Pectoralis major rupture in the elderly

Clinical and sonographic findings

Yichayaou Belooseskya,*, Joseph Grinblata, Miriam Katzb,David Hendelc, Rochelle Sommerb

aDepartment of Geriatrics, Rabin Medical Center, Beilinson Campus, Sackler School of Medicine, Tel Aviv University, Tel Aviv, IsraelbDepartment of Imaging, Rabin Medical Center, Golda Campus, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel

cDepartment of Orthopedics, Rabin Medical Center, Golda Campus, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel

Abstract

We describe clinical and sonographic features of pectoralis major rupture in the elderly, which is relatively rare and unknown.

Patients presented with a large pectoral ecchymosis extending to the axilla, chest wall, breast and arm. The pectoral area was sensitive,

sometimes with a visible and palpable defect in the axilla. Ultrasound examination showed a large hypoechoic, well-circumscribed

structure representing a hematoma within the pectoralis major muscle, partially replacing the normal echo muscle pattern.

Ultrasonography is a useful, low cost diagnostic tool, and is recommended in the investigation of pectoralis major rupture in the elderly.

D 2003 Elsevier Inc. All rights reserved.

Keywords: Pectoralis major rupture; Ultrasonography; Elderly

1. Introduction

Pectoralis major rupture is an uncommon injury occur-

ring in male athletes and manual laborers, mainly between

the ages of 20–40. Approximately 150 cases have been

reported in the literature [1,2]. The injury mechanism is

most commonly indirect, resulting from sudden forceful

overload applied to a maximally contracting muscle [3], or

less commonly by direct trauma [2]. Whereas excessive

muscle tension causes avulsions from insertion on the

humerus or rupture at the musculo-tendinous junction, direct

trauma causes tears in the muscle belly [1]. Recently, we

reported pectoralis major rupture in nursing home patients

occurring during common nursing procedures such as

positioning and transferring [4]. When a frail patient is held

by or under the axillary region, rapid transfer can cause a

brisk tearing movement to a stiff and atrophic pectoral

muscle, resulting in severe force being applied to the

pectoral muscle. Direct trauma to the muscle must also be

considered, either as a result of abuse or when a patient is

turned accidentally into a bed rail. To our knowledge, the

ultrasonographic (US) findings of pectoralis major rupture

in elderly patients have not been described. We therefore

report the clinical and US findings of four affected patients.

2. Materials and methods

During 1998 to May 2002, we diagnosed 13 cases of

pectoralis major rupture. In four patients, US was done. The

patients were female aged 73, 87 and 97, respectively, and

an 83-year-old man. The first was an independent housewife

whose chest and shoulder were accidentally crushed by a

pneumatic bus door. The second and the fourth were fully

dependent and demented nursing home residents whose

chest hematomas were discovered while changing their

clothes. The third was a partially dependent, obese, cogni-

tively normal woman who was hospitalized for functional

deterioration and weakness followed by anemia and increas-

ing heart failure. On admission, a large ecchymosis of the

right pectoral area was found, secondary to a partial pector-

alis major rupture probably due to inadequate care. All

patients were hospitalized in the geriatric department and

had undergone extensive evaluations including orthopedic

0899-7071/03/$ – see front matter D 2003 Elsevier Inc. All rights reserved.

doi:10.1016/S0899-7071(02)00548-X

* Corresponding author. Department of Geriatrics, Rabin Medical

Center, Beilinson Campus, Petach Tikvah 49100, Israel. Tel.: +972-3-937-

6820; fax: +972-3-937-6817.

E-mail address: belo-7@zahav.net.il (Y. Beloosesky).

Journal of Clinical Imaging 27 (2003) 261–264

examinations. The US images were obtained and interpreted

by senior radiologists (R.S. and M.K.) using an ATL 3000

ultrasound machine with a 5– 10-mHz linear probe

(Advanced Technological Laboratories, Bothell, WA,

USA). The examination included scanning all soft tissues

including the subcutaneous fat and the pectoralis muscle as

far as the ribs posteriorly. The contralateral nonaffected side

was compared in each patient.

3. Results

All patients suffered pain, increasing on palpation of the

pectoralis area, necessitating analgesic and careful care. A

large pectoral bulging hematoma and an ecchymosis

extending to the axilla, chest wall and breast were found

(Figs. 1 and 2). The amounts of blood loss calculated by

subtracting the pre-injury with the post-injury hemoglobin

level were 2.6, 2.2, 1.7 and 4.6 g/dl, in the first, second,

third and fourth patients, respectively. Three patients were

treated with aspirin prior to the injury. In the second and the

fourth patient, we could definitively see and palpate a defect

in the axilla (Fig. 2). On US examination, the normal

pectoralis major muscle was identified deep to the hypo-

echoic lobules of the superficial subcutaneous fat (Fig. 3).

The echo pattern of the muscle on the asymptomatic side in

the longitudinal section consisted of parallel echogenic lines

representing septa of fibro-adipose tissue (the perimysium)

against a hypoechoic background representing the muscle

bundles. The thick echogenic anterior border of the muscle

represents the dense connective tissue surrounding the

muscle (the epimysium).

The thick echogenic posterior border of the muscle

represents the bony rib [5]. In all four patients, a large

hypoechoic, well-circumscribed structure representing a

hematoma was identified within the pectoralis major muscle

on the symptomatic side partially replacing the normal echo

Fig. 1. Patient 1. A large pectoral ecchymosis extending to the breast, chest

wall and arm, with some bulging in the pectoral area.

