Axillary artery injury secondary to anterior shoulder dislocation: report of two cases

Aortic Injury After Shoulder Reduction in a Patient with Multiple Rib Fractures: A Case Report

CASE

A 74-year-old woman presented with multiple rib fractures, hemothorax, spleen rupture, and right shoulder dislocation. Shoulder joint reduction was performed using the traction-countertraction method. An injury to the descending aorta, caused by the seventh rib, was confirmed.

CONCLUSION

The authors encountered an aortic injury, a rare complication of shoulder joint reduction, in a patient with a posterior rib fracture. When managing patients with posterior fractures of the fourth to ninth ribs on the left side, the reduction method should be carefully selected depending on the status of the patient to avoid aortic injuries.

Management of primary anterior shoulder dislocations: a narrative review

Abstract

The recurrence rate following acute anterior shoulder dislocations is high, particularly in young, active individuals. The purpose of this paper is to provide a narrative overview of the best available evidence and results with regards to diagnostic considerations, comorbidities, position of immobilization, surgical versus conservative management, and time to return to play for the management of primary anterior shoulder dislocations. Three independent reviewers performed literature searches using PubMed, MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials. Randomized controlled trials and systematic reviews meeting inclusion criteria from 1930 to April 2019 were appraised and discussed with the intent to consolidate the best available evidence with regards to lowering recurrence rates. A majority of studies support early surgical intervention for individuals between 21 and 30 years of age following primary shoulder dislocations, as this group is particularly susceptible to recurrence. Conservative treatment plans favor 1–3 weeks of immobilization in internal rotation, followed by rehabilitation. Surgical methods are associated with longer time to return to play, but lower recurrence rates. Return to play time is best determined on an individualized basis, when subjective and objective function of both shoulders is determined to be symmetric. This paper broadly summarizes the best available evidence for the management of primary anterior shoulder dislocations. There remains a need for randomized studies to determine ideal long-term treatment following conservative or surgical management, as general timelines for returning to play following injury remain vague.

Level of evidence

IV, Narrative Review

Pitch-side management of acute shoulder dislocations: a conceptual review

The shoulder, specifically the glenohumeral joint, by virtue of its anatomical characteristics and biomechanics confers a large range of movement, which ultimately results in a joint that is inherently prone to becoming unstable. The incidence of acute traumatic shoulder dislocation varies within the sporting environment, commonly occurring following direct trauma. Anterior dislocations account for nearly 90% of all dislocations. While most are referred and managed in the emergency department, pitch-side relocation by experienced clinicians does occur prior to referral. The aim of this study was to delineate a guideline specifically for the pitch-side management of this common injury. A literature search of PubMed and Medline using the keywords ‘prehospital’, ‘pitch-side’, ‘shoulder dislocation’ and ‘reduction’ or ‘relocation technique’ was performed, and the available literature was reviewed and collated. Articles focusing on reduction techniques were then reviewed, with particular consideration on their applicability to a pitch-side setting. While studies exist that compare and contrast examination and reduction techniques, most are based in a hospital setting. To date, there is no standardised management protocol published for the initial management of an anterior dislocated shoulder in a pitch-side setting. This article addresses this discrepancy and proposes a structured, algorithmic approach to the pitch-side management of a shoulder dislocation. The article addresses factors to consider in a pitch-side setting, suitable techniques and postreduction care. While a systematic approach has been delineated in this article, we recommend those pitch-side medical practitioners who provide this form of support should have attended appropriate training and ensure adequate malpractice cover.

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.

Anterior humeral circumflex artery avulsion with brachial plexus injury following an isolated traumatic anterior shoulder dislocation

A 70-year-old man presented to accident and emergency with an isolated anteriorly dislocated shoulder, in the absence of a concomitant fracture. There was no neurovascular deficit at presentation, and the shoulder was reduced under sedation, using the Kocher's technique. Following this, the patient developed signs of hypovolaemic shock. Clinical examination revealed an expanding fullness in the deltopectoral area, with compromise of the limb neurovascular status. CT imaging confirmed an expanding haematoma from the axillary vessels, restricting left lung expansion. Once resuscitated, the patient was transferred to theatre for exploration of the bleeding vessels. Intraoperative findings included an avulsed anterior circumflex humeral artery that was subsequently ligated. Postoperatively, the patient developed axillary, radial, median and ulnar nerve neuropraxia, which improved clinically prior to discharge. The patient was ultimately discharged home after a lengthy inpatient stay.

