An eighteen-year-old, right-hand-dominant man was a restrained front-seat
passenger in an automobile that was moving at approximately 50 miles per hour
when it sustained a frontal impact with another vehicle. The patient had no
major injuries as a result of the accident and was able to walk after the
impact; however, evaluation in the emergency room revealed an abrasion and
ecchymosis on the left side of the chest from the seatbelt. He had no
shortness of breath or dyspnea, and a plain chest radiograph revealed no
abnormalities.
The patient continued to have left-sided chest pain, however, and three
weeks after the accident he was evaluated by his primary care physician.
Cardiac sounds were normal, and the lungs were clear to auscultation. It was
recommended that he restrict his activities for several weeks. He continued to
have pain and, at five months after the injury, was assessed by a pediatric
orthopaedic surgeon. A chest-wall contusion was diagnosed, and the patient was
given a prescription for nonsteroidal anti-inflammatory drugs and physical
therapy, which included therapeutic modalities (e.g., ice, heat, and
ultrasound), range-of-motion exercises, and upper-extremity strengthening
exercises.
Eighteen months after the accident, the patient presented to our office
because of continued constant aching pain in the medial portion of the
pectoralis major muscle and at its sternal origin. The pain was worsened by
arm flexion and adduction. There was a noticeable associated asymmetry of the
chest, with a lower-riding nipple on the affected (left) side compared with
the nipple on the right.
On physical examination, the patient was found to be a well-developed young
adult male (68.5 inches [174 cm] tall and 208 lbs [94.3 kg] in weight) who was
in no apparent distress and had no dyspnea. He had an obvious asymmetry of the
chest consisting of a depression of the medial border of the left pectoralis
major muscle (Fig. 1).
Isometric strength was assessed by instructing the patient to press his hands
together in front of his body. During this maneuver, he experienced pain along
the medial border of the left pectoralis major, which was clearly avulsed from
its sternal origin. During manual muscle testing, with the arm flexed, the
adduction strength of the left shoulder was slightly weak compared with that
of the right shoulder. There was some degree of gynecomastia present, which
the patient said was present before the injury.
A computerized tomographic scan of the chest, obtained to evaluate the
chest wall and the osseous structures of the sternum, revealed an avulsion or
rupture of the medial aspect of the left pectoralis major muscle at its
origin. There was no osseous avulsion of the origin and there was no
heterotopic ossification. Treatment options were discussed with the patient
and his family. Because the previous eighteen months of nonsurgical treatment
had been unsuccessful in relieving the persistent weakness, discomfort, and
chest-wall asymmetry, the patient elected to undergo surgical
reconstruction.
With the patient under general anesthesia, a midsternal incision was made,
starting approximately 4 cm below the sternal notch and extending to the
xiphoid. The skin was elevated bilaterally off of the sternum, which permitted
inspection of the noninjured right pectoralis major for comparison. On the
left sternal border, there was substantial scarring and no muscle was
identified. The dissection proceeded laterally on the left, between the
overlying fasciocutaneous tissue and the chest wall until the medial edge of
the ruptured pectoralis was identified at the midclavicular line. The
dissection continued laterally toward the humerus to free the pectoralis major
muscle from the overlying fasciocutaneous tissue and the underlying chest
wall.
Next, the pectoralis major was advanced medially and sutured to the lateral
aspect of the sternal body with nonabsorbable 0-Ticron sutures (GS-21 needle;
United States Surgical, Norwalk, Connecticut) in a modified Kessler fashion
(Fig. 2). The GS-21 needle
allowed for penetration of the outer cortex of the sternum without the need
for drilling. The anterior muscle fascia and the sternal periosteum were then
sutured with a continuous 2-0 Vicryl (Ethicon, Somerville, New Jersey) suture
to reinforce the repair. At the conclusion of the repair procedure, the left
pectoralis major was noted to be in an anatomic location with no signs of
tension during abduction and external rotation of the left shoulder. The skin
was then closed over a drain in multiple layers, with interrupted 2-0 and 3-0
Vicryl sutures in the deep layer and with a 3-0 Prolene (Ethicon) subcuticular
pull-out suture in the superficial layer.
