This section on chest wall disorders encompasses benign disorders of the skeletal and muscular chest wall, including congenital deformities of the chest wall, a group of compressive disorders known collectively as thoracic outlet syndrome, and management of chest wall infections (Fig. 118-1).
Muscular (A) and skeletal (B) anatomy of the chest, anterior view.
Congenital chest wall deformities may be categorized as (1) pectus excavatum, (2) pectus carinatum, (3) Poland's syndrome, (4) sternal defects, and (5) miscellaneous anterior chest wall defects. While most patients present during childhood, some may present in early adulthood as well.
Pectus excavatum, or “funnel chest,” is a congenital deformity characterized by posterior depression of the middle to inferior portion of the sternum and posterior curvature of the associated costal cartilages. Generally, the manubrium and first and second ribs are normal. The severity of the depression varies and is usually asymmetric with a deviation to the right side. Shamberger and colleagues reported that most cases (86%) are diagnosed at or within a few weeks of birth.1 Although it was once commonly believed that children would “grow out of” this deformity, the severity of the sternal depression may increase as the child grows.
Pectus excavatum is the most common congenital chest wall deformity in children. The incidence generally is reported to range from 1 in 300 or 400 to 1 in 1000 live births. In addition, boys are reported to be affected three times as often as girls.1 The etiology of this deformity is unknown. Theories include intrauterine pressure, rickets, and abnormalities of the diaphragm.2 Shamberger and colleagues note that 35% of patients report a positive family history for chest wall deformities.1
Pectus excavatum may be accompanied by other abnormalities. In a study of 704 children with pectus excavatum, 18% had other musculoskeletal abnormalities, such as scoliosis or kyphosis. Pectus excavatum also has been associated with Marfan's syndrome and congenital heart defects (1.5%).1 Patients may be asymptomatic or may complain of dyspnea on exertion or chest pain. Although asymptomatic, children may experience psychological distress as a consequence of their cosmetic appearance. In a recent multicenter prospective trial, shortness of breath on exertion was reported by 66% of patients. Limited exercise tolerance (64.5%), shortness of breath at rest (62.1%), chest pain on exertion (51.1%), chest pain unrelated to exertion (32%), and palpitations (11%) also were reported. Pain on exertion and at rest was presumably musculoskeletal in origin.3
Physical examination reveals a middle to inferior sternal depression of varying severity. Usually the depression is asymmetric, with deviation to the right side being most common. The heart is often rotated more to the left because of the depression. Many studies have investigated the altered cardiac function by means of electrocardiogram (ECG), echocardiogram, nuclear medicine ...