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Ge Y, Zhu Z, Li Y, Luo H. Delayed axillary artery embolism following a proximal humerus fracture dislocation treated with reverse shoulder arthroplasty: A rare case for vigilance in vascular complications. Asian J Surg 2024:S1015-9584(24)01654-3. [PMID: 39097445 DOI: 10.1016/j.asjsur.2024.07.281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 07/16/2024] [Accepted: 07/22/2024] [Indexed: 08/05/2024] Open
Affiliation(s)
- Yanan Ge
- Department of Ultrasound, Taizhou Second People's Hospital, Taizhou, Zhejiang, China
| | - Zhong Zhu
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China
| | - Yimin Li
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China
| | - Hua Luo
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China.
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2
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Kriechling P, Whitefield R, Makaram NS, Brown IDM, Mackenzie SP, Robinson CM. Proximal humeral fractures with vascular compromise. Bone Joint J 2024; 106-B:842-848. [PMID: 39084641 DOI: 10.1302/0301-620x.106b8.bjj-2023-1114.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
Aims Vascular compromise due to arterial injury is a rare but serious complication of a proximal humeral fracture. The aims of this study were to report its incidence in a large urban population, and to identify clinical and radiological factors which are associated with this complication. We also evaluated the results of the use of our protocol for the management of these injuries. Methods A total of 3,497 adult patients with a proximal humeral fracture were managed between January 2015 and December 2022 in a single tertiary trauma centre. Their mean age was 66.7 years (18 to 103) and 2,510 (72%) were female. We compared the demographic data, clinical features, and configuration of those whose fracture was complicated by vascular compromise with those of the remaining patients. The incidence of vascular compromise was calculated from national population data, and predictive factors for its occurrence were investigated using univariate analysis. Results A total of 18 patients (0.5%) had a proximal humeral fracture and clinical evidence of vascular compromise, giving an annual incidence of 0.29 per 100,000 of the population. Their mean age was 68.7 years (45 to 92) and ten (56%) were female. Evidence of a mixed pattern neurological deficit (brachial plexus palsy) (odds ratio (OR) 380.6 (95% CI 85.9 to 1,685.8); p < 0.001), complete separation of the proximal shaft from the humeral head with medial displacement (OR 39.5 (95% CI 14.0 to 111.8); p < 0.001), and a fracture-dislocation (OR 5.0 (95% CI 1.6 to 15.3); p = 0.015) were all associated with an increased risk of associated vascular compromise. A policy of reduction and fixation of the fracture prior to vascular surgical intervention had favourable outcomes without vascular sequelae. Conclusion The classic signs of distal ischaemia are often absent in patients with proximal injuries to major vessels. We were able to identify specific clinical and radiological 'red flags' which, particularly when present in combination, should increase the suspicion of a fracture with an associated vascular injury, and facilitate early diagnosis and appropriate combined orthopaedic and vascular intervention.
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Affiliation(s)
- Philipp Kriechling
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
- University of Zurich, Balgrist University Hospital, Zurich, Switzerland
| | - Reiss Whitefield
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Navnit S Makaram
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
- University of Edinburgh, Edinburgh, UK
| | - Iain D M Brown
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - C M Robinson
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
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3
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Mitsuzawa S, Yamashita S, Tsukamoto Y, Takeuchi H, Ota S, Onishi E, Yasuda T. Axillary Artery Injury Associated with Dislocated or Displaced Proximal Humeral Fracture: A Report of 3 Cases. JBJS Case Connect 2024; 14:01709767-202409000-00030. [PMID: 39146441 PMCID: PMC11323756 DOI: 10.2106/jbjs.cc.24.00006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
CASE (1) A 69-year-old man sustained a proximal humeral fracture-dislocation. During emergency surgery, copious bleeding occurred. A pseudoaneurysm was identified 30 days postoperatively. (2) A 69-year-old man sustained a proximal humeral fracture and axillary artery injury. Physical examination demonstrated a cold but pink hand. Hemiarthroplasty and bypass vein grafting were performed. (3) An 86-year-old woman sustained a proximal humeral fracture and axillary artery injury. Her hand had turned cold and pale. Reverse shoulder arthroplasty and bypass vein grafting were performed. CONCLUSION In cases of proximal humeral fractures with significant displacement, concomitant axillary artery injury must be assessed and if there is a high index of suspicion, prompt advanced imaging is necessary.
