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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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2
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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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3
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Hoffman RA, Covarrubias O, Green A, Paxton ES. Acute-on-Chronic Axillary Artery Thrombus After Reverse Total Shoulder Arthroplasty for Failed Proximal Humerus Open Reduction and Internal Fixation: A Case Report. JBJS Case Connect 2024; 14:01709767-202406000-00030. [PMID: 38728442 DOI: 10.2106/jbjs.cc.23.00681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
CASE A 71-year-old woman presented with post-traumatic arthritis 11 months after open reduction and internal fixation for a left proximal humerus fracture (PHF) dislocation. After revision to reverse total shoulder arthroplasty (rTSA), the patient's left upper extremity was found to be avascular. An emergent thrombectomy was performed with restoration of arterial flow after removal of an acute-on-chronic axillary artery thrombus. CONCLUSION Although rare, as rTSA becomes more common for management of PHF, incidence of associated vascular injuries is likely to rise. Screening methods and clinical vigilance in diagnosis are advised for patients with anterior PHF dislocations and arterial injury risk factors.
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Affiliation(s)
- Ryan A Hoffman
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, Alpert Medical School, Brown University, Providence, Rhode Island
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4
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Ripoll T, Fairag R, Bonomo I, Gastaud O, Psacharopulo D. Axillary Artery Injuries Associated With Proximal Humerus Fractures: A Literature Review and a Proposal of a Novel Multidisciplinary Surgical Approach. Vasc Endovascular Surg 2024; 58:245-254. [PMID: 37823274 DOI: 10.1177/15385744231206834] [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: 10/13/2023]
Abstract
INTRODUCTION Proximal humerus fractures (PHF) are common injuries that can lead to axillary artery injury, which carries the risk of not being identified during initial assessment. The aim of this study was to describe the management of suspected axillary artery injury associated with PHF according to our experience and to describe a new multidisciplinary surgical approach. METHODS This was a single-center retrospective study. A database was created for patients admitted for PHF to the emergency department of the Hospital of Cannes between October 2017 and October 2019. Patients admitted with PHF associated with suspected ipsilateral upper limb ischemia, and/or massive diaphysis displacement, and/or upper limb ipsilateral neurological deficits were included in this study. RESULTS In total, 301 patients diagnosed with PHF were admitted within these periods. Among these patients, 12 presented with suspected axillary artery lesions, of whom, 6 were included in the present study and treated according to our new approach. A description of these 6 cases, along with an extensive literature review is presented. CONCLUSION Based on our experience, the endovascular approach proposed for the management of axillary artery injury associated with proximal humerus fractures is effective, feasible and reproducible.
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Affiliation(s)
- Thomas Ripoll
- Service de Chirurgie Vasculaire, Centre Hospitalier de Cannes, Cannes, France
- Service de Chirurgie Orthopédique, Centre Hospitalier de Cannes, Cannes, France
| | - Rayan Fairag
- Service de Chirurgie Orthopédique, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Iris Bonomo
- Service de Gynécologie, Institut Bergonié, Bordeaux, France
| | - Olivier Gastaud
- Service de Chirurgie Orthopédique, Centre Hospitalier de Cannes, Cannes, France
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Faur CI, Nitu R, Abu-Awwad SA, Tudoran C, Abu-Awwad A. The Arterial Axis Lesions in Proximal Humeral Fractures-Case Report and Literature Review. J Pers Med 2023; 13:1712. [PMID: 38138939 PMCID: PMC10744402 DOI: 10.3390/jpm13121712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 12/06/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND This comprehensive review delves into the nuanced domain of arterial axis lesions associated with proximal humeral fractures, elucidating the intricate interplay between fracture patterns and vascular compromise. Proximal humeral fractures, a common orthopedic occurrence, often present challenges beyond the skeletal realm, necessitating a profound understanding of the vascular implications. METHODS The study synthesizes the existing literature, presenting a collective analysis of documented cases and their respective clinical outcomes. The spectrum of arterial axis lesions, from subtle vascular compromise to overt ischemic events, is systematically examined, highlighting the varied clinical manifestations encountered in proximal humeral fractures. Diagnostic modalities, including advanced imaging techniques such as angiography and Doppler ultrasound, are scrutinized for their efficacy in identifying arterial axis lesions promptly. The review emphasizes the critical role of early and accurate diagnosis in mitigating the potential sequelae associated with vascular compromise, thereby underscoring the importance of a vigilant clinical approach. RESULTS Therapeutic strategies, ranging from conservative management to surgical interventions, are critically evaluated in the context of existing evidence. The evolving landscape of endovascular interventions and their applicability in addressing arterial axis lesions specific to proximal humeral fractures is explored, providing valuable insights for clinicians navigating the therapeutic decision-making process. Furthermore, the review addresses gaps in current knowledge and proposes avenues for future research, emphasizing the need for tailored, evidence-based guidelines in the management of arterial axis lesions in proximal humeral fractures. By consolidating current understanding and pointing towards areas warranting further exploration, this review contributes to the ongoing discourse surrounding the intricacies of vascular complications in orthopedic trauma. CONCLUSIONS this comprehensive review provides a synthesized overview of arterial axis lesions in proximal humeral fractures, offering a valuable resource for clinicians, researchers, and educators alike. The findings underscore the multifaceted nature of these lesions and advocate for a holistic, patient-centered approach to their management.
