Our patient is a 38-year-old male who presented with right chest wall and shoulder pain after a weight lifting injury. The patient was performing a one-rep max bench press when he felt a pop in his right upper arm, accompanied by severe pain. There was no history of anabolic steroid use. He was initially treated with ice and a sling by a trainer and presented to the emergency department for further evaluation. Plain films were negative for fracture or dislocation and the patient was neurovascularly intact, so he was discharged home by ER staff in the sling. He presented to the orthopedic clinic the following day with moderate pain in the chest and arm. He denied numbness and paresthesia. On physical examination, there was a large amount of swelling and ecchymoses throughout the right upper arm extending into the pectoralis major muscle belly. Additionally, there was a large bulge in the anterior chest with loss of contour of the axillary fold (Figure 1). The patient had full active range of motion of the elbow, wrist, and digits. He was sensory intact throughout the right upper extremity with a 2+ radial pulse. An MRI was scheduled to determine the extent of the injury and to aid in surgical planning. The patient was given oxycodone and valium to alleviate the pain and muscle spasms until surgery, which was scheduled after his MRI. The MRI demonstrated avulsion of the pectoralis major tendon from its insertion on the humerus with retraction as well as strain of the anterior deltoid (Figures 2 and 3). He was scheduled for surgery in five days. Two days later, the patient returned to our facility with severe worsening pain in the right upper arm. Intracompartmental pressure readings in the anterior compartment of the arm taken about the midpoint of the biceps at the point of maximal swelling were 37, 39, and 42 mmHg with a diastolic blood pressure of 71 mmHg (Figure 4). Thus, with a diagnosis of compartment syndrome confirmed, we proceeded to the operating room for an emergency fasciotomy with repair of the pectoralis major tendon rupture.
An extended deltopectoral approach was used, and the deltopectoral and biceps fascia were released. Immediately, a large amount of hematoma was expelled and the muscle bellies visibly bulged from the incision sites (Figures 5 and 6). All muscles still appeared viable. No apparent vascular damage was noted. Upon further dissection, both heads of the pectoralis major were found to be avulsed from the proximal humerus (Figure 7). After preparation of the footprint with curette and rongeur, three double-loaded 4.5 mm Mitek suture anchors (DePuy Synthes, Raynham, MA) were placed lateral to the bicipital groove for the repair of the tendon. The proximal and distal suture anchors were used such that one suture of each was run in a Krakow fashion along the superior and inferior aspects of the tendon, respectively. The remaining suture from each of those anchors was passed in a horizontal mattress fashion medial to the Krakow stitches. The middle suture anchor was used to place a horizontal mattress stitch with a medial ripstop stitch (Figure 8). The wound was irrigated, and a negative pressure dressing was applied. The patient was made nonweightbearing and placed in a sling with a circumferential strap to ensure adduction of the arm. The patient returned to the operating room four days later to undergo irrigation and debridement with a tension-free primary wound closure. He was again placed into his sling and given strict instructions to avoid abduction and external rotation of the arm. The patient did well postoperatively and was discharged home in a stable condition that same day with a one-week follow-up appointment. He continued to do well and was instructed to remain nonweightbearing in his sling for a total of 6 weeks before beginning formal therapy. Gentle stretching and passive range of motion were then begun, followed by strengthening exercises at the 12th week mark. At his four-month follow-up, the patient had active forward flexion of the shoulder to 150 , abduction to 150 , and external rotation of 50 . His rotator cuff, biceps, triceps, wrist extensors, wrist flexors, and interossei all demonstrated 5/5 strength. There were no sensory deficits on examination. He continues to attend therapy for motion and strengthening and has a lifting restriction of <5 pounds at work.