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Affiliation(s)
- Sadaki Mitsuzawa
- Department of Orthopaedic Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Shinnosuke Yamashita
- Department of Orthopaedic Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Yoshihiro Tsukamoto
- Department of Orthopaedic Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Hisataka Takeuchi
- Department of Orthopaedic Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Satoshi Ota
- Department of Orthopaedic Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Eijiro Onishi
- Department of Orthopaedic Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Tadashi Yasuda
- Department of Orthopaedic Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
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Wright B, Gutowski C, Fedorka CJ. A proximal humerus fracture with concomitant axillary artery occlusion and axillary nerve palsy treated with reverse total shoulder arthroplasty: a case report. JSES REVIEWS, REPORTS, AND TECHNIQUES 2023; 3:529-533. [PMID: 37928998 PMCID: PMC10624990 DOI: 10.1016/j.xrrt.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Affiliation(s)
- Branden Wright
- Cooper Bone and Joint Institute, Cooper University Hospital, Camden, NJ, USA
| | - Caroline Gutowski
- Department of Orthopaedics, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Catherine J. Fedorka
- Cooper Bone and Joint Institute, Cooper University Hospital, Camden, NJ, USA
- Department of Orthopaedics, Cooper Medical School of Rowan University, Camden, NJ, USA
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5
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Cehelyk EK, Stull JD, Patel MS, Cox RM, Namdari S. Humeral Head Avascular Necrosis: Pathophysiology, Work-up, and Treatment Options. JBJS Rev 2023; 11:01874474-202306000-00017. [PMID: 37368960 DOI: 10.2106/jbjs.rvw.23.00014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
» Avascular necrosis (AVN) of the humeral head is the result of ischemic injury to the epiphyseal bone leading to humeral head collapse and arthritis.» Common causes include trauma, chronic corticosteroid use, or systemic disease processes, such as sickle cell disease, systemic lupus erythematosus, or alcohol abuse.» Nonoperative treatment consists of risk factor management, physical therapy, anti-inflammatory medications, and activity modification.» Surgical treatment options include arthroscopic debridement, core decompression, vascularized bone grafts, and shoulder arthroplasty.
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Affiliation(s)
- Eli K Cehelyk
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Justin D Stull
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Manan S Patel
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Ryan M Cox
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Surena Namdari
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Avascular Necrosis and Posttraumatic Arthritis After Proximal Humerus Fracture Internal Fixation: Evaluation and Management. Curr Rev Musculoskelet Med 2023; 16:66-74. [PMID: 36637717 PMCID: PMC9889581 DOI: 10.1007/s12178-022-09818-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/06/2022] [Indexed: 01/14/2023]
Abstract
PURPOSE OF REVIEW Avascular necrosis (AVN) and posttraumatic arthritis (PTA) are common complications following both conservative treatment and open reduction and internal fixation (ORIF) of proximal humerus fractures (PHFs). Despite the frequent utilization of ORIF, information regarding these leading causes of failure is limited. This review includes a discussion of incidence, risk factors, and evaluation of AVN and PTA following PHF. The mechanisms of treatment options and associated outcomes are also reviewed. RECENT FINDINGS Recent best available evidence demonstrates significant rates of AVN and PTA following ORIF of PHF. This is particularly true of complex fracture patterns. A thorough workup is required in the setting of failure caused by AVN and PTA. This includes a careful patient history, clinical exam, plain film radiographs, and CT scans. EMG and/or aspiration may also be indicated. Special consideration is given to the examination of the deltoid muscle, neurovascular status, rotator cuff function, and the possibility of infection. Biological supplementation, anatomic total shoulder replacement (aTSA), and fusion are rarely employed in the treatment of AVN and/or PTA. Due to satisfactory patient outcomes, reverse total shoulder replacement (rTSA) has increased in popularity for the elderly population, while hemiarthroplasty (HA) may be appropriate for some young, active patients. With careful patient selection and meticulous surgical technique, AVN and PTA can be mitigated. Careful indications for ORIF may decrease the frequency of these complications. For most patients, rTSA is the optimal treatment option. Given the frequent utilization of ORIF and the higher than acceptable complication and failure rates, AVN and PTA warrant our attention.
