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Suprasphincteric: Originates at the dentate line and tracks of surgical therapy amongst various institutions due to lack of cephalad to the external sphincter mechanism before a standard classification and common nomenclature buy viagra sublingual paypal erectile dysfunction pills buy. These fistu- las are not amenable to simple fistulotomy due to high risk of total incontinence 4 buy cheap viagra sublingual on line what age can erectile dysfunction occur. Management Strategies in Fistula-in-Ano the aim of surgery for anal fistula is to cure the patient with minimal or no sequela discount 100mg viagra sublingual with visa creatine causes erectile dysfunction. If the surgeon is too conservative, the fistula may persist or recur after a short period of “healing” but the patient’s continence is preserved. On the other hand, if the surgeon is too aggressive, a false passage may be cre- ated, or the fistula may heal with varying degrees of distur- bance of continence (Fig. A small section of the tract can be excised Fistulotomy or Fistulectomy (biopsied) if there is concern for Crohn’s disease or malig- nancy, in cases of long-standing fistulas. Nelson and colleagues There has been and continues to be a basic controversy stressed the need for taking a biopsy from recurrent abscess whether fistulotomy or fistulectomy should be performed for wall or fistula tract to exclude malignancy. There has been only one randomized trial com- cancer (adenocarcinoma) may penetrate tissue and manifest as 7 Classification and Management Strategies 41 a recurrent abscess fistula. On the other hand, a very long- to avoid postsurgical fecal incontinence and worse yet, recur- standing fistula in ano may develop into a squamous cell can- rence due to creation of an inadvertent false passage. The presence of mucus in fistulous abscess should Staged Fistulotomy implies that a high or complex fistula raise the index of suspicion of malignancy [5]. At the first operation a portion of the sphincter mechanism is incised and a loose (marking) seton is placed around the remaining (undivided) external sphinc- Primary Fistulotomy ter. After a period of 6–8 weeks the patient is reexamined under anesthesia and if the first stage sphincterotomy is At the time of drainage of an abscess, the surgeon may find a healed by fibrosis, the remainder of sphincter is divided and fistula right away or after gentle probing with a blunt tipped the setons removed. Primary fistulotomy was reported to be safe and with Ramanujam and colleagues reported excellent healing with no adverse consequences in 1,000 consecutive cases [6]. In a larger study of staged fistulotomy using seton drainage and the experienced surgeon felt comfortable with from the same institution Pearl and colleagues reported primary fistulotomy, the results of primary fistulotomy were recurrence rate of 3 % and major incontinence, defined as the excellent and the recurrence rate was 3. This is in contradistinction of the of drained abscesses and argued against primary fistulotomy incidence of incontinence in cutting setons, which is reported [8]. In any case primary fistulotomy requires an experienced to be as high as 12 % in a meta-analysis [11 ]. This technique was advocated Surgeons Practice Parameters for fistula surgery recommends: by Mason and Kilpatrick for the treatment of rectourethral Outpatient surgery if the fistula, fistulous abscess, or limited fistulas [15]. The advantage of this approach for extrasphin- anorectal pathology warrants ambulatory care. With the patient in the jackknife (rectovaginal, rectourethral, horseshoe) often needing position an incision is made beginning at the posterior anal extensive surgery. Skin, subcutaneous tissue, and abscess necessitates intravenous antibiotic therapy [13]. The levator plate, puborec- talis, external and internal sphincters are sharply divided and Surgical Alternatives in Fistula-in-Ano marked with paired colored sutures for ease of identification during closure. The posterior rectal wall lies at the depth of Intersphincteric Fistulas the wound and the primary opening of the fistula can be Fistulas can be laid open with minimal internal sphincterot- approached directly. The extent of this operation is no different than that of over pants rectal advancement flap. This procedure is equally (with the aid of colored suture) using absorbable sutures. The external tract of the