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Affiliation(s)
- Cosmin Ioan Faur
- Department XV—Discipline of Orthopedics—Traumatology, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (C.I.F.); (A.A.-A.)
- “Pius Brinzeu” Emergency Clinical County Hospital, Bld Liviu Rebreanu, No. 156, 300723 Timisoara, Romania; (S.-A.A.-A.); (C.T.)
- Research Center University Professor Doctor Teodor Șora, Victor Babes University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
| | - Razvan Nitu
- “Pius Brinzeu” Emergency Clinical County Hospital, Bld Liviu Rebreanu, No. 156, 300723 Timisoara, Romania; (S.-A.A.-A.); (C.T.)
- Department XII—Discipline of Obstetrics and Gynecology, Victor Babes University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
| | - Simona-Alina Abu-Awwad
- “Pius Brinzeu” Emergency Clinical County Hospital, Bld Liviu Rebreanu, No. 156, 300723 Timisoara, Romania; (S.-A.A.-A.); (C.T.)
- Department XII—Discipline of Obstetrics and Gynecology, Victor Babes University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
| | - Cristina Tudoran
- “Pius Brinzeu” Emergency Clinical County Hospital, Bld Liviu Rebreanu, No. 156, 300723 Timisoara, Romania; (S.-A.A.-A.); (C.T.)
- Department VII, Internal Medicine II, Discipline of Cardiology, University of Medicine and Pharmacy “Victor Babes” Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania
- Center of Molecular Research in Nephrology and Vascular Disease, Faculty of the University of Medicine and Pharmacy “Victor Babes” Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania
| | - Ahmed Abu-Awwad
- Department XV—Discipline of Orthopedics—Traumatology, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (C.I.F.); (A.A.-A.)
- “Pius Brinzeu” Emergency Clinical County Hospital, Bld Liviu Rebreanu, No. 156, 300723 Timisoara, Romania; (S.-A.A.-A.); (C.T.)
- Research Center University Professor Doctor Teodor Șora, Victor Babes University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
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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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7
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Krasney LC, Rennie C, Brustein J, Naylor B. Rare finding of axillary artery dissection secondary to a proximal humerus fracture-dislocation: A case report. Trauma Case Rep 2023; 45:100828. [PMID: 37096136 PMCID: PMC10122036 DOI: 10.1016/j.tcr.2023.100828] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2023] [Indexed: 04/05/2023] Open
Abstract
Case Proximal humerus fractures are a relatively common injury, making up approximately 5 % of all extremity fractures. Concurrent damage to the axillary artery, however, is not a commonly associated trauma. We present a unique case of a proximal humerus fracture-dislocation resulting in an axillary artery dissection and upper extremity ischemia, requiring emergent vascular intervention. Conclusion Axillary artery injury secondary to a proximal humerus fracture-dislocation is a rare, but possibly devastating complication. A thorough physical examination to identify any neurovascular deficits is critical in determining an optimal and timely resolution.
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Affiliation(s)
- Leighann C. Krasney
- Department of Orthopaedic Surgery, UPMC Harrisburg, Harrisburg, PA, United States of America
- Corresponding author at: 4300 Londonderry Road, Harrisburg, PA 17109, United States of America.
| | - Christopher Rennie
- Nova Southeastern University College of Osteopathic Medicine, Tampa, FL, United States of America
| | - Jason Brustein
- Resurgens Orthopaedics, Atlanta, GA, United States of America
| | - Brandon Naylor
- Northside Hospital, Atlanta, GA, United States of America
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8
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Rudran B, Little C, Duff A, Poon H, Tang Q. Proximal humerus fractures: anatomy, diagnosis and management. Br J Hosp Med (Lond) 2022; 83:1-10. [DOI: 10.12968/hmed.2021.0554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Proximal humeral fractures are common with a bimodal distribution and sex discrepancy, affecting younger men and older women. The presentation of a proximal humeral fracture can vary greatly because of this bimodal distribution and the associated differences in mechanism of injury. Initial management should involve assessment of life- and limb-threatening injuries as outlined by the British Orthopaedic Association Standards for Trauma, with particular attention paid to axillary nerve function and vascular status. Initial imaging should involve orthogonal X-rays in three planes to determine fracture characteristics and exclude glenohumeral dislocation. Computed tomography imaging improves interobserver agreement and is the gold standard in determining fracture management. Management depends on fracture pattern, patient functionality and bone stock. Most patients with proximal humeral fractures achieve good functional outcomes via conservative methods (sling support and early, graded mobilisation), although there is a lack of evidence in certain populations, including younger patients. Surgery is required for open fractures and more complex fracture patterns where there is a risk of avascular necrosis of the humeral head, unacceptable impairment of functionality or neurovascular compromise. Surgical techniques can be head-sparing or involve replacement of the humeral head. There are several head-sparing techniques, each with different cost–benefit and complication profiles with no one technique superior to any other. However, improvements in plate technology may render open reduction internal fixation a more suitable technique, particularly in younger patients. Head replacement techniques (hemiarthroplasty and reverse shoulder arthroplasty) are indicated when the risk of avascular necrosis is too high or in older patients with osteoporotic bone. In these patients, reverse shoulder arthroplasty is preferred as it achieves better functional results than hemiarthroplasty. Complication rates vary depending on the fracture configuration and the course of management undertaken.
