High Yield Overview

PECTORALIS MAJOR TENDON REPAIR - ACUTE RUPTURE

Deltopectoral Approach | Suture Anchor or Bone Tunnel Fixation

Mnemonic

P-E-C-SPECS - Pectoralis Major Anatomy

Mnemonic

B-E-N-C-HBENCH - Risk Factors for Re-rupture

Critical Danger Structures

Musculocutaneous Nerve

Enters coracobrachialis 5cm from coracoid. CRITICAL: Limit medial dissection to less than 5cm from coracoid tip. Mark coracoid with suture as reminder. Palpate coracobrachialis before placing medial retractors.

Brachial Plexus

Medial and deep to conjoint tendon. Avoid aggressive medial or deep retraction. Stay anterior and lateral in surgical field. No dissection medial to conjoint tendon.

Axillary Vessels

Anterior circumflex humeral artery at surgical neck. Identify and ligate if encountered. No deep medial dissection. Apply direct pressure if massive bleeding, call for vascular backup.

Cephalic Vein

Marks deltopectoral interval in 88% of cases. Identify early and preserve. Usually retract laterally with deltoid. Can be ligated if injured - collateral drainage adequate.

Absolute Surgical Indications

Complete pectoralis major rupture at tendon insertion (Tietjen Type III/IV) in active patient
Acute tear less than 6 weeks old with good tissue quality
Sternal head avulsion with loss of anterior axillary fold
High-demand athlete or manual laborer requiring full strength
Young patient unwilling to accept cosmetic deformity

Exam Pearl

Exam Key: "The classic surgical candidate is a young male weightlifter (95% occur during bench press) with acute complete rupture, loss of anterior axillary fold, and significant weakness. Surgery within 6 weeks while tissue quality is good gives best outcomes."

Relative Indications

Partial tear greater than 50% of tendon width
Combined sternal and clavicular head tears
Chronic tear 6 weeks-3 months in motivated young patient (accept higher revision rate)
Significant cosmetic concern about axillary fold deformity

Contraindications

Absolute Contraindications:

Muscle belly tears (Tietjen Type I) - manage non-operatively (no surgical repair possible)
Active infection or medical instability

Relative Contraindications:

Partial tears less than 50% (especially isolated clavicular head - good outcomes non-op)
Chronic tears greater than 6 months with significant retraction and muscle atrophy
Low-demand elderly patient who accepts weakness
Medical comorbidities precluding anaesthesia

Chronic Tear Considerations

Tears >6 months have poor tissue quality, muscle atrophy with fatty infiltration (visible on MRI), and significant retraction making direct repair impossible. These require allograft reconstruction (Achilles or fascia lata) with lower success rates (75-80% vs 95% for acute).

Equipment

Standard Equipment:

Basic shoulder tray (self-retaining retractor, Fukuda retractor, Army-Navy)
Cephalic vein retractors
Power drill with 3.2mm drill bit (for bone tunnels)
Suture passer or looped wire

Fixation Options:

Suture Anchors: 3-4 × 5.5mm bioabsorbable anchors loaded with #2 FiberWire
Bone Tunnels: 3.2mm drill, suture passers, optional cortical button

Suture Material:

#2 FiberWire or Ethibond for tendon fixation
Krackow stitch or baseball whipstitch configuration

Optional:

C-arm fluoroscopy for anchor/tunnel position
Dermal allograft for augmentation (chronic/revision cases)
Closed suction drain (10Fr Blake)

Positioning and Preparation

Patient Position: Beach chair 30-45° upright or supine. Arm free-draped on armboard allowing full ROM - must be able to adduct across chest (relaxes pectoralis for mobilization) and extend/externally rotate (tensions repair for testing).

Surgical Approach: Deltopectoral approach via traditional vertical incision or axillary crease incision (preferred for cosmesis).

Anaesthesia: General anaesthesia with interscalene or supraclavicular block for post-operative analgesia.

