Chest wall

Question 1

Haller index. Definition? Normal value?

Answer 1

= lateral diameter / AP dimension. On axial CT.
Normal = 2.5
Severe > 3.25

Question 2

Pectus excavatum. Prevalence? more common in which sex?

Answer 2

MC congenital anomaly of the anterior chest wall
Prevalence: ~ 2%
Males > females (3:1)

Question 3

What genetic, valvular, and musculoskeletal disorder associated with Pectus excavatum

Answer 3

Marfan’s
Mitral Valve prolapse due to sternal pressure on annulus
Scoliosis

Question 4

Pathophysiology of pectus excavatum

Answer 4

PFT –> restrictive deficit/reduced vital capacity, does not correlate with degree of exercise limitation
Mechanical compression of RV
Mostly asymptomatic. Symptoms include exercise intolerance, shortness of breath

Question 5

Indication for the repair of pectus excavatum

Answer 5

Symptomatic and esthetic/psychosocial factors. Cosmetic results are excellent; Variable improvement seen in exercise intolerance

Question 6

Work up for pectus excavatum

Answer 6

CT chest –> calculate haller index
PFT –> restrictive/reduced vital capacity, does not correlate with degree of exercise limitation
EKG
Echo –> assess mitral prolapse, RV compression

Question 7

Surgical approach of pectus excavatum

Answer 7

Ravitch repair
Nuss procedure
Sternal eversion

Question 8

Ravitch repair

Answer 8

open midline or transverse inframammary incision –> subperichondrial resection of all deformed costal segments –> wedge sternal osteotomy to allow sternal elevation –> sternal fixation (e.g. retrosternal bar)

Question 9

Nuss Procedure

Answer 9

Thoracoscopy –> a convex bar is passed behind the sternum through the anterior mediastinum –> rotate to push the sternum and deformed cartilages forward –> fix laterally to the chest wall.
(Not done in UWMC)
Limitations:
Perform before the growth spurt.
Greater pain than the open approach.
The bar generally needs to remain in place for 3 years.

Question 10

Sternal eversion

Answer 10

Free graft of sternum

Not common due to complications

Question 11

Pentalogy of Cantrell or thoracoabdominal ectopia cordis

Answer 11

Lower sternal defect/sternal cleft
Abdominal wall defect/omphalocele
Anterior diaphragmatic hernia
Ectopia cordis
Congenital heart malformation (VSD, ventricular diverticulum)

Question 12

Ectopia Cordis

Answer 12

Failure of the covering of the heart (skin, sternum, pericardium). The heart is abnormally located partially or totally outside of the thorax.

Question 13

Pectus carinatum definition

Answer 13

Protrusion deformity of the anterior chest wall.

Haller index < 2.

Question 14

Pectus carinatum types

Answer 14

Chondrogladiolar prominence — The middle and lower portions of the sternum protrude and arch forward.

Chondromanubrial prominence — the upper portion of the sternum protrudes anteriorly, and the body of the sternum is deviated posteriorly. Less common.

Question 15

Pectus carinatum indication and operative approach

Answer 15

Indication is primarily a cosmetic concern. Operative approach similar to pectus excavatum, subperichondrial excision of the affected costal elements with one or more sternal osteotomies is required.

Question 16

Poland’s syndrome

Answer 16

Unilateral absence of the pectoralis major and pectoralis minor muscles associated with syndactyly.
Congenital. Due to uterovascular event of affect subclavian supply
May be associated with rib aplasia, amastia, absence of axillary hair

Question 17

Sternal cleft

Answer 17

rare; a failed embryologic fusion of sternum

Question 18

Jeune’s Syndrome

Answer 18

AKA asphyxiating thoracic dystrophy

Narrow, restrictive chest with ribs oriented horizontally and foreshortened –> Limit pulm development and poor resp mechanics

Question 19

Jarcho-Levin syndrome

Answer 19

AKA spondylothoracic dysplasia

Short alternating hemivertebrae –> very close approximation of the ribs –> poor respiratory mechanics