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Di Giacomo LM, Marzano F, Zaganelli A, Pace V, Petruccelli R, Rinonapoli G, Caraffa A. Two stage treatment of a proximal humeral fracture-dislocation with vascular injury: Case report of a multidisciplinary approach. Trauma Case Rep 2021; 36:100547. [PMID: 34765715 PMCID: PMC8569709 DOI: 10.1016/j.tcr.2021.100547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2021] [Indexed: 11/16/2022] Open
Abstract
Proximal humeral fracture-dislocation associated with neurovascular injury is rare events, associated with poorer outcomes and higher risk of complications. A multidisciplinary approach including the orthopaedic and vascular department is essential in treating such kind of injury. The goal of the treatment is to restore the vascular supply and stabilize the fracture. Usually the orthopaedic surgical stabilization provides a stable substrate for the vascular repair. We report a case of 70 years old woman who sustained a 4 part proximal humerus fracture-dislocation with vascular injury at the level of the transition of the subclavian into axillary artery. Because of the impending severe limb ischemia, the priority of the treatment was given to vascular surgical intervention with a by-pass procedure. After 14 days a reverse shoulder prosthesis was thought to be the best alternative in the second stage surgery. At 18 months follow-up we achieved good clinical and radiological outcomes. Although a lack of consensus on the priority of treatments, we achieved good result following our proposed algorithm of treatment.
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Affiliation(s)
- Lorenzo Maria Di Giacomo
- Trauma & Orthopaedics Department, "S.M. della Misericordia Hospital", University of Perugia, Piazzale Gambuli 1, 06100 Perugia, Italy
| | - Fabrizio Marzano
- Trauma & Orthopaedics Department, "S.M. della Misericordia Hospital", University of Perugia, Piazzale Gambuli 1, 06100 Perugia, Italy
| | - Andrea Zaganelli
- Trauma & Orthopaedics Department, "S.M. della Misericordia Hospital", University of Perugia, Piazzale Gambuli 1, 06100 Perugia, Italy
| | - Valerio Pace
- Trauma & Orthopaedics Department, "S.M. della Misericordia Hospital", University of Perugia, Piazzale Gambuli 1, 06100 Perugia, Italy
| | - Rosario Petruccelli
- Trauma & Orthopaedics Department, "S.M. della Misericordia Hospital", University of Perugia, Piazzale Gambuli 1, 06100 Perugia, Italy
| | - Giuseppe Rinonapoli
- Trauma & Orthopaedics Department, "S.M. della Misericordia Hospital", University of Perugia, Piazzale Gambuli 1, 06100 Perugia, Italy
| | - Auro Caraffa
- Trauma & Orthopaedics Department, "S.M. della Misericordia Hospital", University of Perugia, Piazzale Gambuli 1, 06100 Perugia, Italy
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Stone MA, Ihn HE, Gipsman AM, Iglesias B, Minneti M, Noorzad AS, Omid R. Surgical anatomy of the axillary artery: clinical implications for open shoulder surgery. J Shoulder Elbow Surg 2021; 30:1266-1272. [PMID: 33069906 DOI: 10.1016/j.jse.2020.09.