Incision Options:

Approach	Length	Advantages	Disadvantages
Axillary crease	8-12cm	Hidden scar, Langer's lines	Less extensile
Deltopectoral	8-10cm	Extensile, familiar anatomy	More visible scar

Operative Technique

Step 1: Surgical Setup and Incision

Perform WHO surgical safety checklist. Position patient beach chair 30-45° with arm free-draped. Mark incision - axillary crease preferred for cosmesis in young males. Prep widely including chest wall to clavicle. Make 8-12cm transverse incision in anterior axillary fold or vertical incision from coracoid to deltoid insertion.

Exam Pearl

Axillary Crease Advantage: Hidden in natural fold, follows Langer's lines, less visible especially in men with chest hair. Increasingly preferred for primary acute repairs in young patients concerned about cosmesis.

Step 2: Deltopectoral Interval Development

Incise skin and Scarpa's fascia sharply. Identify cephalic vein marking deltopectoral interval in 88% of cases. Preserve vein and retract laterally with deltoid. Develop interval by blunt and sharp dissection. Divide clavipectoral fascia vertically. Evacuate hematoma in acute tears to improve visualization.

Cephalic Vein

Identify early - marks the interval. Preserve if possible (better drainage) but can ligate if injured. Thermal injury with cautery causes thrombosis - use bipolar carefully near vein.

Step 3: Identification of Ruptured Tendon

Identify torn pectoralis major tendon - typically torn at or near insertion on lateral lip of bicipital groove in acute tears. Tendon usually retracted 3-5cm medially with surrounding hematoma. Grasp stump with Allis or Kocher clamp.

Key Anatomy - Bilaminar Tendon with 180° Twist:

Clavicular head (20%) inserts more proximally via anterior lamina
Sternal head (80%) inserts more distally via posterior lamina
Inferior muscle fibers insert superiorly on bone - this twist is critical for function

Exam Pearl

Most Common Tear Pattern: Sternal head avulsion from lateral lip of bicipital groove (60-70%). Clavicular head often intact in partial tears. Complete tears involve both heads.

Step 4: Tendon Mobilization

Mobilize tendon by dissecting from surrounding hematoma, scar tissue, and chest wall adhesions. Work medially to gain adequate length for tension-free repair. Remove devitalized tendon edges but preserve maximum length. Adduct shoulder to relax muscle-tendon unit during mobilization.

Musculocutaneous Nerve - 5cm Rule

CRITICAL: Limit medial dissection to less than 5cm from coracoid tip. Mark coracoid with suture to remind team. Palpate coracobrachialis before placing medial retractors - can feel nerve within muscle. Use only blunt dissection medially.

Step 5: Tendon Preparation

Place 2-4 heavy braided non-absorbable sutures (#2 FiberWire or Ethibond) through tendon before reduction using Krackow locking stitch or baseball whipstitch pattern. This is easier before repair when access is good.

Step 6: Footprint Preparation

Retract tendon medially to expose lateral lip of bicipital groove (insertion footprint). Identify long head of biceps in groove as medial landmark. Use periosteal elevator to clear soft tissue and scar from lateral lip. Create clean bony surface for healing. Footprint is approximately 5cm long × 1cm wide.

Exam Pearl

Anatomic Landmark: Pectoralis major inserts lateral to biceps groove. Subscapularis inserts medial to groove. Biceps tendon is your medial boundary - stay lateral to it.

Step 7A: Suture Anchor Fixation (Preferred Technique)

Place 3-4 suture anchors (5.5mm bioabsorbable) along lateral lip of bicipital groove:

Space anchors 1.5-2cm apart along 5cm footprint
Use drill guide to create pilot holes perpendicular to cortex
Confirm solid purchase by tugging suture limbs
Multiple anchors provide combined strength of 900-1200N

Advantages of Anchors:

Technical ease compared to bone tunnels
Lower profile - less irritation
Allows revision if needed
Equivalent biomechanics to tunnels

Step 7B: Bone Tunnel Technique (Alternative)

Create 3 unicortical bone tunnels with 3.2mm drill:

Space tunnels 1.5-2cm apart (minimum 1cm to prevent fracture)
Drill perpendicular to cortex, 15-20mm deep - UNICORTICAL ONLY
Pass suture passer or looped wire through each tunnel

Avoid Bicortical Drilling

Penetrating far cortex risks radial nerve in spiral groove on posterior humerus. Unicortical only.

