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CASE REPORT

Spontaneous Rupture Of The Latissimus Dorsi In A Patient Of Rheumatoid Arthritis

 Relwani J*,Shankaranarayana S*,Shrivastava R K*,Brooks C*,Santhakumaran A**

* Department of Trauma & Orthopaedics, William Harvey Hospital , Ashford, Kent
**Department of Radiology, William Harvey Hospital , Ashford, Kent

Address for Correspondence:

J Relwani, FRCS (Tr & Orth), FRCS, MS (Orth), DNB (Orth), MBBS
12 Diamond Estate, 61 Glenburnie Road, London SW17 7DJ.
Email: relwani@hotmail.com

 

Abstract:

Latissimus dorsi rupture, although uncommon, has been described in young athletic individuals following trauma. To our knowledge, a spontaneous rupture of this muscle in a patient of rheumatoid arthritis has never been reported. Spontaneous tendon ruptures have been described in rheumatoid arthritis patients on long term steroid therapy, most commonly the flexor and extensor tendons of wrist(1), (the achilles tendon, biceps brachii tendon, and the rotator cuff of shoulder)(2). We describe a case of spontaneous rupture of latissimus dorsi muscle in a 64 years old, male rheumatoid arthritis patient on steroid therapy for duration of 30 years.

J.Orthopaedics 2007;4(4)e25

 Keywords:
Spontaneous latissimus dorsi rupture; rheumatoid arthritis; steroid-induced; tendon rupture.
Case Report:

A sixty-four year old man complained of sudden onset of sharp pain in the left side of his mid-back as he reached out to pick up a glass of water. He immediately noticed a swelling in the region, which was followed by bruising. He complained of pain with movement of left shoulder and on attempting to lie on the affected side.  

He had no history of trauma or of previous back problems. He was under treatment for poly articular rheumatoid, and had been on steroids (prednisolone average dose 6 mg/ day) for 30 years. He had a ruptured right Achilles tendon 6 years earlier which was treated non-operatively. In addition, he had a supraspinatus deficient shoulder, but was able to manage activities of daily living.

Examination revealed extensive bruising over lower third of left side of back and in the flank (Figure 1). A swelling of 15 x 12 centimetres size was noted with the simultaneous loss of definition of the posterior axillary fold. The swelling was soft, and became more prominent when attempting to elicit a contraction of the latissimus dorsi, with its superior edge moving further distally by 2.5 cm.  

Examination of his shoulder revealed a pre-existing chronic cuff tear with limitation of active abduction to 70 degrees, external rotation of 25 degrees and internal rotation to the sacro-iliac joint.

Functionally patient had difficulty lying down on his back, pushing himself up from the bed due to pain but was able to manage it with little discomfort within 72 hours.  

He was investigated using an ultrasound scan (Figure 2) and also underwent magnetic resonance scanning (Figure 3) which confirmed the presence of the tear in the latissimus dorsi.

The injury was treated non-operatively in view of the limited functional demands of the patient due to his co-morbidities, and the rapid relief of pain over 72 hours. With the help of physical therapy for 4 months, he returned to independent activities of daily living, but with persistent weakness of adduction and internal rotation of the arm.

Fig 1: Extensive left flank bruising and additional skin fold seen in left lower flank.
Fig 2: Ultrasound image confirming a 33mm x 16mm haematoma as a result of the latissimus dorsi rupture  
Fig 3: MRI demonstrating high signal changes of haematoma in left latissimus dorsi muscle in the transverse and coronal planes

Discussion:

There is very limited literature available about latissimus dorsi rupture and the natural history of the latissimus dorsi rupture is unknown.
Spinner et al(3) described a 38 years old golfer with latissimus dorsi and teres major rupture , patient had satisfactory results with conservative management. Kawashima et al(4) described a case of ruptured latissimus dorsi tendon with a rupture of pectoralis major post crush injury in a construction worker. Henry et al(5) described a 42 years old fit skier sustained a latissimus dorsi rupture which was treated with surgical repair and re attachment of latissimus dorsi tendon to humerus with satisfactory results . Butterwick et al(6) describe a 35 years old, rodeo steer wrestler with a right latissimus dorsi rupture which was treated conservatively and patient recovered satisfactorily.
Our patient was a gentleman with underlying rheumatoid arthritis on prednisolone. This predisposed him to tendon injury, and he spontaneously ruptured the latissimus dorsi without any obvious trauma. The diagnosis was confirmed both clinically and on MRI and US examination. He was treated non-operatively and had satisfactory function, keeping in mind his original low-demand status.
This is a rare injury and the first such reported spontaneous rupture of the latissimus in a rheumatoid patient.

 

References:

(1) Ertel AN, Millender LH, Nalebuff E, McKay D, Leslie B. Flexor tendon ruptures in patients with rheumatoid arthritis. J Hand Surg [Am ] 1988; 13(6):860-866.

  (2)   Wanivenhaus A. [Tendon ruptures in rheumatic patients.]. Z Rheumatol 2007.

  (3)   Spinner RJ, Speer KP, Mallon WJ. Avulsion injury to the conjoined tendons of the latissimus dorsi and teres major muscles. Am J Sports Med 1998; 26(6):847-849.

  (4)   Kawashima M, Sato M, Torisu T, Himeno R, Iwabuchi A. Rupture of the pectoralis major. Report of 2 cases. Clin Orthop Relat Res 1975;(109):115-119.

  (5)   Henry JC, Scerpella TA. Acute traumatic tear of the latissimus dorsi tendon from its insertion. A case report. Am J Sports Med 2000; 28(4):577-579.

  (6)   Butterwick DJ, Mohtadi NG, Meeuwisse WH, Frizzell JB. Rupture of latissimus dorsi in an athlete. Clin J Sport Med 2003; 13(3):189-191.  

This is a peer reviewed paper 

Please cite as :Relwani J : Spontaneous Rupture Of The Latissimus Dorsi In A Patient Of Rheumatoid Arthritis

J.Orthopaedics 2007;4(4)e25

URL: http://www.jortho.org/2007/4/4/e25

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