Shoulder fracture dislocation associated with axillary artery injury: a case report

Axillary Artery Injuries Associated With Proximal Humerus Fractures: A Literature Review and a Proposal of a Novel Multidisciplinary Surgical Approach

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.

Axillary Artery Dissection and Thrombosis after Closed Proximal Humerus Fracture - a Rare Interdisciplinary Challenge

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.

Injury to the axillary artery and brachial plexus caused by a closed floating shoulder injury: A case report

BACKGROUND

A floating shoulder may be associated with catastrophic neurovascular injury and requires a multidisciplinary approach for its management. To maximize the likelihood of good patient outcomes, this unique injury pattern should be recognized in patients as early as possible. This can be difficult to achieve, however, as there are currently few reports of floating shoulder in the literature, meaning that associated neurovascular injuries may be overlooked.

CASE SUMMARY

We present here a rare case of floating shoulder with axillary artery injury in a 34-year-old woman. The patient complained of pain and numbness of her left upper limb after losing control of her motorcycle on a highway and falling from the vehicle 2 h ago. No blood pressure reading could be obtained from her left upper limb and no blood oxygen readings could be obtained from any of her left fingers. Computed tomography angiography and duplex ultrasonography revealed interruption of blood flow through the axillary artery, with distal flow being maintained through collateral arteries. The clinical diagnosis including fracture of the left proximal humerus, the left clavicle, and the left scapula, left axillary artery rupture, and left brachial plexus injury. We successfully performed open reduction and internal fixation of the fracture and vascular repair. The patient showed satisfactory recovery that was observed during 4-mo follow-up.

CONCLUSION

Emergency surgery can be an effective therapeutic option for the closed floating shoulder with catastrophic axillary artery injury.

Bilateral anterior shoulder dislocation

Shoulders are the most common major joint to become disarticulated, and shoulder dislocation is a frequent patient presentation to the ED. Bilateral shoulder dislocations, however, are rare and typically caused by seizure activity or electrocution. Posterior disarticulation is most common following seizure activity. This article describes an adolescent girl who dislocated both shoulders anteriorly following seizure activity.

Axillary artery injury after an anterior shoulder fracture dislocation and "periosteal sleeve avulsion of the rotator cuff" (SARC). Case report and review of the literature

We present the rare complication of an axillary artery injury associated with an anterior dislocation of the humerus and what we believe to be the first reported periosteal sleeve avulsion of the entire rotator cuff (SARC). We review the literature and discuss the cause of this unusual injury pattern.

Proximal humerus fracture with injury to the axillary artery: a population-based study

BACKGROUND

The available evidence regarding axillary artery injury as a result of proximal humerus fracture consists of individual case reports or small series. This study used nationally representative data to determine the prevalence and predictors of axillary artery injury secondary to proximal humerus fracture, and to characterise its influence on inpatient mortality, length of stay, cost and discharge disposition.

METHODS

An estimated 388,676 inpatients with a proximal humerus fracture were identified in the Nationwide Inpatient Sample between 2002 and 2011, 331 with concomitant axillary artery injury (8.5 per 10,000). Multivariable regression modelling was used to identify independent predictors of axillary artery injury and to assess its relationship with inpatient outcomes.

RESULTS

Factors associated with axillary artery injury were male sex (odds ratio (OR): 1.6, 95% confidence interval (CI): 1.2-2.0), atherosclerosis (OR: 3.7, 95% CI: 2.5-5.4), open fracture (OR: 2.9, 95% CI: 1.9-4.5) and the presence of concomitant injuries, including brachial plexus injury (OR: 109, 95% CI: 79-151), shoulder dislocation (OR: 3.4, 95% CI: 2.0-5.8), scapula fracture (OR: 3.4, 95% CI: 2.1-5.4) and rib fracture (OR: 2.5, 95% CI: 1.6-4.0). Axillary artery injury was associated with increased length of stay, costs and mortality, but it did not affect discharge disposition.

CONCLUSION

Our study provides important baseline information regarding the epidemiology of axillary artery injury secondary to proximal humerus fracture. Prompt identification of at-risk patients upon admission might lead to improved diagnosis and management of this vascular injury.

LEVEL OF EVIDENCE

Prognostic level II.

Proximal humerus fractures with associated axillary artery injury

Proximal humerus fractures have rarely been associated with injuries to the axillary artery. Most of the fractures described have been Neer 2-part surgical neck fractures with medialization of the shaft fragment and resultant laceration or thrombosis of the axillary artery. No intraoperative deaths have been reported. We present a series of 3 proximal humerus fractures, 2 of which are Neer 3- to 4-part anterior fracture dislocations, and associated axillary artery injury. There were 2 mortalities, 1 intraoperative. After a thorough review of the English literature, we identified an additional 11 cases of axillary artery injury associated with proximal humerus fracture. The purpose of this study was to heighten the clinical suspicion of this vascular injury in patients with proximal humerus fracture dislocations and surgical neck fractures with shaft medialization, as well as to review pathogenesis and guide management decisions.

Life-threatening posterior circumflex humeral artery injury secondary to fracture-dislocation of the proximal humerus

Proximal humeral fractures account for 4% to 5% of all fractures, and most of these are minimally displaced and less prone to neurovascular injuries. This article presents a case of a 65-year-old man who injured the posterior circumflex humeral artery following a fracture dislocation of the proximal humerus leading to a life-threatening hemorrhagic complication during surgical fixation of the dislocated proximal humeral fracture. Preoperative vital signs were normal. Using the deltopectoral approach, the fracture site was exposed and the dislocated head was extracted. Blood pooled and overflowed the cavity at a brisk pace. Blood pressure dropped from 130/70 mm Hg to 90/45 mm Hg, and preoperative follow-up hemoglobin dropped to 4.8 g/dL. The axillary artery was explored and a ruptured posterior humeral circumflex artery was observed that was later ligated. In view of the damage to 1 of the circumflex humeral branches, primary hemiarthroplasty was performed. This article highlights the possibility of encountering life-threatening vascular injuries in highly displaced or dislocated 4-part proximal humeral fractures and the significance of obtaining the angiographic studies early in the course of management in such cases.