Pectoralis Major Tears

Epidemiology

 

Middle age men

 

Aetiology

 

Usually occurs in gym

Bench Press

Increased risk with steroid use / growth hormone

 

Bodendorfer et al Orthop J Sports Med 2020

- systematic review of 23 papers and 664 injuries

- all male, average age 31

- 63% occurred during weight training

https://pubmed.ncbi.nlm.nih.gov/32083144/

 

Anatomy

 

P Major anatomy

 

Clavicular head

- attaches: medial clavicle and upper sternum

- inserts: lowermost aspect of bicipital groove

 

Sternal head

- sternum, aponeurosis external oblique and costal cartilages of first 6 ribs

- inserts at uppermost aspect of bicipital groove

 

2 tendons converge and rotate 90o

- insert lateral to bicipital groove

- superior fibres insert inferiorly and vice versa

 

Tendon is composed of two lamina

- anterior lamina is clavicular head

- posterior lamina is sternal head

 

Nerve supply

 

Lateral pectoral nerve C5-7

- clavicular head

- part of sternal head

 

Medial pectoral nerve C8-T1 

- sternal head

- passes through and supplies pec minor

 

Actions

 

Powerful adductor, flexor and internal rotator

 

History

 

Usually recall significant incident

- tearing sensation

- may hear a pop

- often severe swelling and bruising

 

Only later when it settles is the cosmetic and functional deficiency apparent

 

Examination

 

Significant bruising in the acute phase

 

Acute pectoralis major tear

 

Asymmetry of chest wall

 

Pec major tear chronic

 

Pec Major RupturePec major rupture palpable cord

 

Frequently palpable cord present

- is pectoral fascia still attached to antebrachial fascia

- not to be mistaken for pectoralis tendon

- prevents full retraction

 

In chronic setting, ask patient to adduct against hip / resistance

 

Pectoralis Major TearPectoralis Tear 2

 

Usually complain of weakness, mainly in gym

 

MRI

 

MRI P Major tear 1MRI Pec major tear 2

Coronal T2 MRI Right shoulder

 

Chronic Pectoralis Major 1

Coronal T1 MRI Left shoulder

 

Pectoralis Major 3Pectoralis 3

Coronal T1 MRI Left shoulder

 

Management

 

Non operative

 

Elderly / low function

Chronic setting

 

Musculotendinous tears

- avulsion of muscle off tendon

- need MRI to diagnosis

- not amenable to suture repair

- likely need allograft reconstruction

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6928300/pdf/main.pdf

 

Operative

 

Indications

 

Acute tears in young patients

Cosmesis i.e. body builders

 

Results

 

Bodendorfer et al Orthop J Sports Med 2020

- SR of 23 papers and 664 injuries

- surgery improved strength, functional outcome, satisfaction compared to nonoperative treatment

- no difference between different surgical techniques

- complication rate 14%

- re-rupture rate 3%

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7005984/pdf/10.1177_2325967119900813.pdf

 

Acute repair

 

Options

- suture anchor

- cortical anchor

- bone trough

 

Incision Pec Major RepairPect Major Repair Through Bone Trough

Axillary incision right shoulder

 

Bone Trough Technique

 

Beach chair

- deltopectoral approach

- can also make incision in axillary skin crease

- find pectoralis major tendons medially

- Krackow with high strength sutures

- place Hohmann retractor under deltoid to expose humerus

- identify long head of biceps

- can usually identify previous pectoralis major insertion

- drill one inch trough in humerus lateral to long head of biceps

- make drill holes with 2 mm drill lateral to trough

- use suture passer to pass sutures into trough and out lateral drill holes

- pull tendon into trough and tie sutures

 

Pec major repair 1

Axillary crease incision in right shoulder, with Kocher forceps on the torn pectoralis major tendon

 

P Major tear surgeryPec major tear humerus

Right shoulder, with Hohmann retractor exposing humerus

 

P Major trough in bone

Bone trough with sutures passed through lateral drill holes

 

Completed repairPec major repair complete

Completed repair

 

Cortical button technique

 

Arthrex surgical technique video

https://www.arthrex.com/resources/video/8k0TqUoNMUmNQQFBeowpnA/pectoralis-major-repair-using-the-pec-button-repair-kit?referringTeam=shoulder

 

Complications

 

Infection <1%

DVT < 1%

Re-rupture 3%

Persistent pain 3%

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7005984/pdf/10.1177_2325967119900813.pdf

 

Humerus fracture

- case report with bone trough following fall

 

Chronic Reconstruction of Pectoralis Major tendon

 

Technique

 

Vumedi video

https://www.vumedi.com/video/pectoralis-major-tendon-allograft-reconstruction/

 

Tendoachilles graft with bone block cut off

- pass through allograft tendon through muscle in pul ve taft method

- tie down into bone trough in humerus as per usual technique

 

Pect Major Reconstruction 14 Suturing allograftPec Major Reconstruction 3

Right shoulder.  Allograft has been passed through sternal and clavicular muscle bellies and is being sutured back onto itself