fistula is curetted and kept open for two weeks using a mushroom or Transsphincteric Fistulas Malecot or catheter. This technique is used only rarely, there- These involve varying degrees of external sphincter involve- fore the success rate of the operation is not well documented ment. In my personal series of nine patients, eight healed and nal sphincter, as of necessity, will result in some disturbance one recurred secondary to breakdown of the internal opening of continence estimated in one study to be in the range of repair. The lay-open technique including trans- 3 months and the fistula was closed subsequently with fibrin sphincteric fistulas (low and high) is covered in a separate sealant. Transsphincteric approach niques including seton, fibrin sealant, endorectal advance- is ideal for access to the mid-rectum for fistulas and also for ment flaps, dermal advancement flap, biologic and synthetic excision of retrorectal crysts [18 ]. This type of fistula is often an extension of a midline trans- sphincteric fistula to one or both ischiorectal fossae through Suprasphincteric Fistulas the deep postanal space. The classic treatment of primary the same principals in selection of treatment alternatives used posterior fistulotomy and the lay open of both arms of the in transsphincteric fistulas are also applicable (with more horseshoe results in a large open wound with delayed heal- significant importance) in suprasphincteric fistulas. In 1965 Hanley described a to employ sphincter-sparing operations to prevent postsurgical more conservative technique which included unroofing of incontinence. Alternative techniques are addressed in other deep postanal space, widening of the secondary openings chapters. Hanley and colleagues Extrasphincteric Fistulas reported the long-term results of 41 horseshoe fistulas treated With the internal opening cephalad to the levators, in this manner with no recurrence or incontinence [20 ]. If the internal opening is low enough to allow an stressed the importance of drainage (deroofing) of deep post- endorectal advancement flap, this technique may be anal space and reported 92 % healing rate in 24 patients [22 ]. When appropriate or in doubt, choosing conservative over Summary aggressive approach. Parasacrococcygeal approach for the resection of retrorectal problems: experience with primary fistulectomy for anorectal developmental cysts. Anorectal problems: the deep postanal space— or fistula-in-ano following anorectal suppuration. Velchuru operations, the incidence of sphincter-cutting procedures Introduction such as fistulotomy decreased from 98. Management depends on the etiology, such following sphincter-sacrificing procedures with anorectal as cryptoglandular pathology (commonest), Crohn’s dis- physiology testing and anal ultrasonography. Patients present as an emergency with anorec- than one procedure in patients from 1. Management of anal fistulae is complex and few employed as cutting and a non-cutting seton, i. In this chapter we discuss, a cutting seton, Ayurvedic-medicated setons have been described for non-cutting seton (or a loose seton) and a chemical seton. Hippocrates in fourth century bc has fibrosis, this in turn creates a fibrosed track for a definite pro- described the use of horsehair and lint to cut the muscle to cedure on a later date. In the last few decades, ksharasutra, the aim is to facilitate controlled transection of sphincter-saving procedures have been increasingly used the sphincter muscle to heal the fistula. However, initial drainage of sepsis and seton placement as a temporary or a permanent remedy still has a role. Seton Material High trans-sphincteric fistula remains a challenge even in the twenty-first century, as curative treatment involves mus- the type of seton used is usually typical to the individual cle cutting leading to potential incontinence. Seton means “thick, stiff hair” in Latin in the a 25-year single-institutional review of 2,267 fistula Webster’s dictionary. A few of the type of setons used are the Ayurvedic-medicated thread [6], braided sutures [7], thread, rubber band [8], penrose drains [9], cable tie seton [10 ], etc. Velchuru Loose Seton and Staged Fistulotomy Technique of Seton Insertion A staged fistulotomy is carried out in high trans-sphincteric Patient can be prone (North America) or lithotomy (United or supra-sphincteric fistulas, when single stage fistulotomy is Kingdom) depending on the surgeon’s preference.

