Musculoskeletal System ORGAN SYSTEMS

Pectus excavatum

Congenital deformity of the anterior thoracic wall in which the sternum and rib cage grow abnormally producing a caved-in or sunken appearance of the chest.

Pectus excavatum is a condition in which a person’s breastbone is sunken into his or her chest. Severe cases of pectus excavatum can eventually interfere with the function of the heart and lungs. | Mayo Clinic Staff. (2018) Pectus excavatum – Symptoms and causes – Mayo Clinic. Retrieved June 29, 2018, from


Associated conditions:

  • Congenital disorders:
    • Noonan syndrome
    • Marfan syndrome
    • Loeys-Dietz syndrome
  • Connective tissue disorders:
    • Ehlers–Danlos Syndrome
  • Spinal muscular atrophy
    • Develop pectus excavatum due to their diaphragmatic breathing

Clinical features

  • Sunken appearance of the sternum (HALLMARK)
  • Cup-shaped concavity, involving the lower end of the sternum (M/C form)
  • Lower-most ribs may protrude (“flared ribs“)
  • May be symmetric or asymmetric
  • Chest and back pain
  • Severe cases:
    • Mitral valve prolapse
Severe case | CC BY-SA 3.0,



Chest X-ray or CT-scan


Conservative treatment:

  • Excercise

Magnetic mini-mover procedure (3MP)

Technique used to correct pectus excavatum by using two magnets to realign the sternum with the rest of the chest and ribcage

Vacuum bell (treatment by cup suction) +  physiotherapy

Vacuum bell for pectus excavatum treatment, with hand pump (left) and measuring rod (right) | By –, CC0,

Surgical management: Ravitch technique

  • Two-stage procedure:
    • Creating an incision along the chest through which the cartilage is removed and the sternum detached
    • Small bar is inserted underneath the sternum to hold it up in the desired position.
      • Bar is left implanted until the cartilage grows back (~6 months), then removed in an OPD procedure
X-ray of a 26-year-old male after the modified-ravitch reconstruction (asymmetric pectus excavatum) | BenchTHv – CC BY-SA 4.0,

Nuss procedure

  • Two-stage procedure:
    • Slipping in ≥ 1 concave steel bars into the chest, underneath the sternum
      • Bar is flipped to a convex position so as to push outward on the sternum, correcting the deformity.
    • Bar usually stays in the body for 2-5 years
      • Removed through OPD procedure when the bones have solidified into place
An x-ray scan of a 15 year old male after undergoing the Nuss procedure. The patient has a Lorenz bar under the sternum to correct pectus excavatum. | Stepshep – CC BY-SA 3.0,

Robicsek procedure

  • Single-stage procedure:
    • Pectoralis major muscles then detached from the sternum
    • Using the upper limit of the sternal depression as a guide, the deformed cartilages are removed one-by-one, using sharp and blunt dissection.
    • Lower tip of the sternum is then grabbed with a towel-clip and, using blunt dissection, is freed of tissue connections with the pericardium and the pleura.
    • Sternum is then forcefully bent forward into a corrected position.
      • To keep the sternum elevated, a piece of mesh is placed under the mobilized sternum and sutured under moderate tension bilaterally to the stumps of the ribs.
    • The pectoralis muscles are united in front of the sternum and the wound is closed.
Incentive spirometers, used after corrective surgery to avoid atelectasis by increasing basilar lung ventilation | Janine pohl – CC BY-SA 3.0,

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