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 09/08/2020] [Accepted: 09/21/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Axillary artery injury is a devastating complication related to anterior shoulder surgery and can result in significant morbidity and/or mortality. The purpose of our study was to evaluate the course of the axillary artery in relation to bony landmarks of the shoulder and identify variations in artery position with humeral external rotation. MATERIALS AND METHODS Dissection of 18 shoulders (9 fresh whole-body cadavers) with simulated vessel perfusion using radiopaque dye was performed. The axillary artery position was measured from multiple points including 2 points on the coracoid base (C1 and C2), 3 points on the coracoid tip (C3-C5), 4 points on the glenoid: superior, middle, and inferior glenoid (D1-D4), and 2 points on the lesser tuberosity (L1 and L2). Fluoroscopic measurements were taken and compared at 0° and 90° of external rotation (F1 vs. F1' and F2 vs. F2'). Manual and fluoroscopic measurements were compared with one another using Kendall's τb correlation. RESULTS There were 6 male and 3 female cadavers with an average age of 67.2 ± 9.3 years (range: 49-77 years). The mean distance from the axillary artery to the coracoid base (C1 and C2) measured 21.1 ± 7.3 and 22.3 ± 7.4 mm, respectively, whereas the mean distance to the coracoid tip (C3, C4, and C5) measured 30.7 ± 9.3, 52.1 ± 20.2, and 46.5 ± 14.3 mm, respectively. Measurements relative to the glenoid face (D1, D2, and D3) showed a progressive decrease in mean distance from superior to inferior, measuring 31.6 ± 10.3, 16.5 ± 7.5, and 10.3 ± 7.3 mm, respectively, whereas D4 (inferior glenoid to axillary artery) measured 17.8 ± 10.7 mm. The minimum distance from the axillary artery to any point on the glenoid was as close as 4.1 mm (D3). There was a statistically significant difference in F1 (0° external rotation) vs. F1' (90° external rotation) (18.5 vs. 13.4 mm, P = .03). Kendall's τb correlation showed a strong, positive correlation between manual and fluoroscopic measurements (D4: 16.0 ± 12.5 mm vs. F1: 18.5 ± 10.7 mm) (τb = 0.556, P = .037). CONCLUSION The axillary artery travels an average of 1-1.8 cm from the inferior glenoid margin, which puts the artery at significant risk. In addition, the artery is significantly closer to the inferior glenoid with humeral external rotation. Surgeons performing anterior shoulder surgery should have a thorough understanding of the axillary artery course and understand changes in the position of the artery with external rotation of the humerus.
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Affiliation(s)
- Michael A Stone
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Hansel E Ihn
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Aaron M Gipsman
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Brenda Iglesias
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Michael Minneti
- Fresh Tissue Dissection Program, University of Southern California Surgical Skills Simulation & Education Center, Los Angeles, CA, USA
| | - Ali S Noorzad
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Reza Omid
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Elkbuli A, Ehrhardt J, McKenney M, Boneva D, Martindale S. Axillo-subclavian dissection and pseudoaneurysm following inferior glenohumeral dislocation: Case report and literature review. Int J Surg Case Rep 2019; 66:130-135. [PMID: 31838432 PMCID: PMC6920307 DOI: 10.1016/j.ijscr.2019.11.058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 11/14/2019] [Accepted: 11/28/2019] [Indexed: 11/26/2022] Open
Abstract
This is a rare case of Axillo-subclavian dissection and pseudoaneurysm following blunt chest injury. Inferior shoulder dislocation is uncommon but may cause serious vascular injury and life-threatening hemorrhage. An endovascular approach was life-saving for our patient considering her advanced age and medical comorbidities.