The iliohypogastric nerve may also be seen lying medial to the ilioinguinal nerve in the same fascial plane (Fig generic viagra sublingual 100mg amex impotence 21 year old. Color Doppler may be used to aid in identifying the fascial plane between the internal oblique and transversus abdominis muscles as this plane is also shared with the deep circumflex iliac artery (Fig buy viagra sublingual 100 mg with amex erectile dysfunction doctors in south africa. After the ilioinguinal nerve is identified best purchase for viagra sublingual erectile dysfunction age 55, the nerve is evaluated for obvious abnormality and compression by abnormal mass, tumor, scar tissue, and aneurysm. To perform ultrasound evaluation of the ilioinguinal nerve, an imaginary line is drawn between the anterior superior iliac spine and the patient’s umbilicus. Oblique placement of the ultrasound transducer placed in a plane perpendicular with the inguinal ligament with the inferior aspect of the transducer lying over the anterior superior iliac spine and the superior aspect of the transducer pointed directly at the umbilicus. Oblique ultrasound image demonstrating the hyperechoic anterior superior iliac spine and its acoustic shadow and the external oblique, internal oblique, and transversus abdominis muscles. Note fascial plane between the internal oblique and transversus abdominis muscles. Oblique ultrasound image demonstrating the ilioinguinal nerve lying within the fascial plane between the internal oblique and transversus abdominis muscles. The ilioinguinal nerve and iliohypogastric nerve both lie in the fascial plane between the internal oblique and transversus abdominis muscles. Color Doppler image demonstrating the deep circumflex iliac artery, which lies in the fascial plane between the internal oblique and transversus abdominis muscles adjacent to the ilioinguinal nerve. It should be remembered that pathology affecting the lumbar plexus may mimic the clinical presentation of ilioinguinal neuralgia and should be considered in all patients presenting with groin pain in the absence of trauma to the region (Fig. The nerve exits the lateral border of the psoas muscle to follow a curvilinear course that takes it from its origin of the L1 and occasionally T12 somatic nerves to inside the concavity of the ilium (Fig. The iliohypogastric nerve continues in an anterior trajectory as it runs between the layers of the internal oblique and transverse abdominis muscles along with the ilioinguinal nerve and deep circumflex iliac artery (Fig. It is at this point that it is the nerve can consistently be identified with ultrasound scanning and is amenable to ultrasound-guided nerve block (Fig. Within the fascial plane between the internal oblique and transversus abdominis muscles, the iliohypogastric nerve divides into an anterior and a lateral branch (Figs. The lateral branch provides cutaneous sensory innervation to the posterolateral gluteal region. The anterior branch pierces the external oblique muscle just beyond the anterior-superior iliac spine to provide cutaneous sensory innervation to the abdominal skin above the pubis. The distribution of the sensory innervation of the iliohypogastric nerves varies from patient to patient due to considerable overlap with the ilioinguinal nerve. In most patients, the anterior branch of the iliohypogastric nerve provides sensory innervation to the skin overlying the pubis, with the lateral branch is providing sensory innervation to the skin overlying posteriolateral gluteal region (Fig. The ilioinguinal nerve exits the lateral border of the psoas muscle to follow a curvilinear course that takes it from its origin of the L1 and occasionally T12 somatic nerves to inside the concavity of the ilium. The ilioinguinal nerve continues in an anterior trajectory as it runs between the layers of the internal oblique and transverse abdominius muscles. Oblique ultrasound image demonstrating the hyperechoic anterior-superior iliac spine and its acoustic shadow and the external oblique, internal oblique, and transversus abdominus muscles. Note fascial plane between the internal oblique and transversus abdominis muscles. Red stars indicate the ilioinguinal and iliohypogastric nerves (furthest from the anterior-superior iliac spine) lying within the fascial plane. The anatomic relationship of the ilioinguinal and iliohypogastric nerve as they pass within the fascial plane between the internal oblique and transverse abdominis muscles. Less commonly, iliohypogastric neuralgia can be seen in patients in their third trimester of pregnancy when a rapidly expanding abdomen causes a traction neuropathy of the nerve. The symptoms associated with ilioinguinal neuralgia depend on whether the main trunk of the nerve is damaged or if the injury is isolated to the anterior or the lateral branch of the nerve (Fig. If the injury is isolated to the anterior branch of the iliohypogastric nerve, the patient will complain of burning pain, 690 paresthesias, and numbness in the skin overlying the pubis. If the lateral branch is damaged, the patient will complain