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Compartment syndrome secondary to acute pectoralis major tendon rupture
J Shoulder Elbow Surg (2015) 24, e78-e81
www.elsevier.com/locate/ymse
CASE REPORT
Compartment syndrome secondary to acute pectoralis major tendon rupture Adam J. Smith, BMBSa,*, Stefan Bajada, MD, PhDa, Phillip Wardle, FRCRb, David Morgan, FRCS (Orth)a a b
Trauma & Orthopaedic Department, Royal Glamorgan Hospital, Ynysmaerdy, Pontyclun, Mid Glamorgan, Wales, UK Radiology Department, Royal Glamorgan Hospital, Ynysmaerdy, Pontyclun, Wales, UK
We present a previously unreported case of compartment syndrome involving the upper arm after an acute rupture of the pectoralis major tendon. A high index of suspicion led to prompt diagnosis and surgical management, ultimately leading to successful reconstruction and recovery.
Case report A 35-year-old previously healthy white man presented to the emergency department with pain and swelling in his left anterior chest wall and shoulder. He reported these symptoms after a weightlifting session in the gym. He described a sudden ‘‘pop’’ and pain in his left shoulder while carrying out a dumbbell bench press. He denied current anabolic steroid abuse but admitted to having used steroids a number of years ago; he also denied use of any other nonprescription medication. After review in the emergency department and radiographic examination, he was discharged with a diagnosis of soft tissue injury to the shoulder and advised to take regular analgesia. During the next 12 hours, he developed worsening pain and swelling in the pectoral region and upper arm. This progressed rapidly and was not relieved
Written permission for publication was obtained from the patient. *Reprint requests: Adam J. Smith, BMBS, Trauma & Orthopaedic Department, Royal Glamorgan Hospital, Ynysmaerdy, Pontyclun, Mid Glamorgan, Wales CF72 8XR, UK. E-mail address: [email protected] (A.J. Smith).
Figure 1 Short tau inversion recovery coronal magnetic resonance image showing a large hematoma surrounding pectoralis major tendon insertion.
by simple analgesia, prompting his return to the emergency department. At this time, physical examination demonstrated swelling, extensive bruising, and tight compartments over his chest wall, shoulder, and anterior aspect of his left upper arm. In addition, he complained of paresthesia in his hand and forearm with documented abnormal light touch
1058-2746/$ - see front matter Ó 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2014.10.023
Compartment syndrome after pectoralis major rupture
e79
Figure 2 Short tau inversion recovery axial magnetic resonance image showing ruptured and retracted pectoralis major tendon.
Figure 4
Figure 3 Intraoperative photograph showing ruptured pectoralis major tendon.
Intraoperative repair of pectoralis major tendon.
and pinprick sensation in the median, radial, and ulnar nerve distributions. Passive movement of his arm and forearm led to acute exacerbation of pain. Evaluation and grading of muscle power were not possible because of pain. Compartment pressures were measured with a Stryker Intra-Compartmental Pressure Monitor (Stryker Surgical, Kalamazoo, MI, USA). The anterior compartment pressure was measured over the lateral border of the biceps at 3 separate points, each 5 cm apart. Pressure measurements of 35 mm Hg and a delta P of 0 mm Hg (diastolic 35 mm Hg after induction of general anesthesia) were recorded. On the basis of these measurements and the clinical picture of increasing unremitting pain, tense compartments, and progressing distal neurologic symptoms, a diagnosis of compartment syndrome was made. The decision was made to proceed urgently to fasciotomies and compartment decompression. Compartment decompression was performed through an anterolateral approach and complete fasciotomy over the pectoralis major, deltoid, and anterior upper arm.
e80
Figure 5
A.J. Smith et al.
Intraoperative appearance after tendon repair.
