Managing Pectoralis Major Ruptures in Football Players -...

Vanderbilt Sports Medicine

Managing Pectoralis Major Ruptures in Football Players

John E. Kuhn, MD

Kenneth D. Schermerhorn Professor of Orthopaedics

Chief of Shoulder Surgery

Director of Vanderbilt Sports Medicine


Disclosure InformationTRIA Orthopaedic & Sports Medicine

Conference:

Tackling Football Injuries

John E. Kuhn, MD MSDisclosure of Relevant Financial Relationships

I have no financial relationships to disclose.

Disclosure of Off-Label and/or investigative Uses

I will not discuss off label use and/or investigational use in my presentation.


Origin• Medial 1/3 of Clavicle

• Anterior Aspect of Manubrium and Length of Body of Sternum

• Cartilaginous Attachments of upper 6 Ribs

• External Oblique’s Aponeurosis


Insertion

• Lateral Lip of Bicipital Groove to the Crest of the Greater Tuberosity

• Clavicular Fibers insert Distally and Superficially

• Sternal Fibers insert Proximally and Deep


Two Heads

• Clavicular Head

• Sternal Head


Many Segments to Sternal Head

• Fan Shaped Muscle

ElMaraghy AW, Devereaux MW. A systematic review and comprehensive

classification of petoralis major tears. JSES 2012;21:412-422


Insertion

• Anterior Leaflet

– Clavicular Head

– Upper part of Sternal Head

• Posterior Leaflet

– Lower Part of Sternal Head

– Good for Transfers!


Action• Adduction of

Humerus

• Medial Rotation of Humerus

• Flexion of arm from Extension (Clavicular Portion) Incline Bench Press


Blood Supply

• Pectoralis Branch of Thoracoacromial Artery

• Runs with Lateral Pectoralis Nerve


Innervation

• Clavicular Head: Lateral Pectoral Nerve (C5,6,7)

• Sternal Head: Medial Pectoral Nerve (C8, T1)


Reported Frequency of Injury




Demographics

• Males: Age 20-39

• Females: Elderly and Dependent

• Hand Dominance not a factor

• Increased Risk

– Anabolic Steroids

– Muscle Fatigue/Micro trauma


Mechanisms of Injury

• Bench Press• Sports: (power lifting, rugby,

snow skiing, water skiing, football, wrestling, parallel bar dips, boxing, sailboarding, parachuting, hockey)

• Work: (first case Paris 1822-

butcher boy lifting meat)

• Transfers in the Elderly (stiff and atrophied muscle-a crush injury)


History

• Audible POP

• Tearing Sensation

• Immediate Pain and/or Weakness


Classification of Injury




Physical Exam• Can be Difficult to Determine Type:


Physical Exam• Deformity

• Ecchymosis

• Swelling may Mask Extent


Physical Exam

• Indentations with Flexing


Physical Exam

• Things to Look For:

– Loss of Axillary Fold

– Fullness in Belly of Muscle


Some Hints

• If there is NO Ecchymosis on the Humerus

• AND the Axillary Boarder is Intact

• Then Possibly a Muscle Origin or Muscle Belly Injury


MRI Imaging-Normal

• Pectoralis tendon

• Latissimus Tendon

• Triceps

• Quadrilateral Space


MRI ImagingMuscultotendonous Junction Tear

Case courtesy of Dr Ajay C Desai, Radiopaedia.org


MRI ImagingTendon Avulsion

• Tendon Off Bone

• Tendon is Wavy

• Biceps sits Anterior


Acute InjuryTreatment Option

• Nonoperative

• Surgical repair


ARS Question 2What are the Indications for Surgical Repair?

A.) Low Demand, Elderly Patient

B.) Muscle Origin Tear

C.) Muscle Belly Tear

D.) Active High Demand Patient

E.) Muscle Strain


Nonoperative Management

• Low Demand

• Elderly



• Sling

• Cryotherapy

• Passive exercises as tolerated

• Active assisted and active exercises over next six weeks

• Resisted therapy at 2-3 months



• Muscle Belly Tear Diffuse Strain

• Focal Tear-

• Difficult to Repair

• Muscle Tears


Surgical Management

• Literature Comprises Case Series

• OVERWHELMINGLY Supports Surgery for Active Patients


Surgical Management

De Castro Pochini A et al. Clinical consideration for the surgical treatment of pectorals major muscle ruptures based on 60 cases Am J Sports Med 42(1):95-102, 2013


Surgical Techniques

Petilon J, et al Pectoralis Major Muscle Ruptures. Oper Tech Sports Med 13:162-188, 2005

• Transosseous

• Trough and Drill Holes


Surgical Techniques

• Suture Anchor Repair

Provencher MT, et al Injuries to the Pectoralis Major Muscle: Diagnosis and Management, Am J Sports Med 38:8:1693- 1705, 2010


Surgical Techniques

• Knotless Anchor Repair

Samitier GS, et al. Pectoralis major transosseous equivalent repair with knotless anchors Int J shoulder Surg 9(1):20-23, 2015


Surgical Techniques• Unicortical Endobuttons

Metzger PD et al. Pectoralis major muscle rupture repair: Technique using unicortical buttons. Arthrsocpy Techniques 1(1): 119-125, 2012


Chronic InjurySurgical Techniques

• Hamstring Graft

• Fascia Lata Allograft

Schachter AK et al. Revision reconstruciont of a pectoralis major tendon rupture using hamstring autograft. Am J Sports Med 32:2:295-298, 2006 and Sikka RS. Et al Reconstruction of the pectoralis major tendon with fascia lata allograft Orthopaedcis 28(10):1199-201, 2005.


Postoperative Management

• Sling 4-6 weeks

• Passive Pendulums + Scapula Motion immediately

• Gentle Passive ROM begins at 6 weeks to full Active ROM by 12 weeks

• Progressive Strengthening at 12 weeks

• Unrestricted Activity at 4-6 Months


Complications of Injury/Treatment

• Acute Compartment Syndrome (Smith et al JSES 2015)

• Exercise Induced Compartment Syndrome (Tarkin JSES 2009)

• Infected Hematoma (Pai et al Aust N Z J Surg 1995)

• Proximal Humerus Fracture (Silverstein Orthopedics 2011)


Thank You

Managing Pectoralis Major Ruptures in Football Players -...

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