Traumatic abscess of pectoralis major

Isolated spontaneous biceps abscess causing septic shock in a diabetic patient: A rare case report

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Intramuscular abscesses, particularly in the biceps brachii, are very rare.

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The majority are associated with haematoma secondary to trauma, intramuscular injections, or systemic disease.

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If untreated, it can rapidly lead to septic shock and involvement of surrounding joints.

Introduction

Intramuscular abscesses, particularly in the biceps brachii, are an extremely rare phenomenon. When present they are usually secondary to trauma, intramuscular injections, or systemic disease.

Presentation of case

A 56 year old diabetic woman presented to our emergency department with a 3 day history of fever, cough, and a painful left shoulder. Although she had a mechanical fall 2 weeks prior, she denied any pain in her shoulder immediately after the fall. She also denied any history of drug abuse or recent intramuscular injection. On examination she looked acutely unwell and was in acute septic shock requiring inotropic support. Computed tomography of her shoulder showed a large intramuscular abscess in her left biceps brachii muscle. She was immediately taken to the operating theatre for open exploration and washout of the abscess. The multiloculated abscess was tracking into the glenohumeral joint. Post operatively she showed significant clinical improvement and after a 2 week course of intravenous antibiotics recovered well and was discharged from hospital.

Discussion

Intramuscular abscesses are usually seen in patients who are immunocompromised. Intramuscular needle injections and haematomas secondary to trauma are also risk factors. To the best of our knowledge, there have only been 4 published reports in the English literature of intramuscular abscess formation in the biceps brachii.

Conclusion

We report a case of a seemingly spontaneous intramuscular biceps abscess in a diabetic patient presenting with septic shock.

Anterior mediastinal abscess diagnosed in a young sumo wrestler after closed blunt chest trauma

Most mediastinal abscesses result from infections after thoracotomy, esophageal perforation or pene- trating chest trauma. This disease is rarely caused by closed blunt chest trauma. All previously reported such cases after closed blunt chest trauma presented with hematoma and sternal osteomyelitis resulting from sternal fracture. Here we report a 15-year-old sumo wrestler who presented with an anterior mediastinal abscess without any mediastinal fracture. The mediastinal abscess resulted from the hematogenous spread of Staphylococcus aureus to a hematoma that might have been caused by a closed blunt chest trauma incurred during sumo wrestling exercises.

A systematic review and comprehensive classification of pectoralis major tears

BACKGROUND

Reported descriptions of pectoralis major (PM) injury are often inconsistent with the actual musculotendinous morphology. The literature lacks an injury classification system that is consistently applied and accurately reflects surgically relevant anatomic injury patterns, making meaningful comparison of treatment techniques and outcomes difficult.

MATERIALS AND METHODS

Published cases of PM injury between 1822 and 2010 were analyzed to identify incidence and injury patterns and the extent to which these injuries fit into a classification category. Recent work outlining the 3-dimensional anatomy of the PM muscle and tendon, as well as biomechanical studies of PM muscle segments, were reviewed to identify the aspects of musculotendinous anatomy that are clinically and surgically relevant to injury classification.

RESULTS

We identified 365 cases of PM injury, with 75% occurring in the last 20 years; of these, 83% were a result of indirect trauma, with 48% occurring during weight-training activities. Injury patterns were not classified in any consistent way in timing, location, or tear extent, particularly with regard to affected muscle segments contributing to the PM's bilaminar tendon.

CONCLUSIONS

A contemporary injury classification system is proposed that includes (1) injury timing (acute vs chronic), (2) injury location (at the muscle origin or muscle belly, at or between the musculotendinous junction and the tendinous insertion, or bony avulsion), and (3) standardized terminology addressing tear extent (anterior-to-posterior thickness and complete vs incomplete width) to more accurately reflect the musculotendinous morphology of PM injuries and better inform surgical management, rehabilitation, and research.

Spontaneous bacterial seeding of a biceps hematoma

A 19-year-old male construction worker presented with an injury to his left upper arm after lifting a heavy pipe. He reported an acute onset of sharp pain followed by swelling, warmth, and weakness with elbow flexion. The diagnosis of a distal biceps tendon rupture was made and elective repair was scheduled. Seventy-two hours later, the patient presented with a spontaneous draining wound on his anterior distal humerus. The wound was draining thick purulent material. The patient underwent surgery for irrigation and debridement of his abscess. Nearly 500 cc of hematoma and purulent fluid were evacuated. A large tear of both the biceps and brachialis muscle bellies were found. Cultures were obtained that revealed the infecting organism to be Streptococcus intermedius. Human immunodeficiency virus and hepatitis-C virus testing were negative, and no history, signs, or symptoms of any cause of underlying immunodeficiency were detected. No signs or history of drug use were present. He was discharged home on culture-specific oral antibiotics. At 4-month postoperative follow-up, the patient reported no pain or limitations. He has returned to full duty at his job. Elbow range of motion was measured from 7° to 150° of flexion. Strength of elbow flexion and extension was symmetric to the uninjured side. Pronation and supination of the forearm was symmetric on both sides. He has been released from scheduled follow-up and will be seen again on an as-needed basis.

Injuries to the pectoralis major muscle: diagnosis and management

Injuries to the pectoralis major muscle are relatively infrequent but result in pain, weakness, and deformity of the upper extremity. The usual injury mechanism is during eccentric shortening of the pectoralis major under heavy load, such as when performing a bench press exercise. The ability to detect and treat a pectoralis major rupture is important for both the clinician and the patient and is aided with knowledge of the anatomy, the clinical findings, and results of nonoperative and operative care. It is important to understand the physical demands and desires of the patient as well as to understand the outcomes of both nonoperative and operative care to make an informed decision regarding optimal treatment. This article highlights the importance of the clinical examination in identifying the injury, examines various surgical techniques to repair the rupture, and reports on potential complication and reinjury rates.

Pectoralis major rupture in elderly patients: a clinical study of 13 patients

The purpose of this study was to analyze and describe circumstances and clinical aspects of pectoralis major rupture in elderly patients compared with younger patients. Eleven patients were nursing home residents and two were community residents. All had severe pain with a large pectoral ecchymosis extending to the lateral chest wall and arm. Twelve patients experienced substantial blood loss (average, 2.3 g/dL hemoglobin), which resulted in hemodynamic decompensation in two of the patients, necessitating a blood transfusion. The most probable mechanism of injury was indirect, caused by a brisk tearing movement applied to stiff, atrophic muscle during commonly used nursing procedures for transferring, positioning, and dressing the patients. The authors suspect this injury to be more common than reported. Although surgical repair is not required in the elderly, a proper diagnosis is imperative because the injury has a severe clinical impact necessitating care and followup.

Pectoralis major rupture in the elderly: clinical and sonographic findings

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.

Injuries to the pectoralis major

Pectoralis major injuries typically occur in active individuals participating in manual labour or sports. While these injuries are rarely reported, the actual incidence of pectoralis tears among all shoulder injuries is unknown. Diagnosis can usually be made based on a patient's history and physical examination. However, ultrasound and magnetic resonance imaging are helpful tools for diagnosis and pre-operative planning. Specific treatment options should be based on the severity of the injury and the patient's individual needs. Nonoperative management consisting of immobilisation and physical therapy can offer a functional result with return of shoulder motion and activities of daily living. In recent studies, operative repair of pectoralis major rupture has been shown to restore normal chest-wall muscle contours and pre-operative strength (even in competitive athletes). Although complications such as re-rupture, infection, and heterotopic ossification do occasionally occur, favourable results should be expected when surgical repair is performed either acutely or in a delayed fashion.