Fig. 2. Patient 2. An ecchymosis of the pectoral and breast areas (A)

extending to the axillary region (B).

Fig. 3. Normal pectoralis major muscle in longitudinal section. Short arrows

indicate epimysium anteriorly and rib posteriorly outlining the borders of

the muscle. Note the longitudinal echogenic lines inside the muscle

representing perimysium (fibroadipose septa) against a hypoechoic back-

ground representing normal muscle tissue. Hypoechoic subcutaneous fat

lobules are seen superficial to the muscle (F).

Y. Beloosesky et al. / Journal of Clinical Imaging 27 (2003) 261–264262

pattern. In the first patient, the hematoma was situated deep

inside the muscle, also demonstrating obvious posterior

enhancement indicating the fluid nature of the structure

(Fig. 4). In the second patient, a large expansive hematoma

involving almost the whole width of the muscle was

demonstrated (Fig. 5). The same patient showed an ill-

defined similar hypoechoic structure in the subcutaneous

fat, indicating an additional hematoma in the superficial soft

tissue (Fig. 6).

4. Discussion

The pectoralis major is a broad, thick muscle ranging

from the anterior thorax to the clavicle. The fibers converge

like a fan into three laminae that twist upon each other at 90�before coalescing into a single tendon of insertion. The

fibers of the anterior laminae (clavicular head) arising from

the clavicle and upper sternum, remain parallel as they

course toward the humeral insertion. The manubrial portion

of the sternal head makes up the bulk of the muscle, arising

from the midportion of the sternum and the coastal cartilage

of ribs 1 through 5. The lower or abdominal portion of the

sternal head arises from ribs 5 and 6 and fascia of the

external oblique and transversal muscles. The manubrial and

abdominal portions become the middle and posterior lam-

inae, which coil upon each other so that the abdominal

fibers insert highest on the humerus, while the manubrial

fibers insert inferiorly [2,6].

Muscle rupture is caused by two different mechanisms:

(a) most commonly by distraction (indirect trauma) and (b)

less commonly by compression (direct trauma). In distrac-

tion injury, the muscle fibers are torn as a result of an

intrinsic force generated from sudden forceful overload

applied to a maximally contracting muscle [3,5]. This is

apparently the mechanism of the rupture in the second, third

and fourth cases. In compression injuries, as in the first case

(the closing bus door), the muscle is crushed against the

bone by external force. Muscle fibers are macerated along

with associated vessels leading to hematoma formation.

Healing is slow with extensive scar formation and long-

term functional deficit [5].

Fig. 4. Patient 1. Partial rupture of pectoralis major muscle. Large well-

defined hypoehoic structure with posterior enhancement representing fresh

hematoma situated deep inside the muscle (long arrow). Normal muscle

tissue is seen anterior to the hematoma (M).

Fig. 5. Patient 2. Partial rupture of pectoralis major muscle involving almost

the whole width of the muscle. Well-circumscribed hypoechoic hematoma

within the muscle (long arrow), with posterior enhancement. Arrowheads

indicate anterior border of the muscle. Echogenic posterior border of the

muscle represents a rib (R).

Fig. 6. Patient 2. Superficial hematoma. Irregular hypoechoic structure with

posterior enhancement in subcutaneous fat representing fresh hematoma

(long arrow).

Y. Beloosesky et al. / Journal of Clinical Imaging 27 (2003) 261–264 263

Age related changes in skeletal muscles might increase

the probability of injury. Older muscles have an increased

susceptibility to contraction induced mechanical injuries.

Beginning in middle age or earlier, there is a decrease in the

number and size of muscle cells, resulting in a loss of mass

and strength [7]. In young patients and in complete tears,

surgery is recommended to restore full strength and function

and to resume athletic activity in individuals who require

full use of their upper extremities. MR imaging allows

accurate evaluation of injuries and enables identification

of patients who would benefit from surgical repair [8].

However, the functional limitation of the muscle rupture is

not of great concern among the elderly. Therefore, US

images, as shown in this study, are sufficient in the elderly

in the diagnosis of pectoralis major injury. US is more

readily available than MRI, less costly and can be performed

in the patient’s room. Moreover, US is a simple quick

diagnostic method, does not require the older patient to lie

still in a narrow cylinder and is not contraindicated in the

presence of ferromagnetic implants and splints, and thus is

the ideal imaging technique for elderly patients. Although

infected hematoma has rarely been described in cases of

pectoralis major rupture [9], the US modality can be very

useful in guiding needle aspiration and for follow-up if such

a complication is suspected.

Ultrasound is most frequently used in traumatic and

inflammatory disorders in which a non-invasive method is

greatly appreciated by the patient [10]. Acute hematomas

present differently depending on their age. Initially, they

are seen as hypoechoic areas within the muscle (indic-

ating muscle fiber ruptures), and remain hypoechoic as

hemolysis proceeds. Subsequently, they develop internal

echoes of increasing complexity as they became more

organized [10]. Ultrasound was found to be very useful in

diagnosing other muscular injuries such as rectus sheath

hematoma [11]. This unusual but well-described entity

shares some similarities with the pectoralis major rupture

in the elderly. In both cases, there is frequently a

background of cardiovascular disease and use of anti-

coagulant or anti-aggregate agents, precipitating factors

such as sudden exertion and direct trauma, the presence

of pain and mass, and finally hematocrit decrease sec-

ondary to the bleeding.

In conclusion, these cases demonstrate that ultrasonog-

raphy is a useful, readily available, low cost diagnostic tool,

recommended in investigating pectoralis major rupture in

the elderly.

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