After surgery, the patient was placed in a shoulder immobilizer for four
weeks and allowed to perform only finger, elbow, and wrist range-of-motion
exercises. After four weeks, the immobilizer was discontinued and the patient
was permitted to perform shoulder motion, beginning with pendulum exercises
and gentle stretching. Two months after surgery, active pectoralis muscle
contraction (isometric-type exercise only) was allowed. Four months after
surgery, he regained full range of shoulder motion and was allowed to perform
strengthening exercises with no limitations. He had a palpable pectoralis
contraction along the repair site without any evidence of failure of the
repair.
At the time of the last follow-up, thirty-five months after the operation,
he was employed as a stock boy for a grocery store. He had no chest pain when
performing lifting maneuvers or during activities of daily living. The
examination at that time revealed an anterior hypertrophic surgical scar,
which was asymptomatic. The chest wall was symmetric, as was the contour of
the pectoralis muscle at rest; however, there was some residual deformity with
contraction of the pectoralis muscle, which was considered to be secondary to
the gynecomastia (Fig. 3).
Overall, the patient was satisfied with the surgical result and commented that
he would undergo the operation again.
Rupture of the pectoralis major muscle at its origin is a rare injury that
is distinctly and anatomically different from rupture of this muscle at its
myotendinous junction or at the tendinous insertion into bone or from
congenital absence of this muscle. To our knowledge, the literature records
only one report of this type of
injury25. A
fourteen-year-old boy experienced this injury while rock-climbing; surgical
repair was recommended but refused, and nonoperative treatment resulted in
minimal deformity and no functional deficits. Therefore, our case report is,
to our knowledge, the first to document the successful repair of a tear of the
pectoralis major from its origin. Despite an eighteen-month interim from the
time of injury to the time of repair, careful mobilization of the pectoralis
major muscle permitted the muscle to be reattached to its origin.
Our patient had no history of a pre-existing deformity, and the
distribution of ecchymosis into the chest and the operative findings suggested
that this was an acute injury. The use of anabolic steroids and the presence
of systemic illnesses have been implicated as predisposing factors for rupture
of the pectoralis major
muscle19,24,26,27,
but this patient did not have any known risk factors for this type of
injury.
Because rupture of the pectoralis major muscle at its sternal origin
happens so rarely, the best form of treatment has yet to be determined. In our
patient, nonoperative treatment resulted in unsatisfactory discomfort and
weakness; however, treatment should be individualized to each patient on the
basis of his or her symptoms.
Similarly, the optimum surgical technique for reattachment of the origin of
the pectoralis muscle to the sternum cannot be ascertained from the
information provided in this case report. The technique we used is similar to
one used for covering chest-wall defects that occur as a result of
mediastinitis28,29.
The technique allows sutures to be passed through the lateral border of the
sternum without puncturing the pleural space. However, surgeons who are not
familiar with this anatomy should have a thoracic surgeon as well as the
facilities and equipment available for the treatment of a pneumothorax, should
it occur.
Most studies report that patients have a more satisfactory result when a
torn pectoralis major tendon is reattached to the proximal aspect of the
humerus or repaired to adjacent soft
tissue22,24,26,27,30-33.
Similarly, restoration of the pectoralis muscle origin eliminated pain in our
patient, who stated that the operation had restored his strength to normal. He
was able to be athletically active and to perform heavy lifting as required by
his job, with no subjective deficits. However, it should be noted that we did
not measure preoperative or postoperative strength with objective means.
Although such measurements might have been helpful, they are not typically
considered necessary or routine in clinical practice.
The optimum time for surgical repair of this rare injury also cannot be
ascertained by the information in this case, because our patient underwent
successful repair eighteen months after the injury. In most cases of
pectoralis muscle or tendon injury that occurs distally near the attachment to
the humerus, it is generally believed that early repair provides a better
chance of success than does delayed surgical repair or
reconstruction22,24,30,
although ruptures of the distal part of the pectoralis tendon near the tendon
insertion have been successfully repaired after as many as five years after
the injury26.
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