Congenital chest wall deformities are usually divided into five categories: Pectus excavatum or funnel chest, Pectus carinatum or Pigeon breast, Poland syndrome, sternal defects and other anomalies or chest deformities seen in extensive bone disease. The majority of chest wall deformities are not life-threatening. Most chest wall deformities are not life-threatening, but can cause some functional abnormalities. Funnel chest Funnel chest is the most common chest wall deformity with an incidence of 1 to 4 per 1,000, accounting for more than 90 percent of all chest wall deformities. It is a progressive lesion that may be present at birth, but often becomes more pronounced after a few months or even years and is detected by parents. 90% of patients can be detected within one year after birth, and the deformity generally becomes more severe as the patient grows and develops. The main manifestation is the medial depression of the sternum, giving the anterior chest a funnel shape, anterior extension of the shoulders, a slight hunchback and a prominent epigastrium. The cause of funnel chest is unknown, and some scholars believe it is related to genetics. Etiology: The exact etiology is not fully understood. Some people think that it is due to the uncoordinated growth of the ribs and the backward depression of the sternum caused by the extrusion of the overgrown ribs, but others think that it is due to the short central tendon of the diaphragm attached to the lower end of the sternum, which causes the sternum and the glabella to be pulled backward and depressed. The onset of the disease is not related to “calcium deficiency” and about 10-20% of children have a clear family history of the disease. In a few cases, the funnel chest develops secondary to chest surgery (e.g., surgery for congenital heart disease). Symptoms and signs: depression deformity of the anterior chest wall (funnel-shaped), the fourth to eighth rib cartilage is depressed from the medial or lateral side of the rib-cartilage junction toward the spine to form the two walls of the funnel, the sunken sternal body (especially the root of the saber) forms the lowest point of the funnel, resulting in the anterior chest wall resembling a funnel, the rib alignment slope of the funnel chest is larger than normal, the ribs are depressed sharply from the posterior to the anterior to the inferior, making the front and back closer. In severe cases, the deepest depression of the sternum can reach the spine. The heart is displaced by the pressure, and the lungs are also limited by the thoracic deformity, which affects the cardiopulmonary function of the child. The deformity tends to be symmetrical in young patients with funnel chest, but gradually becomes asymmetrical with age, the sternum tends to rotate to the right, the depression of the right rib cartilage tends to be deeper than the left, and the right breast development is worse than the left. The posterior thorax is mostly flat back or round back, and scoliosis gradually worsens with age, and scoliosis is less likely to appear when the patient is younger, but more obvious after puberty. The special “thoracic posture” is characterized by sloping shoulders and an excessively curved spine, as if the child had a hunchback. There is an anterior tilt of the shoulders, an arching of the back, a sunken anterior chest and a bulging abdomen, a protrusion of the low rib cage and abnormal respiratory dynamics, and a paradoxical depression of the sternum during deep inspiration. Most patients show reduced exercise tolerance and may have symptoms such as tightness of breath and palpitations after strenuous activity. Patients are weak and often develop upper respiratory and pulmonary infections and even heart failure. The symptoms become more obvious after the age of 3, with concave chest, convex belly, emaciation and poor growth. A mild funnel chest can be asymptomatic, but a more severe deformity compresses the heart and lungs, affecting respiratory and circulatory functions, reducing lung capacity, increasing functional residual air volume, reducing activity tolerance, limiting mobility, and significantly reducing expiratory and maximal ventilation. Children are often thin and immobile. Young children often have recurrent respiratory infections, cough and fever, and are often diagnosed with bronchitis or bronchial wheeze. Young children have fewer circulatory symptoms. Older ones can develop dyspnea, rapid pulse, palpitations, and even pain in the precordial region after activity, mainly because the heart is compressed, cardiac blood output cannot meet the needs during exercise, and the myocardium is hypoxic, thus causing pain. Some patients can also develop arrhythmias, as well as systolic murmurs. The less severe symptoms of compression of the funnel chest in infancy often go unnoticed. Some have inspiratory stridor and sternal aspiration depression, but the cause of the airway obstruction is often not detected. Funnel chest is sometimes combined with pulmonary hypoplasia, Marfan syndrome, and asthma, and the combined presence of these conditions often becomes an intolerable deformity for the patient, often requiring early surgical correction. The heart is often displaced to the left and rotated in a clockwise direction, and the right edge of the heart often overlaps the spine; in some severe cases, the heart shadow can be located completely in the left thoracic cavity, and in older patients, the spine is often laterally curved. CT images are more precise and clear, and can clearly show the severity of the thoracic deformity and the degree of heart compression and displacement. The ECG may show inverted or bidirectional P waves in V1. Right bundle branch block may also be present, and cardiac catheterization can be traced to diastolic slopes and plateaus, as seen in constrictive pericarditis. Cardiac angiography shows right heart compressional malformations and right ventricular outflow tract obstruction. Funnel chest is very easy to diagnose clinically and the malformation is readily apparent. However, it is more difficult to determine the severity