High-resolution ultrasound and MRI in the evaluation of pectoralis major injuries

Nicholson Chadwick; Jennifer S. Weaver; Christopher Shultz; Yoav Morag; Arjun Patel; Mihra S. Taljanovic

Open Access

High-resolution ultrasound and MRI in the evaluation of pectoralis major injuries

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| Nov 23, 2023

Journal of Ultrasonography

Volume 23 (2023): Issue 95 (October 2023)

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Published Online: Nov 23, 2023

Page range: e202 - e213

Received: Aug 13, 2023

Accepted: Sep 13, 2023

DOI: https://doi.org/10.15557/jou.2023.0029

Keywords
ultrasound, magnetic resonance imaging, injury, pectoralis major muscle

© 2023 Nicholson Chadwick et al., published by Sciendo

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Anatomical drawing of the pectoralis major (PM) muscle superimposed on a frontal chest radiograph demonstrates the singular clavicular head and seven labeled segments of the sternal head

Sagittal fluid-sensitive MR images show the short axis of the PM muscle with color overlay (B) to indicate the clavicular (blue) and sternal (orange) heads

Axial T1-weighted MR image (A) and long axis gray scale ultrasound image (B) of the arm show the relationship between the PM tendon (solid arrowheads) and the regional anatomy: long head biceps brachii tendon (arrow), short head biceps brachii muscle (asterisk), and coracobrachialis muscle (open arrowhead)

Drawing of the orientation of the PM tendon (A) with superimposition on a coned down frontal chest radiograph at the humeral footprint (B). The anterior tendon layer is comprised of the clavicular head (blue) and the three to five most superior segments of the sternal head (orange). The posterior layer is comprised of the most distal fibers of the sternal head (black)

Axial fluid-sensitive MR image of the arm with FOV tailored for pathology of the shoulder shows edema (asterisk) about the long head biceps tendon (open arrowhead) with anterior positioning of the tendon with respect to the humerus on the most inferior axial image, in keeping with PM tear. Note the residual stump of the PM tendon on the humerus (solid arrowhead)

Drawing of the short axis of the PM tendon showing the different types of tendon tear described by Deveraux and ElMaraghy. Black denotes torn PM fibers. A. Full width, partial thickness tear involving the posterior layer. B. Partial thickness, partial width tear involving the posterior fibers. C. Full width tear of the posterior layer and partial width tear of the anterior layer, together which form a full thickness component involving the inferior fibers. D. Full width full thickness tear

A. Coronal fluid-sensitive MR image shows a PM tear at the clavicular head origin with edema (arrowheads) interposed between the clavicle (asterisk) and the muscle. B. Axial fluid-sensitive MR image shows a PM tear at the myotendinous junction (between empty arrowheads) with edema, fiber disorganization, and surrounding poorly organized hematoma (asterisks). Note intact tendon insertion onto the humerus (solid arrowheads). C. Short axis gray scale ultrasound image shows feathery anechoic fluid (arrows) tracking along the expected course of the pectoralis muscle fibers in the setting of intramuscular PM tear (not shown). D. Coronal fluid-sensitive MR image shows an intramuscular PM tear with edema and discontinuous fibers (arrowheads). E. Long axis gray scale ultrasound image shows an intramuscular PM tear with intramuscular edema at the site of tear (arrowheads) and more focal anechoic abnormality that represents a small intramuscular hematoma (asterisk)

A. Long axis gray scale ultrasound images (A and B) and short axis fluid-sensitive MR image (C) show complete tear of the PM tendon with residual tendon stump (arrowheads) attached to the humerus and hematoma formation (asterisk)

Axial fluid-sensitive MR images in two different patients show complete tear of the PM tendon from the humeral insertion with tendon retraction (empty arrowheads) medial to the short head of the biceps brachii muscle (asterisks) and anterior displacement of the long head biceps brachii tendon (solid arrowhead)

A, B. Consecutive axial fluid-sensitive MR images in a patient who previously underwent PM tendon repair show a full width partial thickness re-tear of the PM tendon. The superficial anterior layer is torn and retracted (B, empty arrowhead) with adjacent hematoma formation (A,B-asterisk) while the deep posterior layer is thickened but intact (A,B – solid arrowheads). Note the susceptibility artifact from surgical hardware (arrow, A). C. Long axis gray scale ultrasound image in a different patient shows an anechoic linear tear in the sternal head, measuring approximately 3 cm superior to inferior (arrows). D. Long axis gray scale ultrasound image further laterally at the PM tendon insertion in the same patient shows the intact superficial anterior tendon layer (arrowheads) and avulsed deep posterior layer with accompanying mineralized periosteum (arrow); bicipital groove is shown for reference (asterisk)

