CITW 12: The Extra Weight

Welcome back to another Clinical Image of the Week from the case files of the Brown EM Residency!

HPI: 27 year old male presents to the ED with left chest wall pain. He states he was bench pressing at the gym when he felt a “sudden twinge of pain and popping sensation” in his left upper arm and shoulder. He was unable to lift weights following this injury without experiencing excruciating pain. He subsequently noticed swelling and bruising on his left upper arm. He denies any other injuries, numbness, or weakness.

VS: HR 54, BP 112/64, RR 11, SpO2 100%, T 98.7

PE: Patient is noted to have weakness of the left arm with internal rotation and shoulder adduction. No other deficits appreciated. Neurovascularly intact.

Exam

What’s the diagnosis?

Pectoralis Major Rupture

A rare entity indeed! Kudos to any who got this one. A review of the anatomy:

Anatomy

The pectoralis major muscle is composed of both the clavicular and sternocostal heads. They converge into a tendon which inserts along the lateral aspect of the bicipital groove of the humerus. You can see how rupture at their insertion would cause bruising and swelling of the upper arm.

So, what do we know about this?

  • Only a few hundred case reports of this exist in the literature.
  • Early operative repair and physical therapy has demonstrated the best functional outcomes (complete return of strength and range of motion), with delayed operative repair considered superior to conservative management.
  • In one prospective study, bench press was the cause of the injury in up to 80% of the cases.
  • Injury can also be seen in football or rugby injuries, in which the patient may describe an anterior blow to the shoulder.
  • Ecchymosis of the anterior chest wall is present with rupture at the sternal or clavicular origins, and lateral chest/upper arm ecchymosis with tears at the humeral insertion.
  • ED management: Ice, sling, anti-inflammatory medications, and referral to an orthopedic surgeon. The patient should refrain from exercises and stretches involving the affected limb.

Case Conclusion: Patient was placed in a sling and referred to orthopedic surgery for operative management.

Sources:

1) Royalty, Brennan. Hosey, Robert. Pectoralis Major Muscle Rupture. Essential Orthopedics. Chapter 37; 158-160. 2010.

2) Aärimaa V, et. al. Rupture of the Pectoralis Major Muscle. American Journal of Sports Medicine. 32 (5); 1256-62. 2004.

3) De Castro Pochini A, et al. Pectoralis Major Muscle Rupture in Athletes: A Prospective Study. American Journal of Sports Medicine. 38 (1); 92-8. 2010.

Shout out to Dr. Adam Janicki for this case!

The contents of this case were deliberately altered to protect the identity of the patient. All content in this report are for educational purposes only. The patient consented to the use of these images.

Faculty Reviewer: Dr. Alyson McGregor

See you next week!

 

3 thoughts on “CITW 12: The Extra Weight

  1. This is a pretty devastating injury for pro football players. Ryan Mallet, formerly the back up for #12 (Tom Brady), tore his last year. One of the NY Giants tore his while lifting. If not operated upon it can be a bit of a career ender for a QB.

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