Introduction Axillo-subclavian arterial injuries are generally associated with penetrating trauma. On rare occasion, blunt mechanisms can cause these injuries in the setting of high-energy trauma, humeral head or neck fractures, and severe glenohumeral dislocations. Glenohumeral dislocations sustained from ground-level falls are generally reduced in the emergency department without associated morbidity. Presentation of case An 80-year-old woman presented with an inferior glenohumeral dislocation after a ground-level fall that was found to be complicated by axillary dissection, pseudoaneurysm, and acute hemorrhage. Endovascular intervention with a balloon-inflatable stent successfully controlled extravasation and restored perfusion to the affected upper extremity. After a short hospitalization, the patient was discharged with intact neurovascular status. Discussion Blunt axillary artery injury and inferior glenohumeral dislocations are both uncommon entities. A correlation exists between inferior dislocations and neurovascular complications. Accordingly, there may be a role for diagnostic vascular imaging for patients with inferior glenohumeral dislocations. Endovascular stenting was successful in our case and backed by case series and cohort studies in the literature. Some controversy exists regarding stent patency and follow-up planning in trauma patients. Conclusion This case represents a critical vascular injury from an unexpected mechanism. Inferior glenohumeral dislocations, regardless of injury mechanism, should raise the index of suspicion for vascular involvement. Endovascular repair in our patient was life-saving given her advanced age, acute blood loss anemia, rarity and severity of her injuries and multiple medical comorbidities.
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Affiliation(s)
- Adel Elkbuli
- Department of Surgery, Kendall Regional Medical Center, Miami, FL, USA.
| | - John Ehrhardt
- Department of Surgery, Kendall Regional Medical Center, Miami, FL, USA; University of South Florida, Tampa, FL, USA
| | - Mark McKenney
- Department of Surgery, Kendall Regional Medical Center, Miami, FL, USA; University of South Florida, Tampa, FL, USA
| | - Dessy Boneva
- Department of Surgery, Kendall Regional Medical Center, Miami, FL, USA; University of South Florida, Tampa, FL, USA
| | - Stacey Martindale
- Department of Surgery, Aventura Hospital and Medical Center, Miami, FL, USA
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Angus LDG, Gerber N, Munnangi S, Wallace R, Singh S, Digiacomo J. Management and Outcomes of Isolated Axillary Artery Injury: A Five-Year National Trauma Data Bank Analysis. Ann Vasc Surg 2019; 65:113-123. [PMID: 31678544 DOI: 10.1016/j.avsg.2019.10.085] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 08/20/2019] [Accepted: 10/19/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND The aim of this study is to evaluate recent national trends in the clinical characteristics, management, and outcomes of patients with isolated axillary artery injuries. METHODS The National Trauma Data Bank was queried to identify records submitted from 2011 to 2015 that contained an ICD-9-CM diagnosis code for an injury to axillary artery (903.01) and an external cause of injury code indicating blunt or penetrating trauma. Records that contained a diagnosis code for an injury to an additional blood vessel (900.00-903.00, 903.2-904.9), an injury to a nonupper extremity or unclassifiable body region, or whose operative management could not be discerned were excluded. The final study sample included 221 patients with isolated axillary artery injury. The patient's clinical management was the primary outcome of interest. The study sample was stratified by trauma type, and descriptive statistics were performed on all variables. RESULTS Seventy-one percent of patients received operative management. Patients with penetrating injury were 24% more likely to be managed operatively than bluntly injured patients (76.9% vs. 62.1%, P = 0.0178). In operatively managed patients, the open repair rate was 82.8% and endovascular repair rate was 10.2%. Graft repair was performed most often (28.0%), followed by placement of a temporary intravenous shunt (17.8%) and surgical occlusion (10.2%). Surgical vessel occlusion was significantly more likely to be performed on patients with penetrating injury than with blunt injury (14.6% vs. 1.9%, P = 0.0124). Patients with penetrating injury had significantly shorter median emergency department length of stay (87.0 min vs. 152.0 min, P < 0.0001), intensive care unit length of stay (2.0 days vs. 3.0 days, P < 0.0388), hospital length of stay (4.0 days vs. 5.0 days, P = 0.0026), and time-to-operative management (1.6 hr vs. 3.9 hr, P < 0.001) compared to bluntly injured patients. Patients with blunt injury had a higher reportable in-hospital complication rate (13.8% vs. 6.0%, P = 0.0477). The overall mortality rate was 3.1% for isolated axillary artery injuries and did not significantly differ by trauma type. CONCLUSIONS Axillary artery injury is more often caused by penetrating trauma. Despite introduction of novel endovascular techniques, the majority of patients with isolated axillary artery injury are managed using open repair. Penetrating axillary artery injury is significantly more likely to be managed using open repair and by surgical occlusion. Patients with blunt injury have higher complication rates and longer hospital length of stays. The mortality rate is lower than previously published.