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Affiliation(s)
- Branavan Rudran
- Department of Specialist Surgery, Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK
| | - Christopher Little
- Oxford University Clinical Academic Graduate School, John Radcliffe Hospital, Oxford, UK
| | - Alexander Duff
- Department of Specialist Surgery, Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK
| | - Henry Poon
- Department of Trauma and Orthopaedics, Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Quen Tang
- Department of Trauma and Orthopaedics, Chelsea and Westminster Hospital, London, UK
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9
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Pramanik S, Munjal R, Kisku N, Gupta A. Traumatic axillary artery repair: A single center experience. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2022. [DOI: 10.4103/ijves.ijves_70_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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10
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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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11
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Mohan K, Hintze JM, Morrissey D, Molony D. Incidence of avascular necrosis following biceps tenodesis during proximal humerus open reduction and internal fixation. Acta Orthop Belg 2021. [DOI: 10.52628/87.2.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Avascular necrosis (AVN) may occur in up to 77% of proximal humeral fractures and can cause fixation failure. Risk factors include fracture position, calcar length and medial hinge integrity. We routinely perform intra-articular biceps tenotomy with tenodesis at the level of pectoralis major to facilitate fragment identification and potentially ameliorate post-operative pain relief. Concern exists that tenotomising the biceps damages the adjacent arcuate artery, potentially increasing the rate of AVN. The purpose of this study was to evaluate whether biceps tenodesis is associated with an increased risk of radiographically evident humeral head AVN.
61 fractures surgically treated over a 52-month period were retrospectively reviewed and radiographically assessed in accordance with Neer’s classification, calcar-length and medial hinge integrity.
40, 20 and 1 were four-, three- and two-part fractures respectively. 37 had a calcar-length less than 8mm and 26 suffered loss of the medial hinge. The median radiographic follow-up was 23 months. There was radiographic evidence of humeral head AVN in only one case, comparing favourably to rates quoted in current literature.
In our experience, intra-articular biceps tenotomy with the deltopectoral approach was thus not associated with a significantly increased risk of humeral head AVN, even in complex four-part fractures.
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12
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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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13
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Hegde N, Kundangar RS, Nishanth A, Bhat SN. Disappearing pulse: proximal humerus fracture with acute thrombosis of axillary artery. BMJ Case Rep 2021; 14:14/4/e242740. [PMID: 33858911 PMCID: PMC8054072 DOI: 10.1136/bcr-2021-242740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Nikhil Hegde
- Manipal Academy of Higher Education, Manipal, Karnataka, India
| | | | - Ampar Nishanth
- Manipal Academy of Higher Education, Manipal, Karnataka, India
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14
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MRI evaluation of axillary neurovascular bundle: Implications for minimally invasive proximal humerus fracture fixation. JSES Int 2021; 5:205-211. [PMID: 33681839 PMCID: PMC7910741 DOI: 10.1016/j.jseint.2020.11.002] [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: 11/25/2022] Open
Abstract
Background Percutaneous fixation of proximal humeral fractures places the axillary nerve and posterior humeral circumflex artery at risk for injury. Safe operative zones for the axillary nerve are described based on external measurements from anatomic landmarks, but no study to date has incorporated advanced imaging to help guide surgical procedures in the region of the axillary neurovascular bundle (ANVB). We sought to define the location and trajectory of the ANVB in relation to osseous landmarks using magnetic resonance imaging (MRI) measurements. Methods Retrospective review of 750 consecutive MRI studies was performed with 55 imaging studies meeting inclusion criteria for patient positioning, image alignment, and quality. Five measurements were performed including the distance from mid-lateral acromion to lateral ANVB, mid-lateral acromion to medial ANVB, greater tuberosity to lateral ANVB, vertical distance between inferior anatomic neck and lateral ANVB, and angle the ANVB crosses the humerus. Height, gender, and age were recorded. Analysis was performed using ANOVA and Pearson correlation tests. Results The lateral ANVB was below the inferior articular margin of the humeral head by an average of 12.9 ± 3.9 mm and within a 22 mm window. It was an average of 57.4 ± 5.1 mm from the lateral mid-acromion, and 34.7 ± 4.3 mm below the greater tuberosity. The angle formed by the ANVB crossing the humerus averaged 19.5 ± 3.9 degrees upward from medial to lateral. Height and gender directly impacted measurements. Conclusions The use of the inferior humeral head articular margin provides a radiographic landmark to aid intraoperative lateral ANVB assessment which may be helpful during percutaneous fracture fixation.