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.

Axillary Artery Injury Accompanying Humeral Neck Fracture

Injuries to the axillary artery from proximal humeral fractures are uncommon. There are only 66 such injuries reported across the world literature to date. We report an additional case of axillary artery injury. This case highlights the importance of maintaining a high index of suspicion to prevent diagnostic delay.

Axillary artery transection after shoulder dislocation

Axillary artery transection after shoulder dislocation without bone fracture is extremely rare. Early diagnosis, use of the occlusion balloon for proximal control of axillary artery bleeding, and surgical treatment are important to avoid morbidity and mortality. A 74-year old man presented with a complete transection of axillary artery associated with anterior dislocation of the shoulder without bone fracture. Left axillary artery transection was seen on angiography. An angioplasty balloon was used to prevent bleeding from the subclavian artery. The brachial plexus was compressed by a hematoma. Axillary artery repair was performed with an autologous reversed saphenous vein graft interposition. The patient had palpable distal pulses postoperatively. Motor function was significantly improved but still impaired in the postoperative period. Follow-up at 3 months showed good function of the left arm.Successful management of axillary artery injuries requires prompt diagnosis and surgical treatment. Neurologic injury may affect the functional outcome of the limb.

Anterior shoulder dislocation

INTRODUCTION

Anterior dislocation of the shoulder is commonly seen in accident and emergency (A&E) and trauma clinics. In this article, we review the existing literature on the injury and the recent trends in management.

MATERIALS AND METHODS

We have discussed this condition with our colleagues and performed a Medline search ('anterior shoulder dislocation') of the relevant papers. We also describe key historical publications and recent developments regarding immobilisation of the joint.

RESULTS

Management decisions regarding this condition continue to vary between units, especially for recurrent and posterior dislocation. This paper lays some emphasis on the choice of analgesic agent when attempting shoulder reduction in the A&E setting. A summary of the data from our own department has provided a graphical representation of the classical age and sex distribution for this condition.

CONCLUSIONS

Shoulder dislocation is a common injury. Delays in diagnosis remain the single biggest obstacle to optimum results in this group of patients. A significant proportion will require eventual surgery and up to a third of these patients will go on to develop long-term shoulder arthritis. Even patients who have experienced a single episode of dislocation may go on to develop long-term sequelae.

Vascular injuries after minor blunt upper extremity trauma: pitfalls in the recognition and diagnosis of potential "near miss" injuries

Background

Low energy trauma to the upper extremity is rarely associated with a significant vascular injury. Due to the low incidence, a high level of suspicion combined with appropriate diagnostic algorithms are mandatory for early recognition and timely management of these potentially detrimental injuries.

Methods

Review of the pertinent literature, supported by the presentation of two representative "near miss" case examples.

Results

A major diagnostic pitfall is represented by the insidious presentation of significant upper extremity arterial injuries with intact pulses and normal capillary refill distal to the injury site, due to collateral perfusion. Thus, severe vascular injuries may easily be missed or neglected at the upper extremity, leading to a long-term adverse outcome with the potential need for a surgical amputation.

Conclusion

The present review article provides an outline of the diagnostic challenges related to these rare vascular injuries and emphasizes the necessity for a high level of suspicion, even in the absence of a significant penetrating or high-velocity trauma mechanism.

[Rupture of the arteria subscapularis following reduction of an anterior shoulder dislocation]

Anterior shoulder dislocations are one of the most common problems seen in an emergency department. Doubtless, immediate reduction is necessary for treatment, a procedure that is extremely rarely accompanied by complications. In these cases early diagnosis and treatment may be limb saving. We report a case with rupture of the arteria subscapularis following reduction of an anterior shoulder dislocation with formation of an axillary hematoma and consecutive paresis of the plexus brachialis. Interdisciplinary operative revision was necessary to remove the hematoma, stop the hemorrhage and for neurolysis of the plexus brachialis. Treatment resulted in a speedy recovery of the patient. Gentle reduction of a dislocated shoulder is a prerequisite for a low complication rate. Contrast-enhanced computed tomography facilitated diagnosis of the hematoma and identification of the bleeding vessel.