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Affiliation(s)
- L D George Angus
- Department of Surgery, Nassau University Medical Center, East Meadow, NY
| | - Noam Gerber
- Department of Surgery, Nassau University Medical Center, East Meadow, NY.
| | - Swapna Munnangi
- Department of Surgery, Nassau University Medical Center, East Meadow, NY
| | - Raina Wallace
- Department of Surgery, Nassau University Medical Center, East Meadow, NY
| | - Shridevi Singh
- Department of Surgery, Nassau University Medical Center, East Meadow, NY
| | - Jody Digiacomo
- Department of Surgery, Nassau University Medical Center, East Meadow, NY
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Razaeian S, Rustum S, Sonnow L, Meller R, Krettek C, Hawi N. Axillary Artery Dissection and Thrombosis after Closed Proximal Humerus Fracture - a Rare Interdisciplinary Challenge. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2019; 158:406-413. [PMID: 31525793 DOI: 10.1055/a-0938-7041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Proximal humerus fractures account for 4 - 6% of all fractures and are a common result of low-energy trauma in the elderly. Concomitant neurovascular injury of the neighboring axillary artery and brachial plexus is a rarity, but has enormous impact on therapy, rehabilitation and prognosis. Diagnosis of axillary artery injury may be delayed due to its varied clinical presentation and lead to prolonged ischemia, distal necrosis and even loss of limb. Thorough clinical examination, high suspicion and identification of known predictors can be helpful in early diagnosis of this rare injury. PATIENTS/MATERIAL AND METHODS We report a case of an intoxicated 76-year-old male who sustained a dislocated proximal humerus fracture, resulting in concomitant brachial plexopathy and axillary artery dissection with secondary thrombosis after a low-energy fall from standing height. Due to mistriage as a neurological emergency the somnolent patient presented under delayed circumstances at our traumatological emergency department, demonstrating pain, paleness, paralysis, paresthesia and non-palpable wrist pulses. Diagnosis was made through high suspicion after clinical examination with the aid of CT angiography. Emergent open reduction and anatomic shoulder hemiarthroplasty was performed followed by axillobrachial interposition grafting using a reversed saphenous vein graft and brachial plexus exploration. RESULTS The surgical treatments were uncomplicated. The affected limb remains viable at 6-week follow-up; however, active shoulder function is limited due to residual brachial plexopathy. CONCLUSION Despite early diagnosis and management of this rare injury, the prognosis for functional recovery is guarded and largely dictated by the extent of neurological injury in the setting of concomitant brachial plexopathy. Brachial plexopathy is highly associated with axillary artery injury and its impact often underestimated in comparison due to its non-limb-threatening nature in the acute setting. Future studies should focus on the long-term prognosis for functional recovery in patients with this rare injury pattern.
