Page 31 - Journal of Special Operations Medicine - Fall 2016

Table 1 Tietjen Classification for Pectoralis Major Injury 12 constituted an injury varied among these studies; some
considered any event requiring assessment on the drop
Grade Injury Location zone an injury, whereas others defined it as any event
I Contusion or sprain requiring evaluation at an emergency room or resulting
II Partial tear in restriction of duty. Some factors associated with in-
III Complete tear creased rate of injury included conducting operations at
IIIA Muscle origin night, jumping with combat equipment, and ground wind
speed of 8 knots or greater. Per Department of Defense
17
IIIB Muscle belly regulations, the maximum allowable ground wind speed
IIIC Musculotendinous junction for static-line parachute operations is 13 knots. Injuries
18
IIID Tendon are more commonly encountered during landing, and
rarely occur during aircraft exit. 15,17 Two reviews iden-
tified chest injuries sustained; however, pectoralis major
immobilization, rest, nonsteroidal anti-inflammatory injury was not specifically documented. 15,17 Our review of
(NSAID) medications, and physical therapy. 3,4,9 Surgical the literature yielded one description of a pectoralis ma-
repair is recommended for complete tears of the muscu- jor injury sustained while exiting an aircraft to perform a
lotendinous junction or tendon (grade IIIC, IIID), espe- static-line parachute jump, similar to our case presenta-
cially in a young, active, athletic population. Multiple tion. This patient sustained a rupture at the musculoten-
1–4
10
studies support early operative intervention for these dinous junction as well; he was managed nonoperatively.
injuries. Patients who undergo surgery, when indicated,
are more likely to have increased range of motion, de- Point-of-Injury Care
creased pain, better preserved strength, improved cos- As with any musculoskeletal condition, patients with
mesis, and higher rate of return to activity. 5,6,9,11 Delayed suspected injury after performing high-risk airborne op-
repair (i.e., several months to several years after injury) erations should undergo thorough history and physical
also may lead to favorable results compared with non- examination. If performed on the drop zone, this should
operative management. 3,11 be done expediently to identify injury, prioritize for trans-
fer to a higher echelon of care if needed, and guide fol-
Performance Enhancing Substance Use and Injury low-on treatment. Any high-energy traumatic mechanism
Performance-enhancing substance use can be an over- of injury should prompt a primary survey assessing for
looked contributor to musculoskeletal injuries, includ- life-threatening injuries. Once these have been ruled out,
ing those of the pectoralis major. Studies have shown it is then appropriate to move on to a peripheral musculo-
anabolic steroids cause changes in tendons that may skeletal evaluation. The area of concern—in our case, the
make them more susceptible to injury. It is also theo- chest and upper extremity—should be visually inspected
rized anabolic steroid use may result in a dispropor- for deformity. The skin should be assessed for ecchymosis,
tionate increase in muscle mass compared with tendon edema, erythema, and integrity. The chest, shoulder, arm,
strength, again putting the structure at increased risk neck, and back should be palpated, feeling for tender-
of injury. 3,4,6,11 A recent study of substance use among ness or anatomic distortion. Range of motion of involved
Military Servicemembers found that 32% (16 of 50 joints should be tested actively and passively, assessing for
US Army Soldiers) endorsed using androgen-containing pain or impairment. Muscles of the chest and upper ex-
substances. Although this sample size is small, other tremity should be analyzed for weakness and compared
research on this topic has corroborated considerable with the unaffected side. Sensation of the peripheral and
use among US Servicemembers, including Special Op- radicular dermatomes should be gauged for integrity. Pe-
erations personnel. In the Special Operations Forces ripheral blood flow should also be checked by palpating
13
community, where every inch counts and every possible the radial pulse or measuring capillary refill.
advantage is evaluated and exploited, it is reasonable to
keep this issue in mind when assessing this injury pat- Patients with suspected pectoralis major injury, in aus-
tern. In the case of our patient, there was low suspicion tere environments where resources for further evalua-
for performance-enhancing substance use as a contribut- tion are limited, should undergo sling immobilization
ing factor, because of the mechanism of injury. of the affected arm in the adducted and internally ro-
tated position. This should be maintained until move-
4
Static-Line Parachute Injuries ment to a higher level of care is possible, preferably as
Musculoskeletal injury is a well-known risk associated soon as operationally viable. If neurovascular impair-
with static-line parachute operations. Several large re- ment, irreducible dislocation, or an open fracture are
views over the past 25 years have demonstrated over- found or suspected, the priority for evacuation should
all static-line parachute injury rates anywhere from 3.8 be increased because of the heightened potential need
to 50.4 per 1,000 descents. 14–17 Definitions for what for emergent surgical intervention.

Pectoralis Major Injury During Airborne Training 13