Step 8: Tendon-to-Bone Fixation

Position arm in 30-45° abduction, neutral rotation. Reduce tendon to footprint without gap.

For Suture Anchors: Pass anchor sutures through tendon in mattress configuration. Tie with sliding knots locked with alternating half-hitches. Use all available suture limbs.

For Bone Tunnels: Pass pre-placed Krackow sutures through tunnels. Tie over bone bridge or cortical button with appropriate tension.

Exam Pearl

Tensioning Principle: Test at 30-45° abduction, neutral rotation - approximates resting muscle length. After repair, should achieve full passive adduction to neutral, IR to abdomen, and 140° forward elevation. If repair limits these motions, it is too tight.

Step 9: Repair Assessment

Test repair construct:

Visual inspection - tendon reduced to bone without gap
Palpation - solid tendon-bone interface
Passive ROM - full elevation, ER, IR, and adduction across chest
Gentle resisted activation - no gapping with gentle pec squeeze

If any concerns about security or tension, revise repair before closing.

Step 10: Closure and Immobilization

Irrigate with 1-2L normal saline. Achieve meticulous hemostasis. Close in layers:

Clavipectoral fascia with 2-0 Vicryl if divided extensively
Deep subcutaneous with 2-0 Vicryl
Dermis with 3-0 Monocryl subcuticular
Skin with 4-0 Monocryl or skin glue

Immobilization: Shoulder sling with arm in NEUTRAL ROTATION and slight ADDUCTION (opposite to Bankart which requires external rotation). Some surgeons use 30° abduction pillow to reduce tension on repair.

Exam Pearl

Drain Decision: Consider 10Fr Blake drain if: extensive dead space, persistent oozing, patient on anticoagulation, revision surgery. Most primary acute repairs do not require drain if good hemostasis achieved. Remove at 24-48 hours.

Post-operative Protocol

Rehabilitation Timeline:

Phase	Timeframe	Activities
Phase 1	0-4 weeks	Strict sling, NO shoulder motion (elbow/wrist/hand ROM only)
Phase 2	4-6 weeks	Begin passive ROM (pendulums, assisted elevation to 90°, ER to 30°)
Phase 3	6-12 weeks	Active-assisted → active ROM, light isometrics week 8
Phase 4	12-16 weeks	Progressive resistance, light bench press
Phase 5	4-6 months	Gradual return to unrestricted activity
Phase 6	6-9 months	Return to competitive sports and heavy lifting

Critical Restrictions:

NO bench press for 6 months (mechanism of injury in 70%)
NO push-ups for 4-6 months
Limit adduction across body for 3 months
Avoid resisted internal rotation for 4 months

Most Common Cause of Re-rupture

Early return to gym and bench press. Young athletic males eager to return to lifting have high non-compliance rate. Strict patient education about 6-month timeline is essential.

Complications

Pectoralis Major Repair Complications

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

EXAMINER

"A 28-year-old male bodybuilder presents 5 days after sudden pop and pain during bench press. Examination shows loss of anterior axillary fold, ecchymosis to elbow, weakness in adduction. MRI shows complete sternal head avulsion. How do you manage this patient?"

EXCEPTIONAL ANSWER

This is an acute complete pectoralis major rupture at the tendon insertion requiring surgical repair in this young active male. I would proceed with urgent surgical repair within 6 weeks while tissue quality remains good. My approach: deltopectoral interval via axillary crease incision for cosmesis, identify and preserve cephalic vein, evacuate hematoma, mobilize tendon staying within 5cm of coracoid to protect musculocutaneous nerve, prepare footprint on lateral lip of bicipital groove, and fix with 3-4 suture anchors in tension-free position tested at 30° abduction. Post-operatively: sling × 4 weeks, passive ROM weeks 4-6, active ROM weeks 6-12, progressive strengthening from week 12, and CRITICALLY no bench press for 6 months - the mechanism of injury.