of burning pain, paresthesias, and numbness in the skin overlying posterior–lateral gluteal region. Tinels sign may be elicited by tapping over the iliohypogastric nerve at the point where it pierces the transversus abdominis muscle. Ultrasound-guided iliohypogastric nerve block can be employed as a diagnostic maneuver when performing differential neural blockade on an anatomic basis to determine if the patient’s lower abdominal and groin pain are subserved by the iliohypogastric nerve (Fig. If destruction of the iliohypogastric nerve is being contemplated, ultrasound-guided iliohypogastric nerve block with local anesthetic can provide prognostic information as to the extent of motor and sensory deficit the patient will experience following nerve destruction. Electromyography can distinguish iliohypogastric nerve entrapment from lumbar plexopathy, lumbar radiculopathy, and diabetic polyneuropathy. Plain radiographs of the hip and pelvis are indicated in all patients who present with iliohypogastric neuralgia to rule out occult bony pathology. Based on the patient’s clinical presentation, additional testing may be warranted, including a complete blood count, uric acid level, erythrocyte sedimentation rate, and antinuclear antibody testing. Magnetic resonance imaging of the lumbar plexus and retroperitoneum is indicated if tumor or hematoma is suspected (Fig. Ultrasound-guided iliohypogastric nerve block can be employed as a diagnostic maneuver when performing differential neural blockade on an anatomic basis to determine if the patient’s lower abdominal and groin pain are subserved by the iliohypogastric nerve. If destruction of the iliohypogastric nerve is being contemplated, ultrasound-guided iliohypogastric nerve block with local anesthetic can provide prognostic information as to the extent of motor and sensory deficit the patient will experience following nerve destruction. The umbilicus, anterior-superior iliac spine, and inguinal ligament are identified by visual inspection and palpation and an imaginary line is drawn between the anterior-superior iliac spine and the umbilicus (Fig. A linear high-frequency ultrasound transducer is placed in a plane perpendicular with the inguinal ligament with the inferior aspect of the transducer lying over the anterior-superior iliac spine and the superior aspect of the transducer pointed directly at the umbilicus and an ultrasound survey scan is obtained (Fig. The hyperechoic anterior-superior iliac spine and its acoustic shadow are identified as are the external oblique, internal oblique, and transversus abdominus muscles which extend outward from it (Fig. The fascial plane between the internal oblique and transversus abdominis muscles are then identified and the iliohypogastric nerve should be easily identifiable as an ovoid hypoechoic structure highlighted by a hyperechoic epineurium lying more medial in relation to the anterior-superior iliac spine as compared to the ilioinguinal nerve which lies closer to the anterior-superior iliac spine (Fig. In larger patients, it is sometimes necessary to slowly move the ultrasound transducer toward the umbilicus to visualize the more medial lying iliohypogastric nerve. Color Doppler identification of the deep circumflex artery may be used to aid in identifying not only the fascial plane between the internal oblique and transversus abdominis muscles which also contains the iliohypogastric and ilioinguinal nerves, but to help distinguish which nerve is which as the artery runs between the ilioinguinal and iliohypogastric nerve, with the ilioinguinal nerve lying closer to the anterior-superior iliac spine (Fig. After the iliohypogastric nerve is identified, the nerve is evaluated for obvious abnormality and compression by abnormal mass, tumor, scar tissue, and aneurysm. To perform ultrasound-guided iliohypogastric nerve block, an imaginary line is drawn between the anterior-superior iliac spine and the patient’s umbilicus. Oblique placement of the ultrasound transducer placed in a plane perpendicular with the inguinal ligament with the inferior aspect of the transducer lying over the anterior-superior iliac spine and the superior aspect of the transducer pointed directly at the umblicus. Oblique ultrasound image demonstrating the hyperechoic anterior-superior iliac spine and its acoustic shadow and the external oblique, internal oblique, and transversus abdominis muscles. Note fascial plane between the internal oblique and transversus abdominis muscles. Oblique ultrasound image demonstrating the iliohypogastric nerve lying within the facial plane between the internal oblique and transversus abdominis muscles. Color Doppler image demonstrating the deep circumflex iliac artery which lies in the fascial plane between the internal oblique and transversus abdominis muscles adjacent to the iliohypogastric nerve. It should be remembered that pathology affecting the lumbar plexus may mimic the clinical presentation of iliohypogastric neuralgia and should be considered in all patients presenting with groin pain in the absence of trauma to the region (Fig.

