the images in this report, it is clear that orthotic bracing with a carefully constructed custom prostheses has the potential to improve the PC deformity to the point where it is barely discernable (Figs. 1, 3).
The importance of patient compliance and motivation in combination with strong parental support cannot be overemphasized. It is clear that in well motivated skeletally immature individuals, bracing can be an effective treatment for cosmetically displeasing PC. We also emphasize an individual-based approach with interval refitting that has been implicit in the excellent results demonstrated in our patients (now totaling 12). This report provides imaging data that clearly demonstrates the potential efficacy of orthotic bracing for PC in strongly motivated and compliant patients.
1. Kravarusic D, Dicken BJ, Dewar R, et al. The Calgary protocol for bracing of pectus carinatum: a preliminary report. J Pediatr Surg
2. Shamberber R. Congenital chest wall deformities. Curr Probl Surg
3. Chidambaram B, Mehta AV. Currarino-Silverman syndrome (pectus carinatum type 2 deformity) and mitral valve disease. Chest
4. Mielke CH, Winter RB. Pectus carinatum successfully treated with bracing. A case report. Int Orthop
5. Banever GT, Konefal SH, Gettens K, Moriarty KP. Nonoperative correction of pectus carinatum with orthotic bracing. J Laparoendosc Adv Surg Tech A
6. Egan JC, DuBois JJ, Morphy M, et al. Compressive orthotics in the treatment of asymmetric pectus carinatum: a preliminary report with an objective radiographic marker. J Pediatr Surg
7. Frey AS, Garcia VF, Brown RL, et al. Nonoperative management of pectus carinatum. J Pediatr Surg
2006;41:40–45; discussion 40–45.
Keywords:© 2009 American Academy of Orthotists & Prosthetists
pectus carinatum; orthosis; bracing