Operative findings included massive swelling secondary to a large hematoma arising from the pectoralis major, which was avulsed from its attachment and retracted. Brachialis and biceps brachii in the anterior compartment were noted to be tense and bulging but viable. The wound was left open. A second-look debridement and primary skin closure were performed 48 hours later. Magnetic resonance imaging confirmed complete tear of the pectoralis major tendon at the musculotendinous junction, retracted 4.9 cm (Figs. 1 and 2). The injury resulted in significant compromise of the soft tissue envelope, making early tendon repair unsafe. Five weeks after original injury, when the soft tissues had recovered, pectoralis major repair was performed as previously described through a separate deltopectoral approach (Figs. 3 to 6). Recovery and rehabilitation progressed successfully. At 4 months after repair, the patient’s neurologic and motor function was normal, with a symmetric appearance and an unrestricted symmetric range of motion, and he was pleased with the outcome (Fig. 7). He has returned to his previous full employment and sporting activities, including triathlon and weightlifting.
Figure 6
Figure 7 surgery.
Intraoperative appearance after wound closure.
Final appearance in outpatient clinic at 4 months after
Discussion Compartment syndrome has been extensively reported in the literature, with a focus on different anatomic sites and etiologies. The location and cause of compartment syndrome in our patient made this case unique. Compartment syndrome around the shoulder girdle is rare. Previously, 8 reports have highlighted compartment
Compartment syndrome after pectoralis major rupture syndrome involving the deltoid in its 3 myofascial compartments. Pectoralis major involvement has been previously documented only once. Tarkin et al7 reported on exercise-induced chronic compartment syndrome involving the shoulder adductor musculature, including the pectoralis major and anterior deltoid, leading to rhabdomyolysis in a professional tree climber. Pectoralis major fascia is continuous with the fascia of the upper arm. Compartmental collection, such as hematoma, would likely track to its contiguous compartments, especially the arm, leading to elevated pressures. Anabolic steroid use needs to be considered in these cases as it has been previously associated with compartment syndrome in both the upper3,4 and lower limb,5 although this particular patient denied recent use. A conclusive cause-effect relationship cannot be established; however, it is postulated that anabolic steroids increase susceptibility to the condition because of the rapid increase in muscle volume, leading to tighter fascial compartments.1 Animal studies have shown that anabolic steroids cause morphologic collagen fibril changes, and they are thought to increase the risk of tendinosis and myotendinous ruptures,2,6,8 which can lead to bleeding and hematoma formation in these less voluminous fascial spaces.
Conclusion This report emphasizes the need to have a high index of suspicion in these patients, and close observation is required. Our case demonstrates that prompt recognition and decompression of pectoral/upper arm compartment syndrome, followed by delayed pectoralis major tendon
e81 repair, can result in a successful return to normal function.
Disclaimer The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
References 1. Bahia H, Platt A, Hart NB, Baguley P. Anabolic steroid accelerated multicompartment syndrome following trauma. Br J Sports Med 2000;34:308-9. 2. David HG, Green JT, Grant AJ, Wilson CA. Simultaneous bilateral quadriceps rupture: a complication of anabolic steroid abuse. J Bone Joint Surg Br 1995;77:159-60. 3. Erturan G, Davies N, Williams H, Deo S. Bilateral simultaneous traumatic upper arm compartment syndromes associated with anabolic steroids. J Emerg Med 2013;44:89-91. http://dx.doi.org/10.1016/j. jemermed.2011.06.015 4. Farkash U, Shabshin N, Pritsch P. Rhabdomyolysis of the deltoid muscle in a bodybuilder using anabolic-androgenic steroids: a case report. J Athl Train 2009;44:98-100. http://dx.doi.org/10.4085/1062-6050-44.1.98 5. Liem NR, Bourque PR, Michaud C. Acute exertional compartment syndrome in the setting of anabolic steroids: an unusual cause of bilateral footdrop. Muscle Nerve 2005;32:113-7. http://dx.doi.org/10.1002/mus. 20314 6. Liow RY, Tavares S. Bilateral rupture of the quadriceps tendon associated with anabolic steroids. Br J Sports Med 1995;29:77-9. 7. Tarkin IS, Perricelli BC, Pape HC. Exercise induced compartment syndrome of the pectoralis major/deltoid in a professional tree climber. J Shoulder Elbow Surg 2009;18:e17-20. http://dx.doi.org/10.1016/j.jse.2008.06.009 8. Visuri T, Lindholm H. Bilateral distal biceps tendon avulsion with use of anabolic steroids. Med Sci Sports Exerc 1994;26:941-4.