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Kanda D, Imagama I, Imoto Y, Ohishi M. Bidirectional endovascular treatment for axillary artery injury secondary to proximal humerus fracture: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2021; 5:ytaa526. [PMID: 33604507 PMCID: PMC7876303 DOI: 10.1093/ehjcr/ytaa526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/14/2020] [Accepted: 11/27/2020] [Indexed: 11/14/2022]
Abstract
Background Axillary artery injury secondary to proximal humerus fracture is a rare but serious complication. The management of this injury has traditionally involved surgical treatment. Case summary A 66-year-old female with gait disturbance slipped and fell off her wheelchair at home. She presented to a local hospital with right shoulder pain and was subsequently urgently transferred to our hospital by helicopter because of suspicion of axillary artery injury. Computed tomography angiography revealed disruption of the right axillary artery. We decided to perform endovascular treatment instead of surgical treatment for axillary artery injury. However, since endovascular treatment via the right femoral artery was impossible, we performed bidirectional (right femoral and right brachial artery approaches) endovascular treatment. We expanded the occluded lesion using a 3.5 mm × 40 mm sized balloon and placed a 5.0 mm × 50 mm stent graft (Gore® Viabahn®) across the lesion. The final subclavian injection confirmed that distal flow to the brachial artery was preserved and that there was no leakage of contrast medium from the axillary artery. Discussion We performed endovascular treatment for axillary artery injury secondary to proximal humerus fracture. Although surgical repair is typically performed for this kind of injury, our experience suggests that endovascular treatment might be an option in patients with axillary artery injury.
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Affiliation(s)
- Daisuke Kanda
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima City, Kagoshima 890-8520, Japan
| | - Itsumi Imagama
- Department of Cardiovascular and Gastroenterological Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima City, Kagoshima 890-8520, Japan
| | - Yutaka Imoto
- Department of Cardiovascular and Gastroenterological Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima City, Kagoshima 890-8520, Japan
| | - Mitsuru Ohishi
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima City, Kagoshima 890-8520, Japan
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Hirata K, Sasanuma H, Fukushima T, Y I, Yano Y, Nakama S, Takei Y, Takeshita K. A case of delayed axillary artery aneurysm after reverse shoulder arthroplasty for a shoulder fracture dislocation: a case report. JSES Int 2020; 5:288-290. [PMID: 33681851 PMCID: PMC7910739 DOI: 10.1016/j.jseint.2020.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Ko Hirata
- Department of Orthopaedic Surgery, Tochigi Medical Center Shimotsuga, Tochigi, Japan
| | - Hideyuki Sasanuma
- Department of Orthopaedic Surgery, Tochigi Medical Center Shimotsuga, Tochigi, Japan
| | - Takashi Fukushima
- Department of Orthopaedic Surgery, Tochigi Medical Center Shimotsuga, Tochigi, Japan
| | - Iijima Y
- Department of Cardiovascuar Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Yuichiro Yano
- Department of Orthopaedic Surgery, Tochigi Medical Center Shimotsuga, Tochigi, Japan
| | - Sueo Nakama
- Department of Orthopaedic Surgery, Tochigi Medical Center Shimotsuga, Tochigi, Japan
| | - Yusuke Takei
- Department of Orthopaedic Surgery, Jichi Medical University, Tochigi, Japan
| | - Katsushi Takeshita
- Department of Cardiovascuar Surgery, Dokkyo Medical University, Tochigi, Japan
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Acute deep venous thrombosis and late onset axillary artery injury after a displaced, proximal humerus fracture-dislocation in an octogenarian patient. Aging Clin Exp Res 2020; 32:1183-1186. [PMID: 31350699 DOI: 10.1007/s40520-019-01284-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 07/18/2019] [Indexed: 10/26/2022]
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Briese T, Theisen C, Schliemann B, Raschke MJ, Lefering R, Weimann A. Shoulder injuries in polytraumatized patients: an analysis of the TraumaRegister DGU®. Eur J Trauma Emerg Surg 2020; 47:1921-1930. [PMID: 32221637 PMCID: PMC8629800 DOI: 10.1007/s00068-020-01340-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 03/02/2020] [Indexed: 11/29/2022]
Abstract
Background The aim of the present study was to analyze the prevalence, epidemiology and relevance of shoulder injuries in polytraumatized patients in a large national trauma database. We hypothesize a high prevalence of shoulder injuries in traffic accidents and a high prevalence of concomitant injuries of the thorax leading to an aggravated clinical course and higher Injury Severity Score (ISS). Furthermore, we hypothesize an increased rate of surgical treatment with the severity of the injury. Materials and methods The retrospective analysis is based on the database (2002–2013) of the TraumaRegister DGU® and includes statistical data from 608 hospitals. The severity of injuries and trauma were scaled using the Abbreviated Injury Scale (AIS), and the Injury Severity Score (ISS), respectively. Patients with an ISS ≥ 16 were included in the study, and injuries were subdivided according to their anatomical involvement and analyzed with respect to the trauma mechanism and the resulting injuries. Results In this study, 54,076 cases of patients with an ISS ≥ 16 were analyzed. Shoulder injuries occurred in 15,115 patients (27.9%). Of these, 68.5% were caused by traffic accidents, especially in motorbike, bicycle, and pedestrian accidents. We found more shoulder injuries in blunt trauma mechanisms. Moreover, patients with shoulder injuries spent on average 1.7 more days on the intensive care unit (ICU), or intermediate care unit (IMCU), according to the severity of the injury, and had longer overall hospital stays (26.2 vs. 24.1 days) than patients without shoulder injuries. The overall ISS was increased in patients with shoulder injuries, whereas an increase of mortality could not be identified. Concomitant thoracic injuries occurred significantly more often in patients with shoulder injuries (82.9% vs. 69.6%). Injuries of the abdomen, pelvis, and lower extremity showed no correlation with shoulder injuries, whereas head and spine injuries showed a significant correlation. Conclusion Shoulder injuries are very common in polytraumatized patients. Together with their distinctive concomitant injuries, they have an aggravating impact on the clinical progress. Our data confirm the correlation with thoracic injuries. Furthermore, we identified an increased risk of shoulder injuries in motorbike, bicycle, and pedestrian accidents. An increase in mortality could not be identified.
