A few months ago -- I don't remember a specific occasion, or what we were doing -- I noticed something odd about the way my oldest son's plaid shirt fell as it draped over his chest. Without making it obvious what I was doing, I watched him more closely over the next few days, and decided that it wasn't just the way he was sitting or the pattern on that particular shirt. Something about the shape of his chest looked unusual.
I am, of course, aware that he is a rapidly growing fourteen-year-old boy; he rather suddenly began borrowing his dad's winter boots just this year. Like his dad, he is slim; where his dad looks athletic and lean, in fourteen-year-old boy terms that translates into "really lanky." The boy has always been able to do this grotesque trick where he sucks in his belly and becomes about three inches wide from back to front.
So my second thought (after the first one, "Huh -- did I imagine that?") was that perhaps I was just looking at an example of rapid adolescent body-changes. He was going through a growth spurt, and teenage boys are famously weird-shaped while that is going on, and he has approximately zero body fat on his skeleton.
I paid attention, though. And I started to get a sneaking suspicion that he, also, had noticed it, because one of the things I noticed over the next few months was that he never, ever appeared outside his room without a shirt on. Or a rash guard if we went swimming.
So after a while I Googled "teenage boy protruding sternum." Up came the term pectus carinatum. I re-googled "pectus carinatum," took a look at the image search and thought -- yeah, that's what it looks like. My son's case doesn't look quite as pronounced as some of the images, but the shape of what I had seen under the fabric of his shirt was very similar.
+ + +
So, some basics of this particular chest wall deformity.
"Pectus carinatum" means "keel-shaped chest," and is more colloquially known as "pigeon chest." Its immediate cause is an abnormal growth of ribcage cartilage. A related condition is pectus excavatum, colloquially, "sunken chest," and that's a much harder problem to correct and also one that tends to create more health problems.
Carinatum is said to be less common than excavatum, but I'm suspicious of that; excavatum looks "more wrong" than carinatum, since everyone knows the chest is supposed to be slightly convex and not concave at all, so I wonder if people who have mild cases of carinatum never seek a diagnosis.
According to Wikipedia, "Most commonly, pectus carinatum develops in 11-to-14-year-old pubertal males undergoing a growth spurt. Some parents report that their child's pectus carinatum seemingly popped up overnight." I read that most patients are treated successfully during adolescence with minimally invasive or noninvasive orthotic bracing, and decided that I would bring it up at the next pediatrician's appointment.
+ + +
Meanwhile, I looked for a time to mention it to Mark privately. Not that I wanted to keep my concerns away from the 14yo; it was more that I didn't want to put him on the spot in case he was feeling sensitive about his appearance, and wanted to see if Mark wanted to be the one to talk to him about it. But Mark beat me to the discussion, not privately but while he was driving us all in the minivan: "I was thinking that I wanted to get the sports physicals for the boys a little early this year," he said to me, "and have you noticed that [our son]'s chest sticks out?"
"Yes," I said, "I was going to talk to you about that. It's called pectus carinatum," I said, and told him what I had learned from my brief search. Later I showed him the images and he agreed with me that the similarity was striking.
Which makes twice this year that Dr. Google Images has come through for us; the other time was when I diagnosed an inguinal hernia in my 4yo son. I'm sure some people will tsk-tsk about untrained personnel like myself taking matters into her own hands, but I for one welcome the availability of information. I believe it saves everyone time and lowers health care costs.
For one thing, we decided to skip the extra step of the pediatrician's appointment and go straight to a St. Paul children's specialty hospital with a reputation for orthopedic care, because we predicted that the pediatrician would just send us there anyway.
The orthopedic surgeon came in to the examining room, shook all our hands. "Nice to meet you," he said to our son.
"Nice to meet you too," said my son, looking him in the eye. All of a sudden, I was struck by my son's poise and manner. Such a small thing, to notice that your child is a person who shakes hands, replies politely, holds up his end of a conversation. We expect it, and at the same time it's a little bit astonishing when it actually happens.
Okay, I know that sounds patronizing. I don't mean it to be. I'm not indulging in oh-my-baby's-growing-up motherly weepiness. I want them all to grow up. I'm -- pleased. If I have any surprise, it's not because I don't have confidence in my own kids; I think it's because I had a tough time with the transition through adolescence, and I feel as though I must find a source of well-being to provide enough for them. We fool ourselves sometimes into thinking that everything our children will become, we have to pass on ourselves personally. I feel impaired. But we are all are agents of our own development. We are fully human, not increasingly so as we grow, but from the outset.
+ + +
The surgeon asked my son's permission to examine him, and having secured it, asked him to take off his shirt. He looked all around, placed a flat hand on my son's sternum and back and compressed him, asked him to bend over and ran an exploratory palm down the curve of his spine -- "No scoliosis," he commented -- and asked him a few questions. No, we don't have a family history of chest wall deformities. Yes, he's had an orthopedic issue in the past, surgical correction of epiphyseal dysplasia in one of his ankles at age four. No, he hasn't experienced pain or discomfort.
Finished, he suggested that our son should put his shirt on and return to the chair.
"So on the spectrum from mild, to moderate, to severe pectus," the surgeon told us, "this is what I would call a moderate case." As recently as a few years ago, he explained, the condition was almost always treated with surgery, but younger patients respond well to a compressive brace which reshapes the ribcage over a period of months. He outlined a non-surgical treatment plan using the orthotic brace, which he said could start anytime between now and our son's fifteenth birthday, and in any case would last until he was seventeen or so and the rib cage began to lose its pliability.
"If he has to wear it until the same end point, what's the advantage of starting earlier and having to wear the brace for longer?"
"It'll appear to be corrected sooner."
Our son said: "I'd rather wait and have to wear it for a shorter time."
The prognosis from the noninvasive technique appear to be good, for everyone who can tolerate it; apparently almost all of the failures are among patients who do not wear the brace consistently because of discomfort, pain, or skin irritation. We are keen to avoid surgery if there is a noninvasive method, and our son is keen to do something that is more than nothing.
Today I will make an appointment with the same doctor, but at a different clinic closer to our home, for the month that our son turns fifteen. At that appointment he will be fitted with an orthotic compressive brace that he will wear under his clothes for three months, "twenty-three hours a day."
"That means," I said, "that he should be wearing it all the time, but he can take it off to shower or to have a swimming lesson." The surgeon affirmed this.
After three months, he will switch to a schedule of wearing the brace eight hours a day.
("Can he choose whether to wear it when he's awake or asleep?" I asked.
"Most kids choose to put it on after school and sleep in it, then they take it off before they go to school. But it doesn't matter. He can wear it on his own schedule, as long as it is eight hours every day.")
The eight-hours-a-day schedule will be maintained until he is seventeen or so. During that time he'll have to come in to have the brace adjusted every four to six months. So, we're in for a fairly lengthy commitment, but hopefully not a very onerous one.
Our son is upbeat about it all. "I'm glad he didn't just tell me I would grow out of it," he said. "This doesn't sound too bad." I am glad that our Internet diagnosis was on-point and that what we heard from the surgeon corresponded well to what I had learned from my own research. We're all glad that he doesn't appear to need surgery.
That's the news here...