www.elsevier.com/locate/ymse
CASE REPORT
Compartment syndrome secondary to acute pectoralis major tendon rupture Adam J. Smith, BMBSa,*, Stefan Bajada, MD, PhDa, Phillip Wardle, FRCRb, David Morgan, FRCS (Orth)a a b
Trauma & Orthopaedic Department, Royal Glamorgan Hospital, Ynysmaerdy, Pontyclun, Mid Glamorgan, Wales, UK Radiology Department, Royal Glamorgan Hospital, Ynysmaerdy, Pontyclun, Wales, UK
We present a previously unreported case of compartment syndrome involving the upper arm after an acute rupture of the pectoralis major tendon. A high index of suspicion led to prompt diagnosis and surgical management, ultimately leading to successful reconstruction and recovery.
Case report A 35-year-old previously healthy white man presented to the emergency department with pain and swelling in his left anterior chest wall and shoulder. He reported these symptoms after a weightlifting session in the gym. He described a sudden ‘‘pop’’ and pain in his left shoulder while carrying out a dumbbell bench press. He denied current anabolic steroid abuse but admitted to having used steroids a number of years ago; he also denied use of any other nonprescription medication. After review in the emergency department and radiographic examination, he was discharged with a diagnosis of soft tissue injury to the shoulder and advised to take regular analgesia. During the next 12 hours, he developed worsening pain and swelling in the pectoral region and upper arm. This progressed rapidly and was not relieved
Written permission for publication was obtained from the patient. *Reprint requests: Adam J. Smith, BMBS, Trauma & Orthopaedic Department, Royal Glamorgan Hospital, Ynysmaerdy, Pontyclun, Mid Glamorgan, Wales CF72 8XR, UK. E-mail address: [email protected] (A.J. Smith).
Figure 1 Short tau inversion recovery coronal magnetic resonance image showing a large hematoma surrounding pectoralis major tendon insertion.
by simple analgesia, prompting his return to the emergency department. At this time, physical examination demonstrated swelling, extensive bruising, and tight compartments over his chest wall, shoulder, and anterior aspect of his left upper arm. In addition, he complained of paresthesia in his hand and forearm with documented abnormal light touch
1058-2746/$ - see front matter Ó 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2014.10.023
Compartment syndrome after pectoralis major rupture
e79
Figure 2 Short tau inversion recovery axial magnetic resonance image showing ruptured and retracted pectoralis major tendon.
Figure 4
Figure 3 Intraoperative photograph showing ruptured pectoralis major tendon.
Intraoperative repair of pectoralis major tendon.
and pinprick sensation in the median, radial, and ulnar nerve distributions. Passive movement of his arm and forearm led to acute exacerbation of pain. Evaluation and grading of muscle power were not possible because of pain. Compartment pressures were measured with a Stryker Intra-Compartmental Pressure Monitor (Stryker Surgical, Kalamazoo, MI, USA). The anterior compartment pressure was measured over the lateral border of the biceps at 3 separate points, each 5 cm apart. Pressure measurements of 35 mm Hg and a delta P of 0 mm Hg (diastolic 35 mm Hg after induction of general anesthesia) were recorded. On the basis of these measurements and the clinical picture of increasing unremitting pain, tense compartments, and progressing distal neurologic symptoms, a diagnosis of compartment syndrome was made. The decision was made to proceed urgently to fasciotomies and compartment decompression. Compartment decompression was performed through an anterolateral approach and complete fasciotomy over the pectoralis major, deltoid, and anterior upper arm.
e80
Figure 5
A.J. Smith et al.
Intraoperative appearance after tendon repair.
