Disclosures: Mani Singh, MD: No financial relationships or conflicts of interest

Case Diagnosis: 91-year-old-female with a past medical history of atrial fibrillation presented with remote falls and intermittent weakness due to right sided embolic/ischemic strokes and developed chest pain secondary to a retropectoral hematoma while on an inpatient rehabilitation unit (IRU).

Case Description: Magnetic resonance imaging showed right-sided infarcts of the parietal corona radiata, postcentral gyrus, and posterior limb of internal capsule. Embolic etiology was suspected with superimposed ischemia from right internal carotid artery stenosis. Warfarin was started, with an enoxaparin bridge, and she was transferred to an IRU for impairments of gait, mobility, and activities of daily living. On admission, she ambulated 150 feet with a rolling walker at a contact guard level, compared to 10 feet during a prior session. She later noted left chest wall and axillary pain, worsened with adduction, medial rotation, flexion, and overhead extension of arm. Exam was notable for point tenderness along the upper pectoralis muscle (clavicular head) with immediate improvement after release of chest wall. Cardiac workup was unremarkable. A diagnosis of left pectoralis major strain was made. Approximately 36 hours later, there was increasing edema and ecchymoses of the left chest wall and decreased hemoglobin levels. Computed tomography (CT) scan revealed a large, retropectoral hematoma.

Setting: IRU at an academic center.Assessment/

Results: CT angiogram revealed an intercostal vein (third rib) as the site of active hemorrhage. Etiology was determined to be iatrogenic secondary to enoxaparin, exacerbated by pectoralis and intercostal muscle overuse/microinjury. A pressure bandage was applied to manually compress the chest wall and her hemoglobin stabilized.

Discussion: To our knowledge, this is the first case of an iatrogenic retropectoral hematoma masquerading as chest pain on an IRU.

Conclusion: Retropectoral hematomas can present as atypical chest pain or pectoralis strain and should be included on the differential diagnosis for chest pain in the setting of therapeutic anticoagulation and functional muscle use.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/retropectoral-hematoma-as-a-unique-etiology-of-chest-pain-on-the-inpatient-rehabilitation-unit-a-case-report/