of funnel chest, and there are many clinical methods to describe it. Currently, the Haller index (the ratio of the left and right transverse diameter and anterior and posterior diameter at the most depressed plane of the thorax) is commonly used to indicate the severity of funnel chest, and a thoracic index of 3.20 or less is considered mild funnel chest. Treatment of funnel chest is usually progressive and aggravating, and the effect on heart and lungs will gradually become obvious, so it should be treated except for mild funnel chest. Surgery is the only effective way to treat funnel chest, and the age of surgery is usually chosen to be over 3 years old, and the best age for surgery is 3 to 6 years old. Indications for surgery: including the following 2 or more criteria: (1) thoracic index greater than 3.20 on CT examination; thoracic index (Haller index, the ratio of left and right transverse diameter and anterior and posterior diameter at the most depressed plane of the thorax); (2) pulmonary function suggesting restrictive or obstructive airway pathology, impaired ventilation of small airways and reduced ventilation reserve function; (3) electrocardiogram, echocardiographic findings (4) the development of a funnel deformity and the combination of significant symptoms; (5) the psychological and psychiatric problems of the child due to the deformity in the appearance of the funnel chest. There are many surgical options for the correction of funnel chest, including minimally invasive funnel chest correction (Nuss procedure), sternal reversal, sternal lift (Ravitch procedure) and its modifications, etc. At present, minimally invasive funnel chest correction (Nuss procedure) is the most widely used. The main principle of surgical correction of funnel chest is to lift the depressed sternum and rib cartilage for the purpose. The initial approach was sternal reversal to modified sternal reversal with preservation of blood vessels and muscle tissues. The later emergence of the Ravitch procedure simplified the surgical operation, but the procedure still required cutting or removing the deformed rib cartilage and sternum and then re-suturing them. It has been gradually replaced by minimally invasive funnel chest correction (Nuss procedure) due to the complicated operation, long operation time, heavy blow to the patient, high postoperative complication and recurrence rate, and unsatisfactory postoperative appearance of the patient. The prognosis of funnel chest is generally better, the surgical complications are lower, and the current minimally invasive funnel chest correction surgery has a satisfactory orthopedic appearance and a low recurrence rate. Cocksucker’s chest Cocksucker’s chest is a common thoracic deformity, a pathological change caused by the forward elevation of the sternum, accounting for about 6-22% of chest deformities, with a male to female ratio of about 3-6:1. Etiology The onset of cocksucker’s chest is mostly related to calcium and phosphorus metabolism. Clinically, there are also families with coexisting funnel chest and pectus excavatum, so very few of them are considered congenital, while only 10% of them are found at birth. A small number of cases are secondary to congenital heart malformations or chest surgery. Symptoms and signs Most pectus excavatum is not detected at birth like funnel chest, but is often noticed gradually after the age of five or six. A mild degree of corpus cavernosum has little effect on the internal organs of the thorax and rarely results in compression of the heart and lungs, but a moderate to severe degree of corpus cavernosum can cause a reduction in the volume of the chest cavity and compression of the heart and lungs, resulting in clinical manifestations of cardiopulmonary insufficiency. Moderate and severe deformities can have adverse effects on the physiological and psychological development of patients. Clinically, according to the different morphology of the sternum, the chicken chest can be divided into three types: 1, boat-shaped chest mainly for the sternum elongated, convex forward, bilateral lower part of the rib cartilage sunken, like the keel of a boat, serious cases to reduce the volume of the chest cavity. On the lateral X-ray, we can see that the ribs are separated from the sternum and the posterior sternal space is prolonged. 2, spherical pigeon chest spherical pigeon chest is characterized by the sternal stalk, sternal body connection with the adjacent rib cartilage bulge, if there is a reduction in the sternal angle, it will cause the sternal body to sink, so that the 2nd to 5th rib cartilage bulge next to the sternum. Spherical pigeonholes are often accompanied by sternal ossification lines, especially early ossification at the sternal stalk and sternal body junction, which can be seen at 3 years of age or even before 3 years of age in affected children. In contrast, in general, the sternal stalk and sternal body junction is open in 99% of individuals regardless of their age. The ossification of the sternal stalk and body junction and the elevation of the sternal angle are called “sternal angular bone junction”. 3.Unilateral pectus excavatum, also known as asymmetric pectus excavatum, is characterized by protrusion of one side of the chest wall, sometimes accompanied by subsidence of the opposite side. The rib cartilage deformity plays an important role in this type, and the abnormal position of the sternum is not obvious. The treatment of moderate to severe pectus excavatum should be surgical at an appropriate age. Surgery is recommended after adolescence because of the possibility of recurrence due to the softness of the bone and the occasional ability of some mild cocksuckers to correct themselves during development. The age of surgery is usually above 10 years old. However, for those who have heavy deformity in appearance and influence on cardiopulmonary function, the age of surgery can be moderately advanced according to the specific situation. If the symptoms do not improve and have an impact on cardiopulmonary function, or if there is a psychological impact and