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Affiliation(s)
- Thorben Briese
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus, Building W1, 48149, Muenster, Germany
| | - Christina Theisen
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus, Building W1, 48149, Muenster, Germany
- Department for Orthopedic Surgery, Schoen Clinic Duesseldorf, Am Heerdter Krankenhaus 2, 40549, Duesseldorf, Germany
| | - Benedikt Schliemann
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus, Building W1, 48149, Muenster, Germany
| | - Michael J Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus, Building W1, 48149, Muenster, Germany.
| | - Rolf Lefering
- IFOM, Institute for Research in Operative Medicine, University of Witten, Herdecke, Germany
| | - Andre Weimann
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus, Building W1, 48149, Muenster, Germany
- OCP-Muenster, Orthopedic, Trauma and Hand Surgery, Schaumburgstrasse 1, 48145, Muenster, Germany
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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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Amini B, Beckmann NM, Beaman FD, Wessell DE, Bernard SA, Cassidy RC, Czuczman GJ, Demertzis JL, Greenspan BS, Khurana B, Lee KS, Lenchik L, Motamedi K, Sharma A, Walker EA, Kransdorf MJ. ACR Appropriateness Criteria ® Shoulder Pain-Traumatic. J Am Coll Radiol 2019; 15:S171-S188. [PMID: 29724420 DOI: 10.1016/j.jacr.2018.03.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 03/04/2018] [Indexed: 02/08/2023]
Abstract
Traumatic shoulder pain is pain directly attributed to a traumatic event, either acute or chronic. This pain may be the result of either fracture (the clavicle, scapula, or proximal humerus) or soft-tissue injury (most commonly of the rotator cuff, acromioclavicular ligaments, or labroligamentous complex). Imaging assessment of traumatic shoulder pain begins with conventional radiography and, depending on physical examination findings, will require MRI or MR arthrography for assessment of soft-tissue injuries and CT for delineation of fracture planes. Ultrasound excels in assessment of rotator cuff injuries but has limited usefulness for assessment of the deep soft-tissues. CT angiography and conventional arteriography are helpful for assessment of vascular injury, and bone scintigraphy can be used in assessment of complex regional pain syndrome after traumatic shoulder injury. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Behrang Amini
- Principal Author, University of Texas MD Anderson Cancer Center, Houston, Texas.
| | | | | | | | | | - R Carter Cassidy
- UK Healthcare Spine and Total Joint Service, Lexington, Kentucky; American Academy of Orthopaedic Surgeons
| | | | | | | | | | - Kenneth S Lee
- University of Wisconsin Hospital & Clinics, Madison, Wisconsin
| | - Leon Lenchik
- Wake Forest University School of Medicine, Winston Salem, North Carolina
| | - Kambiz Motamedi
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | | | - Eric A Walker
- Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania; and Uniformed Services University of the Health Sciences, Bethesda, Maryland
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23
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Dixit A, Cautela FS, Cooper CS, Beyer GA, Messina JC, Mait JE, Shah NV, Diebo BG, Paulino CB, Urban WP. ORIF versus arthroplasty for open proximal humerus fractures: Nationwide Inpatient Sample data between 1998 and 2013. J Orthop Traumatol 2018; 19:12. [PMID: 30132086 PMCID: PMC6103959 DOI: 10.1186/s10195-018-0503-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 11/27/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Limited data exists in analyzing open reduction and internal fixation (ORIF) and arthroplasty in the management of open proximal humerus fractures. We analyzed differences in hospital course between these procedures, patient demographics, complication rate, length of stay, hospital charges, and mortality rate. MATERIALS AND METHODS This is a retrospective review of the Nationwide Inpatient Sample database. ICD-9 codes identified patients hospitalized for open proximal humerus fractures from 1998 to 2013 who underwent ORIF or shoulder arthroplasty (hemi-, total, or reverse). Demographics and in-hospital complications were compared. Logistic regression controlling for age, gender, and Deyo index tested the impact of ORIF vs ARTH on any complications. RESULTS Seven hundred thirty patients were included (ORIF, n = 662 vs ARTH, n = 68). ORIF patients were younger (p < 