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A neutrophil is a leukocyte that expresses Fc receptors and can participate in antibody-dependent cell-mediated cytotox- lineage order viagra sublingual cheap encore vacuum pump erectile dysfunction. It has the capacity to phagocytize microorganisms and blood count numbering 2500 to 7500 cells/mm3 quality viagra sublingual 100mg impotence juicing. They may be attracted to a local Neutrophils chemotaxis: See chemotaxis and chemotactic site by such chemotactic factors as C5a discount viagra sublingual 100 mg on line laptop causes erectile dysfunction. Besides serving as the frst line of cel- Neutrophil microbicidal assay is a test that assesses the lular defense infection, they participate in such reactions as the capacity of polymorphonuclear neutrophil leukocytes to kill uptake of antigen–antibody complexes in the Arthus reaction. Molecules, Cells, and Tissues of the Immune Response 125 Neutropenia refers to a diminished number of polymor- 25 to 94. Neutrophilia refers to signifcantly elevated numbers of Platelets represent the tissue source, whereas neutrophils, neutrophils in the blood circulation. Myeloperoxidase is an enzyme present in the azurophil gran- ules of neutrophilic leukocytes which catalyzes peroxidation of A superoxide anion is a free radical formed by the addi- many microorganisms. Myeloperoxidase, in conjunction with tion of an electron to an oxygen molecule, causing it to hydrogen peroxidase and halide, has a bactericidal effect. The hexose monophosphate Secondary granule is a structure in the cytoplasm of shunt activation pathway enhances superoxide anion gen- polymorphonuclear leukocytes which contains vitamin B12- eration. Superoxide anion interacts with protons, additional binding protein, lysozyme, and lactoferrin in neutrophils. Oxidation of one Cationic peptides are present in eosinophil secondary gran- superoxide anion and reduction of another may lead to the ules. Histamine, platelet-activating factor, and heparin are formation of oxygen and hydrogen peroxide. Injury induced by superoxide anion is associated with age-related A tertiary granule is a structure in the cytoplasm of polymor- degeneration. The superoxide anion plays a pivotal 3 precursor, acid hydrolase, and gelatinase are located. It is smaller and fuses with phagosomes more quickly oxidative burst that culminates in the formation of hydrogen than does the azurophil granule. In addition to this oxygen-dependent killing mechanism, phagocytized Respiratory burst is a process used by neutrophils and intracellular microbes may be the targets of toxic substances monocytes to kill certain pathogenic microorganisms. It released from granules into the phagosome leading to micro- involves increased oxygen consumption with the generation of bial cell death by an oxygen-independent mechanism. This occurs also in oxygen-dependent killing of microbes, membranes of spe- macrophages that kill tumor cells. The initial event is a one-electron reduction superoxidase ion is converted to hydrogen peroxide. The oxidative mechanism kills microbes action leading to the generation of hypochlorous acid, which through a complex process. Hydrogen peroxide, together with causes the oxidation of nucleic acids, amino acids, and thi- myeloperoxidase, transforms chloride ions into hypochlo- ols of the microbe. Antimicrobial 126 Atlas of Immunology, Third Edition White blood cells in lumen of venule Capillary bed Post capillary venule Chemotaxin Margination (e. They are far less effective Approximately 50% of polymorphonuclear neutrophils mar- against Gram-positive microorganisms. During infammation, there is margination of leukocytes, followed by their migration out of the vessels. Neutrophils and endothelial cells of a post-capillary venule and, through their macrophages are the main phagocytic cells in mammals. Margination refers to the adherence of leukocytes in the peripheral blood to the endothelium of vessel walls. Adherence to post-capillary venule endothelium occurs in three phases: Adherence Phagocytosis Emigration Chemotaxis figure 2. Molecules, Cells, and Tissues of the Immune Response 127 Opsonization is the facilitation of the phagocytosis of micro- organisms or other particles such as erythrocytes through the coating of their surface with either immune or nonimmune opsonins. The enhanced phagocytosis of a pathogenic micro- organism or macromolecule is attributable to the linkage of molecules that interact with phagocyte cell surface receptors. Antibody, such as IgG molecules, and complement fragments may opsonize extracellular bacteria or other microorganisms, rendering them susceptible to destruction by neutrophils and macrophages through phagocytosis. In opsonophagocytosis antibodies and/or complement, mainly C3, serve as opsonins by binding to epitopes on micro- organisms and increasing their susceptibility to phagocytosis by polymorphonuclear leukocytes, especially neutrophils. Serum bactericidal activity and phagocytic killing are two principal mechanisms in host defense against bacteria. Opsonic antimicrobial antibodies are critical for optimal functioning of figure 2. Toll-like receptors are receptors on the surfaces of phago- Surface phagocytosis refers to the facilitation of phagocy- cytes and other cells that signal