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Su F, Tangtiphaiboontana J, Kandemir U. Management of greater tuberosity fracture dislocations of the shoulder. JSES REVIEWS, REPORTS, AND TECHNIQUES 2024; 4:578-587. [PMID: 39157260 PMCID: PMC11329025 DOI: 10.1016/j.xrrt.2023.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/20/2024]
Abstract
Background Despite extensive literature dedicated to determining the optimal treatment of isolated greater tuberosity (GT) fractures, there have been few studies to guide the management of GT fracture dislocations. The purpose of this review was to highlight the relevant literature pertaining to all aspects of GT fracture dislocation evaluation and treatment. Methods A narrative review of the literature was performed. Results During glenohumeral reduction, an iatrogenic humeral neck fracture may occur due to the presence of an occult neck fracture or forceful reduction attempts with inadequate muscle relaxation. Minimally displaced GT fragments after shoulder reduction can be successfully treated nonoperatively, but close follow-up is needed to monitor for secondary displacement of the fracture. Surgery is indicated for fractures with >5 mm displacement to minimize the risk of subacromial impingement and altered rotator cuff biomechanics. Multiple surgical techniques have been described and include both open and arthroscopic approaches. Strategies for repair include the use of transosseous sutures, suture anchors, tension bands, screws, and plates. Good-to-excellent radiographic and clinical outcomes can be achieved with appropriate treatment. Conclusions GT fracture dislocations of the proximal humerus represent a separate entity from their isolated fracture counterparts in their evaluation and treatment. The decision to employ a certain strategy should depend on fracture morphology and comminution, bone quality, and displacement.
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Affiliation(s)
- Favian Su
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, USA
| | | | - Utku Kandemir
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, USA
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2
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Kriechling P, Whitefield R, Makaram NS, Brown IDM, Mackenzie SP, Robinson CM. Proximal humeral fractures with vascular compromise. Bone Joint J 2024; 106-B:842-848. [PMID: 39084641 DOI: 10.1302/0301-620x.106b8.bjj-2023-1114.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
Aims Vascular compromise due to arterial injury is a rare but serious complication of a proximal humeral fracture. The aims of this study were to report its incidence in a large urban population, and to identify clinical and radiological factors which are associated with this complication. We also evaluated the results of the use of our protocol for the management of these injuries. Methods A total of 3,497 adult patients with a proximal humeral fracture were managed between January 2015 and December 2022 in a single tertiary trauma centre. Their mean age was 66.7 years (18 to 103) and 2,510 (72%) were female. We compared the demographic data, clinical features, and configuration of those whose fracture was complicated by vascular compromise with those of the remaining patients. The incidence of vascular compromise was calculated from national population data, and predictive factors for its occurrence were investigated using univariate analysis. Results A total of 18 patients (0.5%) had a proximal humeral fracture and clinical evidence of vascular compromise, giving an annual incidence of 0.29 per 100,000 of the population. Their mean age was 68.7 years (45 to 92) and ten (56%) were female. Evidence of a mixed pattern neurological deficit (brachial plexus palsy) (odds ratio (OR) 380.6 (95% CI 85.9 to 1,685.8); p < 0.001), complete separation of the proximal shaft from the humeral head with medial displacement (OR 39.5 (95% CI 14.0 to 111.8); p < 0.001), and a fracture-dislocation (OR 5.0 (95% CI 1.6 to 15.3); p = 0.015) were all associated with an increased risk of associated vascular compromise. A policy of reduction and fixation of the fracture prior to vascular surgical intervention had favourable outcomes without vascular sequelae. Conclusion The classic signs of distal ischaemia are often absent in patients with proximal injuries to major vessels. We were able to identify specific clinical and radiological 'red flags' which, particularly when present in combination, should increase the suspicion of a fracture with an associated vascular injury, and facilitate early diagnosis and appropriate combined orthopaedic and vascular intervention.