0.001), more likely to be males (p < 0.001), and had a lower Deyo score (p = 0.012). Both groups had comparable complication rates (21.4% vs 18.0%, p = 0.535), lengths of stay (7.86 days vs 7.44 days, p = 0.833), hospital charges ($76,998 vs $64,133, p = 0.360), and mortality rates (0.2% vs 0%, p = 0.761). Type of surgery was not a predictor of any complications (OR = 0.67 [95% CI 0.33-1.35], p = 0.266), extended length of stay (OR = 1.01 [95% CI 0.58-1.78], p = 0.967), or high hospital charges (OR = 1.39 [95% CI 0.68-2.86], p = 0.366). CONCLUSION We revealed no differences in hospital course between ORIF and arthroplasty for management of open proximal humerus fractures. Although differences in demographics existed, no differences in complication rates, length of stay, hospital charges and mortality rates were noted. Future studies can evaluate the long-term outcomes of these procedures. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Anant Dixit
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York, Downstate Medical Center, 450 Clarkson Avenue, Box 30, Brooklyn, NY, 11203, USA
| | - Frank S Cautela
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York, Downstate Medical Center, 450 Clarkson Avenue, Box 30, Brooklyn, NY, 11203, USA
| | - Colin S Cooper
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York, Downstate Medical Center, 450 Clarkson Avenue, Box 30, Brooklyn, NY, 11203, USA
| | - George A Beyer
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York, Downstate Medical Center, 450 Clarkson Avenue, Box 30, Brooklyn, NY, 11203, USA
| | - James C Messina
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York, Downstate Medical Center, 450 Clarkson Avenue, Box 30, Brooklyn, NY, 11203, USA
| | - Jeffrey E Mait
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York, Downstate Medical Center, 450 Clarkson Avenue, Box 30, Brooklyn, NY, 11203, USA
| | - Neil V Shah
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York, Downstate Medical Center, 450 Clarkson Avenue, Box 30, Brooklyn, NY, 11203, USA
| | - Bassel G Diebo
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York, Downstate Medical Center, 450 Clarkson Avenue, Box 30, Brooklyn, NY, 11203, USA.
| | - Carl B Paulino
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York, Downstate Medical Center, 450 Clarkson Avenue, Box 30, Brooklyn, NY, 11203, USA
| | - William P Urban
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York, Downstate Medical Center, 450 Clarkson Avenue, Box 30, Brooklyn, NY, 11203, USA
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Karita Y, Kimura Y, Sasaki S, Nitobe T, Tsuda E, Ishibashi Y. Axillary artery and brachial plexus injury secondary to proximal humeral fractures: A report of 2 cases. Int J Surg Case Rep 2018; 50:106-110. [PMID: 30098526 PMCID: PMC6089080 DOI: 10.1016/j.ijscr.2018.04.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 04/30/2018] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Axillary artery and brachial plexus injuries have been reported to be associated with proximal humeral fractures. In this report, we present two cases of axillary artery and brachial plexus injury secondary to proximal humeral fracture. PRESENTATION OF CASES Case 1: An 88-year-old woman with cognitive impairment slipped and fell at home. The diagnosis was left proximal humeral fracture. The second day, paralysis of left upper arm due to left axillary artery occlusion appeared. Axillary-brachial artery bypass surgery was performed. After that, a radial artery pulse was palpable. Ten months have passed since the operation, but the neurologic deficit has not been restored. Case 2: A 74-year-old woman fell from a ladder. She was diagnosed with a right proximal humeral fracture and right axillary artery occlusion. Emergency axillary-brachial bypass surgery and osteosynthesis were performed. After reestablishing the blood flow, there have been no signs of blood flow disorders but paralysis has remained. DISCUSSION In neither of the two cases, were obvious findings of brachial plexus injury detected during surgery. The delayed onset of motor palsy implied that an ischemic factor was implicated in case 1. The acute onset of motor palsy might have been caused by a mechanical factor such as the dislocated of humeral head in case 2. CONCLUSION Axillary artery and brachial plexus injury secondary to proximal humeral fracture is rare but it can develop severe sequels. By identifying the high-risk patients, diagnosis and management of this vascular and plexus injury might lead to improvement.