the activation of macro-phages tosis when microorganisms become attached to the surfaces responding to microbial products such as endotoxin in the nat- of tissues, blood clots, or leukocytes. This family of membrane-bound pattern recognition phagocyte membrane cores the particle by a progressive receptors has been conserved in evolution. It is a host protein that coats a pathogenic microorganism of detecting intracellular pathogen products. Related struc- or macromolecule to make it bind more readily to phagocyte turally to toll-like receptors. Following interaction, the Fc Pseudopodia are membrane extensions from motile and region of the antibody becomes anchored to Fc receptors on phagocytic cells. In contrast to these so-called heat-stable antibody Catalase is an enzyme present in activated phagocytes that opsonins are the heat-labile products of complement activation causes degradation of hydrogen peroxide and superoxide such as C3b or C3bi, which are linked to particles by transa- dismutase. C3b combines with comple- ment receptor 1 and C3bi combines with complement receptor Cationic proteins are phagocytic cell granule constituents 3 on phagocytic cells. Opsonins A phagolysosome is a cytoplasmic vesicle with a limiting facilitate phagocytosis of particulate antigens by neutrophils membrane produced by the fusion of a phagosome with a or macrophages. Substances within a phagolysosome are digested the basement membrane constituent, fbronectin. A suppressor macrophage is a macrophage activated by its response to an infection or neoplasm in the host from which it was derived. It is able to block immunologic reac- tivity in vitro through production of prostaglandins, oxygen radicals, or other inhibitors produced through arachidonic acid metabolism. Defensins are widely reactive antimicrobial cationic pro- teins present in polymorphonuclear neutrophilic leukocyte granules. They block cell transport activities and are lethal for Gram-positive and Gram-negative microorganisms. Defensins (human neutrophil proteins 1 to 4) are elevated in individuals with parasitic infestations. Because of its action in promot- staining of secondary granules in the leukocyte cytoplasm. After a brief residence in the circulation, eosinophils migrate into tissues by pass- Eosinophil chemotactic factors are mast cell granule ing between the lining endothelial cells. These cytokines enhance eosinophil activation in the airways of patients with bronchial asthma, which leads to epithelial injury.

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B: After division of the lateral and long heads of triceps order viagra sublingual online pills otc erectile dysfunction drugs walgreens, the superior generic viagra sublingual 100 mg without a prescription impotence means, middle order 100 mg viagra sublingual amex impotence beavis and butthead, and inferior radial nerves (asterisks) can be seen coursing posteriorly and inferolaterally around the humerus in the spiral groove. A: Compound fracture is easily seen in a plain radiograph of the right humerus, the bullet still in the soft tissue. B: In a cross-sectional ultrasound image at the level of fracture, the radial nerve (dotted line) is seen between the bone fragments of the fractured humerus (arrows). Although the bullet (apparent on the x-ray lateral to the fracture) is not shown in this ultrasound image, it was readily identified by ultrasound just below the skin overlying the triceps (T). It rides over the distal fixation screw (arrow) with distorted 299 fascicles and impingement signs. Traumatic neuropathies: spectrum of imaging findings and postoperative assessment. The nerve is encased by hypoechoic fibrous callus (asterisks) at the level of the humeral fracture. It can be identified from surrounding fibrous tissue based on the presence of intrasubstance sutures (arrowhead). Traumatic neuropathies: spectrum of imaging findings and postoperative assessment. A careful neurologic examination and electromyography and nerve conduction velocity testing will aid the clinician in identifying the level of nerve compromise and direct the ultrasound evaluation. Supracondylar radial nerve block for treatment of distal radius fractures in the emergency department. The muscle finds its origin from the anterior surface of the proximal clavicle, the anterior surface of the sternum, the cartilaginous attachments of the second through sixth and occasionally seventh ribs, and from the aponeurotic band of the obliquus externus abdominis muscle. These muscle fibers are laid out in an overlapping bilaminar pattern, with some muscle fibers running upward and laterally and others running horizontally. These muscle fibers wind around each other so that the inferior muscle fibers insert via a broad flat tendon uppermost on the greater tubercle of the humerus and the superior muscle fibers end up inserting via a broad flat tendon onto the lowermost portion of the greater tubercle of the humerus (Fig. All of this latticework of fibers coalesces into a broad flat tendon which inserts into the crest of the greater tubercle of the humerus. It is at this distal insertion that the musculotendinous unit of the pectoralis major frequently ruptures, although ruptures of the muscle belly and at the sternoclavicular origin can also occur (Fig. The motor innervation