This document discusses various chest wall disorders and deformities including scoliosis, pectus excavatum, flail chest, thoracoplasty, pectus carinatum, and Poland syndrome. Scoliosis is defined as a lateral curvature of the spine and can reduce lung volumes and compliance. Pectus excavatum involves a sunken sternum while pectus carinatum is a protruding sternum. Flail chest involves multiple broken ribs disrupting chest wall motion. Thoracoplasty was previously used to treat tuberculosis by compressing the lung. Surgical repair options are discussed for various conditions.

1. Chest Wall Disorder or
Deformities
Group A

2. Chest Wall Deformities
Scoliosis
Pectus Excavatum
Ankylosing Spondylitis
Flail chest
Thoracoplasty
Pectus carinatum
Poland Syndrome
Chest wall tumors

3. CLASSIFICATION:

4. Scoliosis
• Scoliosis is defined as a
lateral curvature of the
spine and is associated
with rotation of the spine
and viscera adjacent to it.
• It may be (but is usually
not) accompanied by
kyphosis.

5. • Thoracic scoliosis to the right- most common
presentation.
• More prevalent- Girls.
• Higher & Increase angle of curvature- worse
prognosis.

6. Cobb’s angle
• Lines are drawn parallel
to the upper border of
the upper vertebral body
and to the lower border
of the lowest vertebra of
the structural curve.
• Perpendiculars are then
erected from these lines
to cross each other, the
angle between the
perpendiculars being the
angle of curvature or
Cobb’s angle

7. Pathology
• Total lung volume is reduced and the lungs
differ in size, with distortion of lobar shapes
due to the deformity.
• Alveolar size may vary, alveolar numbers per
acinus may correspond to that developmental
stage.
• Vascular medial hypertrophy- Cor pulmonale

8. Physiology
• Lung volumes are reduced, with a restrictive
pattern.
• VC, TLC, MVV, functional residual capacity
(FRC) and peak expiratory flow (PEF)- reduced.
• The higher the curve in the dorsal spine, the
more severe its effect on function.
• FEV1/FVC ratio is normal unless obstructive
disease such as asthma supervenes.
• Dlco is reduced

9. • Lung compliance in scoliosis is commonly low-
inability to take a deep breath.
• Exercise tolerance is limited.
• Patients with severe scoliosis (with an angle
≥100°), severe desaturation may occur during
sleep with episodes of central or obstructive
apnoea and hypopnoea.
• In severe disease- increasing hypoxia- Pulmonary
artery hypertension.
• Co2 retention- diminished ventilatory responses.

10. Clinical features
• Mild scoliosis to have respiratory symptoms-
unusual.
• Daytime somnolence may indicate the presence
of nocturnal desaturation.
• Exertional dyspnoea- due to the restriction.
• PHT and RVH often occurs in the fourth decade.
• Death most commonly occurs as a result of
respiratory failure or cardiac disease.
• Respiratory tract infection.

11. Treatment- Surgery
Surgical intervention- may ameliorate the angle of
curvature and halt the progression of scoliosis &
halt the progression of scoliosis.
• Surgical fusion of spine- role in children with
congenital spinal deformities or in children with
KS secondary to neurological defects.
• Non-fusion approach includes implantation of
growth-friendly rods such as expandable spinal
rods, titanium rib implants, or remotely
distractible magnetically controlled rods.

13. Medical treatment
• Long-term domiciliary oxygen therapy-
respiratory failure,
• Assisted ventilation- PPV (nasal mask or full-face
mask),
• Life-threatening hypoventilation include tank
respirators or cuirass shells,
• Less satisfactory for the patient, but equally
effective, is nocturnal ventilation via a permanent
tracheostomy,
• Diuretic therapy- RVH,

14. Medical treatment
• Bronchodilator therapy,
• Smoking cessation,
• Maintenance of body weight within a desirable
range, engaging in frequent physical activity to
improve exercise capacity,
• Immunization against influenza and
pneumococci,
• Prompt treatment of respiratory infections,
• Psychological support for those with diminished
self-esteem.

16. Pectus Excavatum
• Funnel chest or trichterbrust
• Posterior depression of the sternum and
costal cartilages
• 1st & 2nd ribs & manubrium : normal
position
• Lower costal cartilages and the body of the
sternum are depressed
• Asymmetry of the depression is frequently
present Rt. > Lt.

18. Pectus Excavatum
• Present at birth or within first year of life
in the majority : 86%
• Rarely resolves with increasing age
• May worsen during rapid adolescent
growth
• Scoliosis: 26%
• Asthma : 5.2%
• CHD : 1.5%

19. Pectus Excavatum
• Etiology and Incidence
- 1 in 400 live births
- Boys > Girl 4: 1
- Etiology : unknown
- Variable pattern of inheritance
- Multifactorial

20. Pectus Excavatum
• Symptoms
- Well tolerated in infancy and childhood
- Older children :
 pain in the area of the deformed cartilages
 precordial pain after sustained exercise
 palpitations
 transient atrial arrhythmias
 may have mitral valve prolapse