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Affiliation(s)
- Yukiko Karita
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan.
| | - Yuka Kimura
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Shizuka Sasaki
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Taisuke Nitobe
- Department of Orthopaedic Surgery, Tsugaru General Hospital, Goshogawara, Japan
| | - Eiichi Tsuda
- Department of Rehabilitation Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yasuyuki Ishibashi
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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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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26
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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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27
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Singh AK, Rudge W, Quick T. An important lesson in assessing neurovascular involvement in proximal humeral fractures: the presence of neuropathic pain in a dysvascular limb. J Shoulder Elbow Surg 2018; 27:e20-e24. [PMID: 29221576 DOI: 10.1016/j.jse.2017.09.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 09/25/2017] [Accepted: 09/30/2017] [Indexed: 02/01/2023]
Affiliation(s)
- Ashok K Singh
- Department of Trauma & Orthopaedics, Queen Elizabeth University Hospital, Glasgow, UK.
| | - William Rudge
- Shoulder and Elbow Unit, Royal National Orthopaedic Hospital, Stanmore, Middx, UK
| | - Tom Quick
- Peripheral Nerve Injury Unit, Royal National Orthopaedic Hospital, Stanmore, Middx, UK
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Palanisamy JV, Vaithilingam A, M A, Das S, Trikha V. Proximal humerus fracture dislocation leading to axillary artery injury in an young adult: Case report of an unusual presentation. J Clin Orthop Trauma 2017; 8:S62-S66. [PMID: 28878544 PMCID: PMC5574851 DOI: 10.1016/j.jcot.2017.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Revised: 03/17/2017] [Accepted: 05/20/2017] [Indexed: 10/19/2022] Open
Abstract
Proximal humerus fractures constitute five percent of all fracture cases. Though rare, severely comminuted proximal humerus fractures can cause injury to neurovascular structure. Majority of these injuries reported in literature were in elderly age group from low velocity injury owing to loss of elasticity of vessel wall. We report a case of proximal humerus fracture dislocation associated with axillary artery injury in a young male due to fall of heavy iron object. Timely exploration and removal of impinging bone fragment restored the blood supply. The purpose of this report is to heighten the clinical suspicion of the vascular injury in patients with proximal humerus fracture dislocations in all age groups.
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Padegimas EM, Schoch BS, Kwon J, DiMuzio PJ, Williams GR, Namdari S. Evaluation and Management of Axillary Artery Injury: The Orthopaedic and Vascular Surgeon’s Perspective. JBJS Rev 2017. [DOI: 10.2106/jbjs.rvw.16.00082] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Leclerc B, Loisel F, Ferrier M, Al Sayed M, Rinckenbach S, Obert L. Axillary artery transection and bilateral pulmonary embolism after anterior shoulder dislocation: case report. SICOT J 2017; 3:3. [PMID: 28074775 PMCID: PMC5225835 DOI: 10.1051/sicotj/2016041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 11/19/2016] [Indexed: 12/03/2022] Open
Abstract
Introduction: Anterior shoulder dislocation can be associated with vascular and neurological complications. However, axillary artery injury associated with shoulder dislocation is rare and extremely rare without bone fracture. An early diagnosis of these complications allows predicting long-term functional outcomes. Methods: This article reports the case of a 66-year-old patient who presented an anterior shoulder dislocation after a ski fall without any neurological dysfunction or pulse deficit. Results: The first reduction attempts were unsuccessful and during the new attempt, we observed a hematoma. A CT scan showed a disruption of the axillary artery and a bilateral pulmonary embolism. Conclusion: Neurovascular injury must be systematically sought before and after reduction, and a multidisciplinary approach is always necessary.
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Affiliation(s)
- Betty Leclerc
- Vascular Surgery Unit, University Hospital of Besançon, 25030 Besançon, France
| | - François Loisel
- Orthopaedic, Traumatology and Hand Surgery Unit, University Hospital of Besançon, 25030 Besançon, France
| | - Maxime Ferrier
- Orthopaedic, Traumatology and Hand Surgery Unit, University Hospital of Besançon, 25030 Besançon, France
| | - Mazen Al Sayed
- Vascular Surgery Unit, University Hospital of Besançon, 25030 Besançon, France
| | - Simon Rinckenbach
- Vascular Surgery Unit, University Hospital of Besançon, 25030 Besançon, France
| | - Laurent Obert
- Orthopaedic, Traumatology and Hand Surgery Unit, University Hospital of Besançon, 25030 Besançon, France
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Lange M, Brandt D, Mittlmeier T, Gradl G. Proximal humeral fractures: non-operative treatment versus intramedullary nailing in 2-, 3- and 4-part fractures. Injury 2016; 47 Suppl 7:S14-S19. [PMID: 28040071 DOI: 10.1016/s0020-1383(16)30848-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Little is known about non-operative treatment of proximal humerus 4-part and severe displaced fractures as those are normally treated operatively. In this study, we present a historical collective of two level I trauma centers, where all humeral head fractures, despite displaced fractures, received non-operative treatment within a 10 years period. Functional and clinical results of 2-, 3- and 4-part fractures were compared to those after fixed angle intramedullary nailing by matched pair analysis. METHODS Between 2000 and 2010, 167 patients with 2-, 3- and 4-part humeral head fractures were treated non-operatively in two level I trauma centers in Rostock. Complete clinical, functional and radiographic follow-up were available for 41 patients in the retrospective analysis. The results were compared by matched-pair analysis to a prospective series of 143 patients treated by antegrade intramedullary nailing using a proximal humeral nail. Of these 143 patients complete radiological and clinical 12 months' follow-up was available for 117 patients. Thus, it was possible to built 41 pairs according to age, gender, and fracture type. Statistical significant differences in constant score (CS), pain, activity of daily living (ADL), range of motion (ROM) and muscle strength were evaluated by Wilcoxon test. Furthermore, x-ray analysis of fracture healing and complications were recorded. RESULTS Operative treatment was not superior to non operative treatment concerning functional results, even in displaced fractures. The only significant difference was found in 3-part-fractures, where better ROM was reached in the non-operative group (p = 0.05). In contrast, there was a tendency toward better activity of daily living (ADL) in intramedullary nailing, but this did not reach statistical significance. X-ray findings revealed better anatomical reconstruction with less valgus and varus displacements after surgery (15% versus 50%, p < 0.005). The complication rate of 37% was higher in the surgery group with a reoperation rate of 32%. CONCLUSION In our study, surgical treatment by fixed angle intramedullary nailing (Targon PH) seems not to be superior to non-operative treatment, regardless of fracture type. In 2-, 3- and 4-part fractures functional and clinical results were similar.
