Pec Rupture

Transcription

Pec Rupture

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
Vanderbilt Sports Medicine
Disclosure Information
TRIA Orthopaedic & Sports Medicine
Conference:
Tackling Football Injuries
John E. Kuhn, MD MS
Disclosure 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 1822butcher 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
Physical Exam
• Things to Look
For:
Fold
of Muscle
Physical Exam
• Things to Look
For:
Fold
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 Imaging
Muscultotendonous Junction Tear
Case courtesy of Dr Ajay C Desai, Radiopaedia.org
MRI Imaging
MRI Imaging
MRI Imaging
Tendon Avulsion
•
•
•
Tendon Off Bone
Tendon is Wavy
Biceps sits Anterior
Acute Injury
Treatment Option
• Nonoperative
• Surgical repair
ARS Question 2
What 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
ARS Question 2
What 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 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
• Transosseous
• Trough and
Drill Holes
Petilon J, et al Pectoralis Major Muscle Ruptures. Oper Tech Sports Med 13:162-188, 2005
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 Injury
Surgical 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

Pec Rupture

Transcription

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