of the pectoralis major muscle is from the medial and lateral pectoralis nerve which can both be blocked to provide surgical anesthesia for breast surgery as well postoperative pain relief. Craniocaudal (A) and mediolateral (B) mammographic views of the right breast show a circumscribed, oval, hyperdense mass (arrows) in the right pectoralis major muscle. The muscle fibers of the pectoralis major muscle wind around each other so that the inferior muscle fibers insert via a broad flat tendon uppermost on the greater tubercle of the humerus and the superior muscle fibers end up inserting via a broad flat tendon onto the lowermost portion of the greater tubercle of the humerus. The characteristic musculotendinous junction injury of pectoralis major muscle rupture. Most often, full-thickness tears occur at the tendon’s point of insertion into the crest of the greater tubercle of the humerus (Fig. Injuries of the pectoralis major musculotendinous unit are most commonly seen in weight lifters, martial artists, gymnasts, water skiers, wake boarders, skate boarders, steer wrestlers, and paragliders due to the horizontal forces placed on the muscle. The use of anabolic steroids may increase the risk of tendon rupture due to the drug’s propensity to cause a pathologic loss of flexibility of tendon fibers. Minor tears of the pectoralis muscle present clinically as anterior chest wall pain and require minimal treatment. Complete full-thickness tears occur at the tendon’s point of insertion into the crest of the greater tubercle of the humerus present acutely with massive ecchymosis and hematoma formation and weakness of internal rotation of the humerus (Fig. With complete rupture of the musculotendinous insertion, a classic cosmetic deformity is often present with a bunching of the muscle in the anterior chest wall and a webbed appearance of the axilla (Fig. If the rupture of the sternocostal portion of the muscle with sparing of the clavicular portion, a classic deformity known as sign of the triangle will be present (Fig. Complete rupture of the musculotendinous unit requires prompt surgical repair and failure to repair the rupture will result in further muscle retraction and calcification, worsening the functional disability and cosmetic deformity. Edema and ecchymosis on the right shoulder of an athlete who sustained an acute rupture of the pectoralis major muscle. Clinical considerations for the surgical treatment of pectoralis major muscle ruptures based on 60 cases: a prospective study and literature review. The cosmetic deformity associated with complete rupture of the distal musculotendinous unit of the pectoralis major muscle presents with a bunching of the muscle in the anterior chest wall and a webbed appearance of the axilla. Patient with a 4-month-old lesion with maintenance of the clavicular portion, rupture of the sternocostal portion, and muscular retraction. Clinical considerations for the surgical treatment of pectoralis major muscle ruptures based on 60 cases: a prospective study and literature review. The insertion of the musculotendinous unit of the pectoralis major muscle lies just medial to the bicipital tendon (Fig. A high-frequency linear ultrasound transducer is placed in the transverse axis centered over the bicipital groove and an ultrasound survey scan is taken (Fig. The bicipital groove is identified with the biceps tendon which appears as a hyperechoic ovoid structure lying within it (Fig. The ultrasound transducer is then turned to a longitudinal axis and is moved inferiorly along the path of the biceps tendon following the margin of the medial aspect of the humeral head as it curve inward to the medial margin of the shaft of the humerus (Figs. The insertions of the pectoralis major will be seen as they attach to the humerus (Fig. The insertions are identified for strain, hematoma formation, and/or tear as the clinical presentation dictates (Figs. Careful evaluation for tumor, mass, or other muscle abnormalities of the pectoralis major muscle and surrounding tissues is also carried out (Figs. The relationship of the bicipital tendon and the musculotendinous insertion of the pectoralis major muscle. Proper transverse position of the ultrasound transducer for ultrasound-guided injection for identification of the bicipital groove. Proper longitudinal position of the ultrasound transducer to follow the bicipital tendon and the medial margin of the humerus. Longitudinal ultrasound view of the medial aspect of the humeral head as it curves inward. Longitudinal ultrasound view of the insertion of the musculotendinous unit of the pectoralis major muscle onto the humerus. B: Normal two heads of the left pectoralis major muscle (open arrows), seen as a structure consisting of thin, white, echogenic lines. A: Gray-scale sonogram shows a circumscribed, oval, complex mass containing numerous small cleft-like cystic areas within the right pectoralis major muscle. B,C: Sonograms show the mass splitting the fibers of the pectoralis major muscle (arrows). Subacute tear of the pectoralis major sternal head myotendinous junction following forced abduction and external rotation caused by falling into a manhole. A: Extended field-of-view sonogram shows complete tear with retraction of the sternal head muscle belly, which has fatty infiltration (P).