the patient and his family strongly request it, it is also advisable to consider surgery to correct the deformity. When surgically correcting the corpus cavernosum deformity, we should pay attention to whether the original protruding sternum will compress the heart after surgery, so we should carefully study the chest film and CT film before surgery, if there is no lung tissue between the sternum and the heart, the sternum may compress the heart after surgery, and the sternum should be properly elevated during surgery. There are traditional orthopedic surgery for chicken breast and minimally invasive orthopedic surgery for chicken breast. The traditional orthopedic surgery is a transverse or longitudinal incision in the middle of the chest to free the soft tissues of the chest wall and the pectoralis major muscle on both sides; subperiosteal stripping to remove the bilateral pairs of deformed rib cartilage, cutting off the middle part of the sternum or making incomplete osteotomy at the proximal end according to its different anatomical shape, fully loosening the sternum to restore the straightness; sinking the sternal ribs to restore the normal thorax, removing the overgrown rib cartilage after sinking, and suturing the periosteum. If the sternum is unstable, a kyphotic pin can be placed transversely or longitudinally in the sternal body to fix it to the chest wall. Bilateral pectoralis major muscles are pulled together and sutured in front of the ribs to prevent rebound of the sternum. Minimally invasive corpus cavernosum orthopedic surgery using a bony external thoracic plate to compress the anteriorly convex chest wall and thus achieve orthopedic purposes is a new surgical procedure carried out this year. Patients with good chest wall compliance, symmetrical, basic symmetrical, mildly asymmetrical or localized protrusion without obvious depression are suitable for minimally invasive surgery; older patients with hard bone and poor chest wall elasticity; patients with obvious depression and heavy rotation of the sternum in addition to the protruding chest wall; patients with high thoracic stenosis Patients who have a high degree of thoracic stenosis, squeeze the heart and lungs, so that the cardiopulmonary function is seriously affected, accompanied by other comorbidities may not be suitable for minimally invasive surgery. The prognosis of surgery for chicken chest is better, the surgical complications are lower, and the surgical orthopedic effect is more satisfactory, but there is a certain recurrence rate after surgery. Other rare chest wall deformities I. Poland syndrome Poland syndrome is epidemic, with an incidence of only about 1/30,000 -32,000, and is a group of congenital malformations of the skeletal-muscular system. There is a remarkable diversity in its clinical manifestations. All children with Poland syndrome have hypoplasia or hypoplasia of the pectoralis major, sternum, and cartilage, combined with at least one other malformation, such as absence of the pectoralis minor, absence of ribs, localized chest wall subsidence, absence of nipples or breasts and syndactyly or short fingers, absence of axillary hair, and limited subcutaneous fat. The degree of muscle involvement. Patients with rib sternal defects or hypoplasia resulting in severe chest wall defects or severe depression of the chest wall require surgical transplantation of rib cartilage or muscle for correction, and most girls require breast reconstruction, but surgery is eventually deferred until late adolescence. Second, sternal defects Sternal defects are much less common and are classified as: thoracic cardiac ectasia, cervical cardiac ectasia, thoracoabdominal cardiac ectasia and sternal bifurcation or sternal splitting. Sternal defects require surgery to repair the defective sternum to protect the heart and other intrathoracic organs from injury. Third, other abnormalities or chest deformities seen in extensive bone disease 1, asphyxiating thoracic atrophy (thoracic insufficiency syndrome, TIS) — Jeune syndrome asphyxiating thoracic atrophy is a rare autosomal recessive genetic The disease is characterized by small thorax, pelvic deformity, shortened limbs, and polydactyly. The clinical manifestations are short ribs, narrow thorax, difficulty in respiratory movement, and polydactyly in 20% of cases. This type of patients in the neonatal period and infancy are mostly due to respiratory infections, infants and young children can cause respiratory difficulties due to thoracic dysplasia, repeated respiratory infections, resulting in severe pneumonia and death, if you can pass the infancy, children in childhood due to thoracic growth of the incidence of respiratory infections is reduced, but can cause chronic renal failure due to renal fibrosis and death. 2, poor thoracic structure of the spine – Jarcho-Levin syndrome autosomal recessive disorder, mostly occurs in Puerto Ricans. Alternating multiple hemivertebrae may affect most or all of the thoracic and lumbar vertebrae, and the ossification centers of the vertebrae rarely span the midline. Multiple posterior fusion of the ribs and marked shortening of the thoracic vertebrae give the thorax a crab-like appearance on radiographic imaging. Approximately 1/3 are combined with other malformations, including congenital heart disease and renal malformations. Most patients die before 15 months of age, usually in early infancy due to respiratory failure and pneumonia. 3, Cerebro-costo-mandibular syndrome (Cerebro-costo-mandibular syndrome ) before and after birth growth retardation, mental retardation, 50%. Palatal malformation (absent soft palate, short hard palate with central foramen, absent uvula) Prolapsed tongue, resulting in neonatal respiratory distress at presentation. Severe micrognathia with a cleft between the hard and soft ribs (especially the 4th to 10th ribs). Small, bell-shaped thorax. Loose skin, spinal deformities, and elbow hypoplasia. Occasionally, there is a small head deformity. The prognosis of the disease is poor, mostly due to respiratory distress equal to early death, and 40% die within 1 year.