Know Your Limits: The Line You Do Not Want To Cross

HISTORY: A 17-year-old female, senior high school cross-country runner with history of trapezius strain, presents with right posterior shoulder pain. She was doing physical therapy and underwent dry needling of the right parascapular region 2 days prior. She had pain during needle placement in the posterior chest wall. Shortly after that, her pain increased and extended to the apex of her right hemithorax, shoulder, anterior and posterior chest. The pain worsened with running, which she attempted earlier that day. However, denied any shortness of breath, trauma, numbness, tingling, weakness, chills, or fever. She was seen at the sports medicine clinic, where she was hemodynamically stable, had X-rays, and was referred to the ED, where she was evaluated by pediatric surgery. PHYSICAL EXAMINATION: Vital signs were normal, and O2 saturation was 99% in room air. She was in no distress. Skin was intact, with no excoriation or rashes. Neck was supple, with midline trachea and no JVD. Breathing was unlabored, and breath sounds were decreased in the right upper lung field. Tenderness with pressure over the rib bodies near T6 and T7 posteriorly. She showed weakness in active abduction, reporting pain limited her, and intact passive ROM. She was alert and oriented, with normal sensitivity, bulk, and tone. DIFFERENTIAL DIAGNOSIS:- Quadrangular space syndrome - Post Procedural Trapezius Hematoma - Pneumothorax TEST AND RESULTS: Chest PA and lateral X-ray: Moderate-sized pneumothorax on the right that measured 3.2 cm at the apex. Clear lung fields. No pleural effusion. Normal cardio mediastinal silhouette. No bony abnormalities. (Fig.1) FINAL WORKING DIAGNOSIS: Acute Traumatic Right Pneumothorax TREATMENT AND OUTCOMES: She underwent urgent bedside right lateral chest 12fr pigtail catheter placement. An immediate rush of air was noted, and the catheter was connected to suction. Post-procedural Chest X-ray showed decreased size of the right pneumothorax with a small persistent apical component of 9.8 mm. (Fig. 2) After 48hs, the catheter was placed in water seal, and removed 4 hours later. Post-catheter removal Chest X-ray showed no pneumothorax. (Fig. 3) She was tolerating diet, afebrile, ambulating with minimal incisional discomfort, and was discharged home. She was instructed to follow up in 2 weeks with repeat Chest Xray.