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Affiliation(s)
- Sam Razaeian
- Unfallchirurgische Klinik, Medizinische Hochschule Hannover
| | - Saad Rustum
- Klinik für Herz-, Thorax-, Transplantations- und Gefäßchirurgie, Medizinische Hochschule Hannover
| | - Lena Sonnow
- Institut für diagnostische und interventionelle Radiologie, Medizinische Hochschule Hannover
| | - Rupert Meller
- Unfallchirurgische Klinik, Medizinische Hochschule Hannover
| | | | - Nael Hawi
- Unfallchirurgische Klinik, Medizinische Hochschule Hannover
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Githens M. Life-Threatening Hemorrhage from an Unrecognized Axillary Vein Injury During Treatment of a Proximal Humeral Fracture-Dislocation with a Known Axillary Artery Injury: A Case Report. JBJS Case Connect 2018; 8:e33. [PMID: 29794488 DOI: 10.2106/jbjs.cc.17.00156] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 57-year-old man presented with bilateral proximal humeral fracture-dislocation and an associated axillary artery injury. He was treated urgently with reduction, arterial repair, fasciotomies, and skeletal stabilization. The patient sustained a massive intraoperative hemorrhage from an unrecognized axillary vein injury after the arterial repair. CONCLUSION An unrecognized axillary vein injury led to substantial blood loss that required a massive transfusion protocol. Although an axillary arterial injury is readily identified with computed tomography angiography, concomitant venous injuries may go unrecognized. The surgical team, including the vascular and orthopaedic surgeons and the anesthesiologists, should be prepared to manage a life-threatening hemorrhage.
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Affiliation(s)
- Michael Githens
- Department of Orthopaedic Surgery, Harborview Medical Center, University of Washington School of Medicine, Seattle, Washington
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13
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Kurnaz R, Ikizler M, Ozbayburtlu M, Gunes T. A Limb-Threatening Long Arterial Dissection Caused by Humerus Neck Fracture: A Case Report. Malays Orthop J 2018; 12:51-53. [PMID: 29725515 PMCID: PMC5920261 DOI: 10.5704/moj.1803.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Proximal humerus fracture is a common arm trauma and rarely occurs with vascular injury which however is a serious complication. In this case report, we present a long segment dissection of the axillary and brachial arteries as a rare complication due to fragmented proximal humerus fracture and shoulder dislocation. An 80-year old female patient was seen at the emergency department. Radiograph examination has revealed a fragmented proximal humerus fracture besides dislocation of the head of humerus towards the axillary area. On vascular examination, acute arterial occlusion such as absence of radial and ulnar pulses were observed in her left hand. The patient was immediately taken to the operating room. The dissection included the entire segment approximately 20cm between the distal subclavian artery and the distal brachial artery. This injured segment was removed and a 6mm Polytetrafluroethylene (PTFE) graft with rings was interpositoned between subclavian and brachial arteries. This case is a rarity because of such a significant complication after a small injury. Axillary artery injuries caused by humeral neck fractures are rare but should not be missed by the physician.
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Affiliation(s)
- R Kurnaz
- Department of Orthopaedics and Traumatology, Acibadem Eskisehir Hospital, Eksisehir, Turkey.,Department of Cardiovascular Surgery, Acibadem Eskisehir Hospital, Eksisehir, Turkey
| | - M Ikizler
- Department of Cardiovascular Surgery, Acibadem Eskisehir Hospital, Eksisehir, Turkey
| | - M Ozbayburtlu
- Department of Cardiovascular Surgery, Acibadem Eskisehir Hospital, Eksisehir, Turkey
| | - T Gunes
- Department of Orthopaedics and Traumatology, Acibadem Eskisehir Hospital, Eksisehir, Turkey.,Department of Cardiovascular Surgery, Acibadem Eskisehir Hospital, Eksisehir, Turkey
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Mehta VM, Mandala CL, Shriver RJ, Shah R. Proximal humeral fracture-dislocation with axillary artery involvement treated with reverse shoulder arthroplasty. JSES OPEN ACCESS 2018; 2:100-103. [PMID: 30675575 PMCID: PMC6334852 DOI: 10.1016/j.jses.2017.12.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | | | | | - Rachit Shah
- Fox Valley Orthopaedic Institute, Geneva, IL, USA
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15
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Bokser E, Caputo W, Hahn B, Greenstein J. Blunt traumatic axillary artery truncation, in the absence of associated fracture. Am J Emerg Med 2018; 36:340.e1-340.e2. [DOI: 10.1016/j.ajem.2017.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 10/07/2017] [Indexed: 10/18/2022] Open
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