VIVA SCENARIOStandard

EXAMINER

"Describe the anatomy of pectoralis major insertion and how this affects your repair technique."

EXCEPTIONAL ANSWER

Pectoralis major has two heads: the clavicular head (20% of muscle mass) originates from medial clavicle, and the sternal head (80%) originates from sternum and ribs 1-6. The key anatomical feature is the BILAMINAR TENDON WITH 180° TWIST - the inferior muscle fibers (from sternal head) rotate to insert superiorly on the lateral lip of bicipital groove, while superior fibers insert inferiorly. This creates the characteristic 'humeral rotation' twist. The footprint is approximately 5cm long by 1cm wide. During repair, I must: (1) recognize which head is torn - sternal head tears most common at tendon-bone junction, (2) prepare the entire footprint, (3) restore the anatomic tension relationship - repair with arm at 30-45° abduction to approximate resting muscle length, and (4) achieve secure fixation across the footprint with 3-4 anchors spaced 1.5-2cm apart.

VIVA SCENARIOStandard

EXAMINER

"Your pectoralis major repair patient returns at 3 months with sudden pop while doing push-ups at home despite your instructions. What is your assessment and management?"

EXCEPTIONAL ANSWER

This is likely a re-rupture due to non-compliance with restrictions - push-ups were specifically prohibited until 4-6 months. My assessment: examine for return of loss of anterior axillary fold, palpable gap, weakness in adduction and internal rotation. Obtain MRI to confirm complete re-rupture versus partial failure and assess tissue quality and retraction. Management: Given this is early re-rupture at 3 months, I would recommend urgent revision repair within 2-4 weeks while tissue quality is still salvageable. Revision approach: same deltopectoral interval, more extensive mobilization may be needed, and I would augment with dermal allograft patch given this is a revision with likely compromised tissue. Post-op: same protocol but with even more emphasis on compliance - frank discussion that another failure would likely result in permanent weakness and deformity. Consider more frequent follow-up visits and possible formal rehabilitation facility rather than home exercises.

Pectoralis Major Repair - Exam Summary

High-Yield Exam Summary

References

Bodendorfer BM, et al. Pectoralis major tears: Epidemiology, outcomes, and surgical technique. J Am Acad Orthop Surg. 2020;28(13):532-541.
Sanchez A, et al. Pectoralis major ruptures: A systematic review. Am J Sports Med. 2021;49(4):1067-1076.
ElMaraghy A, Devereaux M. A systematic review and comprehensive classification of pectoralis major tears. J Shoulder Elbow Surg. 2012;21(3):412-422.
Bak K, et al. Surgical repair of pectoralis major ruptures in athletes. A review of the current state of management. Am J Sports Med. 2000;28(4):590-595.
de Castro Pochini A, et al. Complete rupture of the pectoralis major muscle in athletes: A prospective study. Am J Sports Med. 2010;38(1):92-98.
Cordasco FA, et al. Pectoralis major tendon ruptures: Functional outcome after repair. J Shoulder Elbow Surg. 2022;31(5):946-952.
Tietjen R. Closed injuries of the pectoralis major muscle. J Trauma. 1980;20(3):262-264.
Hanna CM, et al. Pectoralis major tears: Comparison of surgical techniques. Am J Sports Med. 2001;29(1):9-15.
Shepard NP, et al. Biomechanical comparison of suture anchor versus bone tunnel repair of pectoralis major tendon. J Shoulder Elbow Surg. 2019;28(11):2194-2199.
Provencher MT, et al. Surgical management of pectoralis major ruptures in athletes. JBJS Rev. 2018;6(2):e7.

Grade	Description	Location	Management
I	Contusion/strain	Muscle	Non-operative
II	Partial tear	Any	Non-op if <50%
III	Complete muscle tear	MTJ	Surgical if active
IV	Tendon avulsion	Insertion	Surgical

Pectoralis Major Tendon Repair - Acute Rupture