Operative findings included massive swelling secondary to a large hematoma arising from the pectoralis major, which was avulsed from its attachment and retracted. Brachialis and biceps brachii in the anterior compartment were noted to be tense and bulging but viable. The wound was left open. A second-look debridement and primary skin closure were performed 48 hours later. Magnetic resonance imaging confirmed complete tear of the pectoralis major tendon at the musculotendinous junction, retracted 4.9 cm (Figs. 1 and 2). The injury resulted in significant compromise of the soft tissue envelope, making early tendon repair unsafe. Five weeks after original injury, when the soft tissues had recovered, pectoralis major repair was performed as previously described through a separate deltopectoral approach (Figs. 3 to 6). Recovery and rehabilitation progressed successfully. At 4 months after repair, the patient’s neurologic and motor function was normal, with a symmetric appearance and an unrestricted symmetric range of motion, and he was pleased with the outcome (Fig. 7). He has returned to his previous full employment and sporting activities, including triathlon and weightlifting.
Figure 6
Figure 7 surgery.
Intraoperative appearance after wound closure.
Final appearance in outpatient clinic at 4 months after
Discussion Compartment syndrome has been extensively reported in the literature, with a focus on different anatomic sites and etiologies. The location and cause of compartment syndrome in our patient made this case unique. Compartment syndrome around the shoulder girdle is rare. Previously, 8 reports have highlighted compartment
Compartment syndrome after pectoralis major rupture syndrome involving the deltoid in its 3 myofascial compartments. Pectoralis major involvement has been previously documented only once. Tarkin et al7 reported on exercise-induced chronic compartment syndrome involving the shoulder adductor musculature, including the pectoralis major and anterior deltoid, leading to rhabdomyolysis in a professional tree climber. Pectoralis major fascia is continuous with the fascia of the upper arm. Compartmental collection, such as hematoma, would likely track to its contiguous compartments, especially the arm, leading to elevated pressures. Anabolic steroid use needs to be considered in these cases as it has been previously associated with compartment syndrome in both the upper3,4 and lower limb,5 although this particular patient denied recent use. A conclusive cause-effect relationship cannot be established; however, it is postulated that anabolic steroids increase susceptibility to the condition because of the rapid increase in muscle volume, leading to tighter fascial compartments.1 Animal studies have shown that anabolic steroids cause morphologic collagen fibril changes, and they are thought to increase the risk of tendinosis and myotendinous ruptures,2,6,8 which can lead to bleeding and hematoma formation in these less voluminous fascial spaces.
Conclusion This report emphasizes the need to have a high index of suspicion in these patients, and close observation is required. Our case demonstrates that prompt recognition and decompression of pectoral/upper arm compartment syndrome, followed by delayed pectoralis major tendon
e81 repair, can result in a successful return to normal function.
Disclaimer The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
References 1. Bahia H, Platt A, Hart NB, Baguley P. Anabolic steroid accelerated multicompartment syndrome following trauma. Br J Sports Med 2000;34:308-9. 2. David HG, Green JT, Grant AJ, Wilson CA. Simultaneous bilateral quadriceps rupture: a complication of anabolic steroid abuse. J Bone Joint Surg Br 1995;77:159-60. 3. Erturan G, Davies N, Williams H, Deo S. Bilateral simultaneous traumatic upper arm compartment syndromes associated with anabolic steroids. J Emerg Med 2013;44:89-91. http://dx.doi.org/10.1016/j. jemermed.2011.06.015 4. Farkash U, Shabshin N, Pritsch P. Rhabdomyolysis of the deltoid muscle in a bodybuilder using anabolic-androgenic steroids: a case report. J Athl Train 2009;44:98-100. http://dx.doi.org/10.4085/1062-6050-44.1.98 5. Liem NR, Bourque PR, Michaud C. Acute exertional compartment syndrome in the setting of anabolic steroids: an unusual cause of bilateral footdrop. Muscle Nerve 2005;32:113-7. http://dx.doi.org/10.1002/mus. 20314 6. Liow RY, Tavares S. Bilateral rupture of the quadriceps tendon associated with anabolic steroids. Br J Sports Med 1995;29:77-9. 7. Tarkin IS, Perricelli BC, Pape HC. Exercise induced compartment syndrome of the pectoralis major/deltoid in a professional tree climber. J Shoulder Elbow Surg 2009;18:e17-20. http://dx.doi.org/10.1016/j.jse.2008.06.009 8. Visuri T, Lindholm H. Bilateral distal biceps tendon avulsion with use of anabolic steroids. Med Sci Sports Exerc 1994;26:941-4.