Pete Wilder: A 23-Year-Old Printer With Persistent Chest Wall Pain Following CPR

Learning Objectives

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Learn the common causes of chest wall pain.
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Develop an understanding of the anatomy of the manubriosternal joint.
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Develop an understanding of the unique clinical presentation of manubriosternal joint pain.
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Develop an understanding of the differential diagnosis of chest wall pain.
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Learn how to use physical examination to identify the manubriosternal joint as the source of chest wall pain.
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Develop an understanding of the treatment options for manubriosternal joint pain.

Pete Wilder

Pete Wilder is a 23-year-old printer with the chief complaint of, “Every time I take a deep breath, it feels like somebody is stabbing me in the chest with a knife.” Pete stated that he stopped to help a woman in a minivan full of kids who was trying to change a tire. The next thing he knew, he woke up in the intensive care unit of the university medical center. “Doctor, I guess I was trying to lift the spare up onto the wheel when a guy in a pickup truck came over the hill and knocked me into next week. A bystander decided I didn’t have a pulse and started CPR. He must have really pumped the hell out of my chest because now my breastbone clicks with every breath. The ICU doctor said I had a dislocation or something.”

“Doctor, I consider myself a pretty tough guy—you know, I joined the Marines right out of high school—but any time I cough or sneeze, the pain is so bad I just want to scream. It really, really hurts.”

I asked Pete if he had experienced any pain or had any previous injury or surgery of the chest wall before all this started, and he shook his head no and replied, “I am as healthy as a horse. I guess no good deed goes unpunished. I guess I am lucky that I didn’t get killed trying to help that lady. I really don’t remember getting hit by the car or getting my chest pounded on. I guess that’s a good thing—or not!?” I asked, “How is your sleep?” Pete replied, “I’m sleeping in my recliner because it keeps me from rolling over, which really hurts. Even then, I bet the pain wakes me up 50 times a night. My boss has been pretty nice about the whole thing, but printing is a pretty physical activity.”

I asked Pete to show me the location of the pain, and he pointed to the center of his sternum. “It hurts right here. It’s right here, and this is where the clicking comes from, right here.” I asked Pete about any fever, chills, or other constitutional symptoms such as weight loss or night sweats, and he shook his head no. He denied any other musculoskeletal or systemic symptoms.

On physical examination, Pete was afebrile. His respirations were 18, his pulse was 74 and regular, and his blood pressure was 124/76. Pete’s head, eyes, ears, nose, throat (HEENT) exam was normal, as was his thyroid exam. Auscultation of his carotids revealed no bruits, and the pulses in all four extremities were normal. He had a regular rhythm without abnormal beats. His cardiac exam was otherwise unremarkable. His abdominal examination revealed no abnormal mass or organomegaly. There was no peripheral edema. His low back examination was unremarkable, although flexion of the lumbar spine caused some pain in the right buttocks. There was no costovertebral angle (CVA) tenderness. Visual inspection of Pete’s anterior chest wall was unremarkable. There was no evidence of ecchymosis or obvious swelling. Pressure on the sternum caused Pete to cry out in pain. There was an obvious bony deformity with a clearly defined step-off of the manubriosternal joint, suggestive of a manubriosternal dislocation ( Fig. 2.1 ). Pete said, “I’ve had about all the fun with the poking around that I can stand. Are you about done?” “Sorry, Pete, I just want to figure out what we need to do to get you better. We are about done here.” Careful neurologic examinations of both the upper and lower extremities were normal. Deep tendon reflexes were physiologic throughout. “I am pretty sure I know what is causing the pain, and we should be able to get you better.”

Key Clinical Points—What’s Important and What’s Not

The History

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History of severe midsternal pain after receiving CPR
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Pain made worse with pressure on the manubriosternal joint
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No history of previous chest or chest wall pain
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No fever or chills
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Significant sleep disturbance

The Physical Examination

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Patient is afebrile
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Pain on pressure to the midsternum ( Fig. 2.2 )

Fig. 2.2

Palpation of the manubriosternal joint.
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No obvious ecchymosis or swelling
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No obvious deformity of the sternum or manubriosternal joint