Orthopedics

Case Report 

Proximal Humerus Shaft Fracture After Pectoralis Major Tendon Rupture Repair

Jeff A. Silverstein, MD; Ben Goldberg, MD; Preston Wolin, MD

Abstract

Surgical repair of a complete pectoralis major tendon rupture at the humeral insertion has superior results compared to nonoperative treatment. To our knowledge, a proximal humerus shaft fracture occurring at the site of the bone trough and cortical drill holes after a pectoralis major tendon rupture repair has not been reported in the literature.

A 45-year-old man sustained an acute left pectoralis major tendon rupture at the humeral insertion while performing a bench press maneuver. He underwent acute surgical repair. Approximately 8 weeks postoperatively, the patient fell from a standing height and sustained a proximal humerus shaft fracture through the repair site at the bone trough. Three days after the fracture, the patient underwent open reduction and internal fixation of the proximal humerus shaft fracture and exploration of the pectoralis major tendon repair. The fracture was found to be at the level of the repair site, and the pectoralis major tendon was completely intact to the distal fragment. The fracture healed uneventfully, and the patient regained full motion and strength of his extremity with no limitations.

Any type of surgical fixation that creates a hole in the humerus or decreases the cross-sectional area such as a bone trough creates a stress riser. Patients undergoing pectoralis tendon repair that involves violating the humerus with a bone trough or hole have a slight risk of postoperative humerus fracture, especially if sustaining an early traumatic event such as a fall.

Drs Silverstein, Goldberg, and Wolin are from the Department of Orthopedics, University of Illinois-Chicago Medical Center, Chicago, Illinois.

Drs Silverstein, Goldberg, and Wolin have no relevant financial relationships to disclose.

Surgical repair of a complete pectoralis major tendon rupture at the humeral insertion has superior results compared to nonoperative treatment regarding patient satisfaction, strength, comesis, and return to sport. 1–12 Nonoperative treatment is recommended for proximal, partial, or complete tears in a more sedentary individual. 1–12 Bak et al 2 performed a meta-analysis review of 112 pectoralis tendon ruptures at the humeral insertion and reported 88% good/excellent results for surgically treated patients compared to 27% nonoperative patients.

Several techniques have been reported for surgical fixation of the pectoralis tendon, including suturing the ruptured tendon back to the humerus with use of a bone trough and cortical drill holes, suture anchors, screw fixation, direct suture approximation, and barbed stapling. 3,4,10,12–16 To our knowledge, a proximal humerus shaft fracture occurring at the site of the bone trough and cortical drill holes after a pectoralis major tendon rupture repair has not been reported in the literature.

A 45-year-old man sustained an acute left pectoralis major tendon rupture while performing a bench press maneuver. The tear occurred at the humeral insertion. He underwent acute surgical repair as described by Schepsis et al. 4 This technique involves creating a 3- to 5-cm bone trough lateral to the bicipital groove. Using No. 5 nonabsorbable sutures, 2 sets of modified Kessler sutures are used to grasp the muscle and fascia. The sutures are then passed and tied through 4 cortical drill holes made 1 cm lateral to the trough. Any remaining distal tendon is oversewn into the muscle with absorbable suture.

There were no intraoperative complications, and the patient did well for 8 weeks. Approximately 8 weeks postoperatively, the patient fell from a standing height and sustained a proximal humerus shaft fracture through the repair site at the bone trough (Figure ).

Figure 1:. AP (A) and Lateral (B) Radiographs of the Shoulder Showing Oblique Fracture Through the Area of the Bone Trough with Slight Separation and Widening of the Trough.

Three days after the fracture, the patient underwent open…

Proximal Humerus Shaft Fracture After Pectoralis Major Tendon Rupture Repair

Abstract

Surgical repair of a complete pectoralis major tendon rupture at the humeral insertion has superior results compared to nonoperative treatment. To our knowledge, a proximal humerus shaft fracture occurring at the site of the bone trough and cortical drill holes after a pectoralis major tendon rupture repair has not been reported in the literature.

A 45-year-old man sustained an acute left pectoralis major tendon rupture at the humeral insertion while performing a bench press maneuver. He underwent acute surgical repair. Approximately 8 weeks postoperatively, the patient fell from a standing height and sustained a proximal humerus shaft fracture through the repair site at the bone trough. Three days after the fracture, the patient underwent open reduction and internal fixation of the proximal humerus shaft fracture and exploration of the pectoralis major tendon repair. The fracture was found to be at the level of the repair site, and the pectoralis major tendon was completely intact to the distal fragment. The fracture healed uneventfully, and the patient regained full motion and strength of his extremity with no limitations.

Any type of surgical fixation that creates a hole in the humerus or decreases the cross-sectional area such as a bone trough creates a stress riser. Patients undergoing pectoralis tendon repair that involves violating the humerus with a bone trough or hole have a slight risk of postoperative humerus fracture, especially if sustaining an early traumatic event such as a fall.