21. Pectus Excavatum
• Surgical Repair
Haller and associates : tripod fixation
- Subperichondrial resection
- Posterior sternal osteotomy
- Most cephalad normal cartilages are then
divided obliquely in a posterolateral
- Sternum elevated, the sternal ends of
the cartilage rest on the costal ends

22. Pectus Excavatum
• Nuss and procedure
• Minimally Invasive Repair of Pectus
Excavatum (MIRPE)

27. Before and After Surgery

28. Non surgical treatment.

29. The open surgical technique

38. Complication : Nuss procedure
Early
• Pneumothorax
• Pericarditis
• Pneumonia
• Hemothorax
• Transient extremity
paralysis
• Superficial wound
infection
• Bar infection
Late
• Bar displacement
• Hemothorax
• Overcorrection deformity
• Pectus carinatum
deformity

39. Flail chest
• double fractures of three or more adjacent ribs or
the combination of sternal and rib fractures are
required to produce a flail segment of the rib
cage and lead to respiratory failure.
Causes:
• trauma related to automobile accidents or falls
• aggressive cardiopulmonary resuscitation
• pathological rib fractures (i.e., multiple myeloma,
other metastases).

40. • Disruption of rib cage integrity in flail chest
renders motion of the flail segment entirely
dependent on pleural pressure changes during
breathing.
• The most common anatomical location for flail
chest is the lateral rib cage.
• VC and FRC can be reduced to as much as 50% of
predicted.
• With surgical stabilization , VC usually returns to
normal range in about 3 months.

41. Inspiration
• Pleural pressure becomes
sub-atmospheric, which is
inflationary to the lung and
deflationary to the rib
cage.
• Consequently, the flail
segment moves inward
rather than outward during
inspiration.

42. Expiration
• Pleural pressure becomes
more positive and the flail
segment moves outward.
• This paradoxical motion of
the flail segment is
augmented by conditions
that load the respiratory
system thereby amplifying
pleural pressure swings.

43. Pathogenesis of respiratory failure

44. Treatment
Objective of treatment:
a) Pain control:
• enhance cough efficiency
• use of oral or intravenous narcotics, intercostal nerve
blocks, or epidural anesthesia.
b) Minimize atelectasis:
• frequent tracheal bronchial toilet
c) Mechanical ventilation:
• low impedance modes- CPAP- associated with less chest
wall distortion during inspiration.
• Reduce morbidity and length of hospitalization.
c) Surgical fixation of the flail chest

45. Thoracoplasty
Pre-antituberculous chemotherapy era,
thoracoplasty was the standard surgical
approach to control PTB.
• Rib removal,
• Rib fracture,
• Phrenic nerve resection,
• Lung compression by filling the pleural space
with foreign material (i.e., ping pong balls)

47. • Thoracoplasty is indicated for treatment of
bronchopleural fistulae that have failed to
close following decortication or
• For treatment of persistent empyema in which
decortication is not feasible or has failed to
eradicate the infection

48. Treatment
• Supplemental oxygen,
• Antibiotics for respiratory infections,
• Noninvasive ventilatory support.

49. Pectus carinatum or pigeon chest
• sternum is prominent, forming an anterior ridge
like the keel of a ship with the ribs falling away
steeply on either side.
• associated with other congenital anomalies,
especially cardiac lesions and coarctation of the
aorta.
• Less frequent than pectus excavatum
• M:F 4:1
• Cause: unknown
• Positive family history in 26%

50. Pectus Carinatum
• CHD : 18%
• FH of chest wall deformity : 26 %
• Boys > Girls = 78 : 22 %
• Mild form at birth but often progresses
during early childhood
• The chondromanubrial deformity, often
noted at birth

51. Pectus Carinatum

52. Pectus Carinatum

53. Poland’s syndrome
• Hypoplasia of the sternal head of
the pectoralis major and minor
muscles
• Normal underlying ribs to complete
absence anterior portions of the 2nd –
5th ribs and costal cartilages
• The etiology is unknown.

54. Poland's Syndrome
• Hypoplasia of the sternal head of the
pectoralis major and minor muscles
• Normal underlying ribs to complete
absence anterior portions of the 2nd – 5th
ribs and costal cartilages

55. Poland's Syndrome

56. Poland's Syndrome

58. Poland's Syndrome
• Surgical Repair
- Assessment of the extent of involvement
limited to the sternal component of the
pectoralis major and minor muscles,
• little functional deficit
• repair is not necessary except to
facilitate breast augmentation in
women

59. Poland's Syndrome
• Surgical Repair
- Assessment of the extent of
involvement underlying costal cartilages
are depressed or absent
• repair must be considered to minimize
the concavity
• to eliminate the paradoxic motion of
the chest wall if ribs are absent
• in girls to provide an optimal base for
breast reconstruction

60. Poland's Syndrome
• Surgical Repair
Ravitch :
– Correction of posteriorly displaced costal
cartilages by unilateral resection of the
cartilages
– A wedge osteotomy of the sternum, allowing
rotation of the sternum; and fixation with
Rehbein struts and Steinmann pins
– The sternum is then displaced anteriorly and
supported with a retrosternal strut

62. Thank you