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Affiliation(s)
- Philipp Kriechling
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
- University of Zurich, Balgrist University Hospital, Zurich, Switzerland
| | - Reiss Whitefield
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Navnit S Makaram
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
- University of Edinburgh, Edinburgh, UK
| | - Iain D M Brown
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - C M Robinson
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
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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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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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5
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Balakrishnan S. CT angiography of non-aortic thoracic arterial trauma. Emerg Radiol 2023; 30:667-681. [PMID: 37704920 DOI: 10.1007/s10140-023-02170-5] [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] [Received: 05/19/2023] [Accepted: 08/28/2023] [Indexed: 09/15/2023]
Abstract
While aortic injury is the most commonly cited thoracic arterial injury, non-aortic arterial injuries represent an uncommon but significant source of morbidity and mortality in blunt and penetrating thoracic trauma patients. Knowledge of the spectrum of vascular injury and anatomic considerations that dictate patterns of associated thoracic hemorrhage will assist the radiologist in the accurate and efficient diagnosis of these injuries. This article provides a review of anatomy, pertinent clinical exam and CT angiography findings, as well as therapeutic options for non-aortic thoracic arterial trauma.
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Affiliation(s)
- Sudheer Balakrishnan
- Department of Radiology, Division of Emergency and Trauma Imaging, Emory University School of Medicine, Atlanta, GA, USA.
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6
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Pandey R, Raval P, Manibanakar N, Nanjayan S, McDonald C, Singh H. Proximal humerus fracture s: A review of current practice. J Clin Orthop Trauma 2023; 43:102233. [PMID: 37636006 PMCID: PMC10457443 DOI: 10.1016/j.jcot.2023.102233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 07/11/2023] [Accepted: 08/03/2023] [Indexed: 08/29/2023] Open
Abstract
The management of proximal humeral fractures (PHF) remains controversial. Its incidence is increasing. Patients should be meticulously assessed clinically for co-morbidities and neuro-vascular injuries. Radiological investigation helps provide information on the fracture configuration and dislocations. Enhanced by 3-dimensional CT scanning, these further help in decision making and operative planning. PHF classifications have been demonstrated to have poor intra-observer and inter-observer reliability. Research has identified some radiographic predictive factors for humeral head ischaemia and likely failure of surgical fixation. The range of management options include non-operative treatment, operative fixation, intramedullary nailing and arthroplasty (hemiarthroplasty, reverse shoulder replacement). The majority of PHFs are stable injuries and non-operative management is usually successful. Some degree of malunion is readily tolerated especially by elderly patients. Surgical management of significantly displaced, unstable proximal humerus fractures should aim to stabilise the fracture adequately and provide satisfactory function for the long term. Management of the greater tuberosity is pivotal for the eventual outcome. When fixation may appear to be compromised by poor bone quality, likely poor function, age related rotator cuff degeneration or likely humeral head ischaemia clinicians may opt for arthroplasty. Successful hemiarthroplasty outcomes are dependent on sufficient healing of the tuberosity and recovery of the rotator cuff integrity. Reverse shoulder replacement can predictably deliver good functional outcomes for the shoulder in elderly patients, where rotator cuff dysfunction is suspected or as a revision procedure following failure of other surgical interventions. As opposed to hemiarthroplasty, which has shown a downward trend, there has been an increasing trend towards the use of reverse shoulder replacement in proximal humeral fractures. The management of PHFs should be patient specific, fracture specific and meet the functional demands and needs of the individual patient. The surgeon's skill set and clinical experience also plays an important role in the options of management available.