Drs Silverstein, Goldberg, and Wolin are from the Department of Orthopedics, University of Illinois-Chicago Medical Center, Chicago, Illinois.

Drs Silverstein, Goldberg, and Wolin have no relevant financial relationships to disclose.

Correspondence should be addressed to: Jeff A. Silverstein, MD, Department of Orthopedics, University of Illinois-Chicago Medical Center, 1425 N Wood St, Apt 2B, Chicago, IL 60622 (jeffsilver-stein78@gmail.com).
Posted Online: June 14, 2011

Surgical repair of a complete pectoralis major tendon rupture at the humeral insertion has superior results compared to nonoperative treatment regarding patient satisfaction, strength, comesis, and return to sport. 1–12 Nonoperative treatment is recommended for proximal, partial, or complete tears in a more sedentary individual. 1–12 Bak et al 2 performed a meta-analysis review of 112 pectoralis tendon ruptures at the humeral insertion and reported 88% good/excellent results for surgically treated patients compared to 27% nonoperative patients.

Several techniques have been reported for surgical fixation of the pectoralis tendon, including suturing the ruptured tendon back to the humerus with use of a bone trough and cortical drill holes, suture anchors, screw fixation, direct suture approximation, and barbed stapling. 3,4,10,12–16 To our knowledge, a proximal humerus shaft fracture occurring at the site of the bone trough and cortical drill holes after a pectoralis major tendon rupture repair has not been reported in the literature.

Case Report

A 45-year-old man sustained an acute left pectoralis major tendon rupture while performing a bench press maneuver. The tear occurred at the humeral insertion. He underwent acute surgical repair as described by Schepsis et al. 4 This technique involves creating a 3- to 5-cm bone trough lateral to the bicipital groove. Using No. 5 nonabsorbable sutures, 2 sets of modified Kessler sutures are used to grasp the muscle and fascia. The sutures are then passed and tied through 4 cortical drill holes made 1 cm lateral to the trough. Any remaining distal tendon is oversewn into the muscle with absorbable suture.

There were no intraoperative complications, and the patient did well for 8 weeks. Approximately 8 weeks postoperatively, the patient fell from a standing height and sustained a proximal humerus shaft fracture through the repair site at the bone trough (Figure ).

AP (A) and Lateral (B) Radiographs of the Shoulder Showing Oblique Fracture Through the Area of the Bone Trough with Slight Separation and Widening of the Trough.

Figure 1:. AP (A) and Lateral (B) Radiographs of the Shoulder Showing Oblique Fracture Through the Area of the Bone Trough with Slight Separation and Widening of the Trough.

Three days after the fracture, the patient underwent open reduction and internal fixation, exploration of the proximal humerus shaft fracture, and exploration to assess the integrity of the pectoralis major tendon repair. The fracture was found to be at the level of the repair site, and the pectoralis major tendon was completely intact to the distal fragment. For fear of compromising the integrity of the pectoralis tendon repair, it was elected to accept a slight step-off of the reduction, and the fracture was plated with a long proximal humeral locking plate without disrupting the pectoralis major tendon repair (Figure ).

AP (A, B) and Lateral (C) Radiographs of the Shoulder Showing Open Reduction and Internal Fixation with a Synthes (Paoli, Pennsylvania) 8-Hole Proximal Humeral Locking Plate Used to Repair the Fracture.

Figure 2:. AP (A, B) and Lateral (C) Radiographs of the Shoulder Showing Open Reduction and Internal Fixation with a Synthes (Paoli, Pennsylvania) 8-Hole Proximal Humeral Locking Plate Used to Repair the Fracture.

The fracture healed uneventfully 12 weeks postoperatively. At 18 weeks postoperatively, the patient had full motion and strength of his shoulder and arm with no limitations.

Discussion

Several techniques have been reported for surgical fixation of the pectoralis tendon. 3,4,10,12–16 Any type of surgical fixation that creates a hole in the humerus or decreases the cross-sectional area such as a bone trough creates a stress riser, which is an area where the stress is concentrated and can be in the shape of a hole, sharp angle, crack, or decrease in cross sectional area. 17,18 A reduction in the cross-sectional area results in a localized stress riser, which could lead to potential failure or fracture as resistance to torsion and bending are directly proportional to the cross-sectional area. 17,18 Bone troughs and drill holes reduce humeral cross-sectional area and subsequently decrease the ability to resist torsion and bending, which can lead to potential failure (fracture). 17,18 Patients undergoing pectoralis tendon repair that involves violating the humerus with a bone trough or hole have a slight risk of postoperative humerus fracture, especially if sustaining an early traumatic event such as a fall. Patients should be informed of this risk, and caution should be used in the early postoperative period.

References

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