Surgical anatomy of the pectoralis major tendon insertion revisited: relationship to nearby structures and the pectoral eminence for defining the anatomic footprint

Aaron J Bois, Ian K Y Lo, Aaron J Bois, Ian K Y Lo

Abstract

Background: Intraoperative identification of the normal pectoralis major (PM) footprint can be challenging to identify in the acute and chronic settings. The purpose of this study was to revisit the anatomic footprint of the PM tendon and to determine which nearby landmarks can be used to re-create the normal insertion site during anatomic repair or reconstruction.

Methods: Twenty-one fresh-frozen human cadaveric shoulder specimens were used to define the PM tendon width (ie, superior-to-inferior) and to determine the relationship between the superior aspect of the PM insertion and that of the latissimus dorsi (LD) and anterior deltoid (AD) tendons. An attempt was made to identify potential useful bony landmarks that can be used during anatomic repair or reconstruction of the PM tendon.

Results: The mean PM tendon width was 68.8 ± 4.4 mm. The superior margin of the LD insertion was 9.4 ± 5.9 mm above and the AD was 48.4 ± 7.1 mm below the superior margin of the PM tendon insertion, respectively. In 17 of 21 specimens (81%), the superior insertion of the PM tendon attached onto a bony prominence, named the pectoral eminence.

Conclusions: The LD and AD tendon insertions represent reliable soft tissue landmarks for identifying the superior extent of the PM tendon along its bony footprint. The pectoral eminence can also be used as an additional reference point in the majority of cases to facilitate anatomic restoration of the pectoralis tendon during repair and reconstruction. Surgeons should be familiar with the proximity of nearby neurovascular structures when performing PM repairs.

Keywords: Pectoralis major; anatomy; footprint; pectoral eminence; reconstruction; repair; rupture; tendon.

© 2020 The Author(s).

Figures

Figure 1
Figure 1
The falciform ligament is demonstrated in 2 different left shoulder specimens (►). (A) The pectoralis major tendon (PM) can be differentiated from the falciform ligament as a thick tendinous expansion spanning in the transverse plane to the humeral footprint (→). (B) The superior-oblique orientation of the falciform ligament is visualized and easily differentiated from the PM. The intimate relationship with the transverse humeral ligament (THL) and bicipital tunnel is appreciated.
Figure 2
Figure 2
Relationship between the pectoralis major (PM), latissimus dorsi (LD), and anterior deltoid tendons. (A) Left shoulder specimen demonstrating one of the few examples encountered of a clearly defined bilaminar PM tendon, represented by the anterior (PM-ant) and posterior (PM-post) laminae. The posterior lamina is observed extending in an oblique fashion to the humeral insertion; a less well-defined falciform ligament is observed immediately superior to its upper margin. This was also one of the few examples demonstrating the close relationship of the superior aspect of both the PM and LD tendons inserting onto the humerus. (B) A different left shoulder specimen demonstrating the broad PM tendon footprint on the humerus. The superior-oblique falciform ligament is present extending above the upper border of the PM (→).
Figure 3
Figure 3
Measurements obtained from a left shoulder specimen between the pectoralis major tendon (PM) and the anterior deltoid (A) and the latissimus dorsi (LD) tendons (B).
Figure 4
Figure 4
Illustration summarizing the mean (range) pectoralis tendon width and measurements between the pectoralis major, latissimus dorsi, and anterior deltoid tendons.
Figure 5
Figure 5
(A) Left shoulder specimen demonstrating the relationship between the pectoralis major and latissimus dorsi (LD) tendons. The pectoral eminence is clearly demonstrated (→). (B) Superior aspect of pectoralis major tendon held in forceps adjacent to pectoral eminence.
Figure 6
Figure 6
(A) Left shoulder specimen demonstrating the pectoral eminence (→). (B) A different left shoulder specimen revealing the relationship between the pectoralis major (PM), latissimus dorsi (LD), and anterior deltoid (D) tendons. Above the anterior deltoid tendon insertion on the humerus, the PM tendon is shown inserting into a visible and palpable bony ridge along the lateral lip of the bicipital groove (ie, pectoral tuberosity), continuous with the pectoral eminence at the most superior PM tendon insertion (→).

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