ALLEGED DELAYED DIAGNOSIS AND TREATMENT

UPON REVIEW IN CONJUNCTION WITH A BOARD CERTIFIED ORTHOPAEDIC SURGEON:

• Optimal treatment of an acute pectoralis muscle rupture is surgical; the injury can heal by secondary intention (fibrosis, scarification) with less optimal function with regard to strength.  To ensure the greatest chance for the best outcome, surgery needs to be performed within 3-4 weeks, and as a consequence the injury must be properly diagnosed clinically and/or in conjunction with diagnostic imaging either by the initial treating physician, consultation with an orthopaedic surgeon and/or suggestion by a radiologist.

• Subsequent to the 3-4 week post injury period the potential for surgical treatment with optimal recovery diminishes as tissues, including any remaining tendon, become more friable due to the progressive inflammatory process.  

• As any chance to improve physical function (adduction) would require surgical treatment, though conservative treatment would lead to progressive scarification with anticipated less than optimal functional capacity with regard to adduction, ongoing delay, presumably because of the need for authorization through Workers’ Compensation, would progressively diminish chances for the most profitable functional outcome. 

• Subsequent to surgical treatment (done at any time) requires extremely close supervision for the first four weeks with regard to movement of the upper extremity which may lead to recurrent rupture, i.e., the upper extremity should remain immobilized; this may require a plaster wrap or strict instructions not to remove the immobilizer in order to facilitate post-operative scarification.  Should physical therapy begin earlier, the physical therapist should have precise instructions with regard to avoiding any potential movement  which might lead to recurrent rupture.

• Preexisting conditions may have had a mild effect on the patient’s condition, and the patient may also have sustained an additional injury to the cervical spine which was undiagnosed prior to surgical treatment. 

• The preexisting healed compound forearm fracture of the left arm with residual inability to extend fingers in conjunction with an additional injury to the cervical spine was not fully diagnosed prior to treatment of the ruptured pectoralis major muscle.

• Preexisting degenerative arthritis of the cervical spine and modification of pain from the primary injury may have caused manifestations of pain in the neck and numbness in the left upper extremity to become more symptomatic.

CONCLUSION:                             

By the above criteria,

• The patient’s left pectoralis major muscle rupture was not diagnosed within the period for optimal surgical treatment with regard to functional recovery.  

• Delay in surgical treatment subsequent to the eventual decision for surgical treatment as the only option, albeit small, for the most effective optimal recovery of physical functional (adduction) was presumably prolonged as a consequence of bureaucratic decision making within the Workers’ Compensation system. 

• As post operative management within the first four weeks is critical, strict supervision of the patient’s movement prior to adequate post-operative scarification is essential to avoid the potential for post-operative rupture,and should this attention not be available, the patient should have absolute instructions not to remove the shoulder immobilizer, and/or a plaster wrapping should be applied. 

• Moreover, the patient’s preexisting residual physical restrictons as a consequence of a compound left forearm fracture may have an additional mild effect on forces applied to the healing site as well as the development of manifestations of numbness in the left arm which also may have developed in conjunction with a concurrent injury to the cervical spine, symptoms of which may have become more prominent subsequent to surgical treatment and rehabilitation. 

THE HEALTH PLACE
A Private Medical Practice of David P. Kalin, M.D., M.P.H.
Tel  813.966.1431  Fax 813.925.1932