Axial T1 (A) and axial fluid-sensitive (B) MR images show periosteal thickening and edema (arrowheads) at the insertion of the PM tendon (arrow) with marrow edema (B – asterisk) consistent with mechanical tug-type changes without overt tendon tear

Axial fluid-sensitive MR image (A) shows avulsion of the PM tendon from the humeral insertion (arrow) with associated bone marrow edema (asterisk). AP (B) and axillary (C) radiographs of the shoulder show the avulsed cortical fragment from the anterior proximal humeral diaphysis (circle, B, C)

Axial T1 (A) and axial fluid-sensitive (B) MR images show focal fat at site of discontinuous muscle fibers (A, between arrowheads) from a chronic tear. Note the paucity of associated edema on the fluid-sensitive sequence (B, circle). C. Short axis gray scale ultrasound image shows a thickened and retracted torn PM tendon stump medially (between arrows). D. Corresponding MR image shows the retracted tendon stump (between arrows) with relative paucity of surrounding edema in this patient with chronic PM tear. Fibrosis was confirmed intraoperatively, which can also be seen with chronic tears

Coronal (A) and axial (B) fluid-sensitive MR images show diffuse, feathery signal hyperintensity in the PM muscle (open arrowheads) without fiber disorganization or laxity, consistent with PM strain. C. Long axis gray scale ultrasound image in another patient demonstrates increased echogenicity and poorer fiber conspicuity in a patient with strain of the clavicular head of the PM (asterisk). Note the normal architecture of the adjacent deltoid muscle (arrowhead). There is no frank fiber disruption or disorganization in these images to suggest tear

A. Axial fluid-sensitive MR image shows hyperintensity in the PM muscle. B–D. Post contrast axial T1 MR image with fat saturation (B) shows a region of peripheral enhancement (asterisk) in the medial fibers of the PM with corresponding high diffusion weighted imaging (C) and low apparent diffusion coefficient (D) values, in keeping with intramuscular abscess. Note the similarity in appearance of Figures 15A and 14B, underscoring the importance of clinical history

Intra-operative clinical photo of a left shoulder during PM tendon reattachment at the humeral insertion. The clavicular head (C) is superficial and superior to the sternal head (S). Both tendon stumps are clamped and will be sutured to attach to the proximal humerus

A. Axillary shoulder radiograph shows endobuttons from previous PM tendon repair (arrow). B. Long axis gray scale ultrasound image shows the intact repaired PM tendon (solid arrowheads) and echogenic artifact from the surgical hardware with posterior acoustic shadowing (open arrowhead)

Classification of pectoralis tear, modified by Bak et al.

Grade		Location
I	muscle contusion	A	muscle origin	D	tendon avulsion from humerus
II	partial tear	B	muscle belly	E	Bony avulsion from tendon insertion
III	complete tear	C	myotendinous junction	F	tendon intra-substance tear

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High-resolution ultrasound and MRI in the evaluation of pectoralis major injuries

Article Category: Review Paper

Published Online: Nov 23, 2023

Page range: e202 - e213

Received: Aug 13, 2023

Accepted: Sep 13, 2023

DOI: https://doi.org/10.15557/jou.2023.0029

Keywords
ultrasound, magnetic resonance imaging, injury, pectoralis major muscle

© 2023 Nicholson Chadwick et al., published by Sciendo

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

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Classification of pectoralis tear, modified by Bak et al.

High-resolution ultrasound and MRI in the evaluation of pectoralis major injuries

Article Category: Review Paper

Published Online: Nov 23, 2023

Page range: e202 - e213

Received: Aug 13, 2023

Accepted: Sep 13, 2023

DOI: https://doi.org/10.15557/jou.2023.0029

Keywordsultrasound, magnetic resonance imaging, injury, pectoralis major muscle

© 2023 Nicholson Chadwick et al., published by Sciendo

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

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Classification of pectoralis tear, modified by Bak et al.

Keywords
ultrasound, magnetic resonance imaging, injury, pectoralis major muscle