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Affiliation(s)
- Mirjam Lange
- Department of Trauma, Orthopedic and Reconstructive Surgery, Munich University Hospital (LMU), Munich, Germany
| | - Daniel Brandt
- Department of Trauma, Hand and Reconstructive Surgery, University of Rostock, Medical Center, Germany
| | - Thomas Mittlmeier
- Department of Trauma, Hand and Reconstructive Surgery, University of Rostock, Medical Center, Germany
| | - Georg Gradl
- Department of Trauma, Orthopedic and Reconstructive Surgery, Munich Municipal Hospital Group, Clinic Harlaching, Germany.
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Axillary artery injury from a closed humeral neck fracture: A case report. ACTA ACUST UNITED AC 2016; 41:407-411. [PMID: 27745944 DOI: 10.1016/j.jmv.2016.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 07/01/2016] [Indexed: 11/22/2022]
Abstract
Axillary artery injury from humeral neck fracture is an uncommon event. Vascular damage due to these injuries may threaten limb loss. In some cases, the signs of ischemia may not be evident just after the injury and may only appear later on. Therefore, a high index of suspicion is essential. It is important to bear this association in mind, so as to make an early diagnosis and avoid serious complications. We are describing the case of a young patient involved in a motor vehicle crash with an axillary artery trauma due to the surgical neck of humerus fracture. The patient underwent a basilic vein grafting, the postoperative course was good.
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Abstract
INTRODUCTION Proximal humeral fractures with a spiral line of fracture extending from the humeral head to the diaphyseal region are increasing. Treatment for these fractures is comparable to that for shaft fractures. The purpose of this study was to evaluate the use of a new "Long" humeral nail for this type of lesion and identify the best distal locking. MATERIALS AND METHODS Forty-three patients treated with a Long Diphos Nail® were selected for this study: main exclusion criteria were poor cognitive and responsive ability to physical therapy, four-part fracture requiring humeral head replacement, an isolated greater or lesser tubercle fracture and a head-splitting fracture. All patients were divided into two groups according to the distal locking (single or double) and clinically evaluated at 1, 3, 6 and 12 months after surgery. The following parameters were evaluated: fracture healing on radiographic images every month; level of pain with Visual Analogue Scale (VAS); recovery of shoulder function or ability to resume normal daily activities according to the Constant Scoring System (CSS); patient satisfaction; and complications, like fracture consolidation defect or delay. A statistical analysis was performed. RESULTS Improvements in pain, satisfaction and shoulder functional recovery were recorded. Patients reached fracture healing in two to six months. The mean healing time was better for double distal locking (p=0.04).There was a clinically greater difference (p=0.006) between the groups for the mean Constant score at 3 months follow-up, with better results for the double distal locking group. Complications were: one patient with a consolidation delay with a single distal locking screw breakage; it was necessary to remove the nail and perform a second treatment. CONCLUSIONS The results of the study indicate the efficacy of Long Diphos Nail® in the treatment of fractures with a line of fracture extending to the proximal diaphyseal region. The features of a multiplane stabilisation above the fracture and a distal double locking may represent the key for a good fixation for 11-A2, A3 or B2 fractures with a long spiral line. A double distal locking reduces fracture micro-instability and so patients recover function and strength quicker because of less pain at the fracture site. STUDY DESIGN retrospective, cohort of cases. LEVEL OF EVIDENCE IV.
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Abstract
Necrosis of the humeral head, infections and non-unions are among the most dangerous and difficult-to-treat complications of proximal humeral fractures. The aim of this work was to analyse in detail non-unions and post-traumatic bone defects and to suggest an algorithm of care. Treatment options are based not only on the radiological frame, but also according to a detailed analysis of the patient, who is classified using a risk factor analysis. This method enables the surgeon to choose the most suitable treatment for the patient, thereby facilitating return of function in the shortest possible time. The treatment of such serious complications requires the surgeon to be knowledgeable about the following possible solutions: increased mechanical stability; biological stimulation; and reconstructive techniques in two steps, with application of biotechnologies and prosthetic substitution.
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