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Affiliation(s)
- R. Pandey
- Trauma and Orthopaedic Surgeon, University Hospitals of Leicester, Leicester, United Kingdom
| | - P. Raval
- Trauma and Orthopaedic, University Hospitals of Leicester, Leicester, United Kingdom
| | - N. Manibanakar
- Trauma and Orthopaedic, University Hospitals of Leicester, Leicester, United Kingdom
| | - S. Nanjayan
- Trauma and Orthopaedic Surgeon, University Hospitals of Leicester, Leicester, United Kingdom
| | - C. McDonald
- Trauma and Orthopaedic, University Hospitals of Leicester, Leicester, United Kingdom
| | - Harvinder Singh
- Trauma and Orthopaedic Surgeon, University Hospitals of Leicester, Leicester, United Kingdom
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7
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Labrum JT, Kuttner NP, Atwan Y, Sanchez-Sotelo J, Barlow JD. Fracture Dislocations of the Glenohumeral Joint. Curr Rev Musculoskelet Med 2023:10.1007/s12178-023-09846-y. [PMID: 37329400 PMCID: PMC10382466 DOI: 10.1007/s12178-023-09846-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/11/2023] [Indexed: 06/19/2023]
Abstract
PURPOSE OF REVIEW Proximal humerus fracture dislocations typically result from high-energy mechanisms and carry specific risks, technical challenges, and management considerations. It is vital for treating surgeons to understand the various indications, procedures, and complications involved with their treatment. RECENT FINDINGS While these injuries are relatively rare in comparison with other categories of proximal humerus fractures, fracture dislocations of the proximal humerus require treating surgeons to consider patient age, activity level, injury pattern, and occasionally intra-operative findings to select the ideal treatment strategy for each injury. Proximal humerus fracture dislocations are complex injuries that require special considerations. This review summarizes recent literature regarding the evaluation and management of these injuries as well as the indications and surgical techniques for each treatment strategy. Thorough pre-operative patient evaluation and shared decision-making should be employed in all cases. While nonoperative management is uncommonly considered, open reduction and internal fixation (ORIF), hemiarthroplasty, and reverse total shoulder replacement are at the surgeon's disposal, each with their own indications and complication profile.
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Affiliation(s)
- Joseph T Labrum
- Department of Orthopaedic Surgery, Mayo Clinic, 200 1St St SW, Rochester, MN, 55902, USA
| | - Nicolas P Kuttner
- Department of Orthopaedic Surgery, Mayo Clinic, 200 1St St SW, Rochester, MN, 55902, USA
| | - Yousif Atwan
- Department of Orthopaedic Surgery, Mayo Clinic, 200 1St St SW, Rochester, MN, 55902, USA
| | - Joaquin Sanchez-Sotelo
- Department of Orthopaedic Surgery, Mayo Clinic, 200 1St St SW, Rochester, MN, 55902, USA
| | - Jonathan D Barlow
- Department of Orthopaedic Surgery, Mayo Clinic, 200 1St St SW, Rochester, MN, 55902, USA.
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8
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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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9
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Management of proximal humeral fractures: a review. CURRENT ORTHOPAEDIC PRACTICE 2021. [DOI: 10.1097/bco.0000000000001002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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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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11
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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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12
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O'Neill DR, King JJ, Farmer KW. Reverse total shoulder arthroplasty after iatrogenic axillary artery injury: a case report. J Shoulder Elbow Surg 2021; 30:e121-e128. [PMID: 33220415 DOI: 10.1016/j.jse.2020.10.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/06/2020] [Accepted: 10/15/2020] [Indexed: 02/01/2023]
Affiliation(s)
| | - Joseph J King
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA
| | - Kevin W Farmer
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA.
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13
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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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14
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Magister S, Bridgforth A, Yarboro S. Axillary Artery Injury Following Closed Reduction of an Age-Indeterminate Anterior Glenohumeral Dislocation. J Orthop Case Rep 2019; 8:53-56. [PMID: 30687664 PMCID: PMC6343555 DOI: 10.13107/jocr.2250-0685.1158] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction: Axillary artery injury is a rare and potentially devastating sequelae of glenohumeral dislocation. While neurovascular exam is critical in all presentations, the presence of “soft” and/or “hard” signs should prompt a more thorough examination and possible employment of advanced imaging techniques. Case Report: We present a case of a 51-year-old male with an axillary artery injury associated with an anterior glenohumeral dislocation. The patient was initially evaluated at an outside hospital where the vascular injury was not immediately identified, and then was subsequently transferred to our institution where he underwent bypass grafting without significant sequela. Additional prophylactic fasciotomies were also performed due to concern for reperfusion compartment syndrome. Conclusion: Although rare, clinicians should actively rule out vascular injuries when evaluating shoulder dislocations, especially in the elderly patient with a known history of atherosclerotic disease, those with evidence of chronic joint instability, and in the setting of high energy injury mechanisms. Hard signs of vascular injury including diminished distal pulses are the hallmark of this complication, and should always prompt vascular surgery consultation.
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Affiliation(s)
- Steven Magister
- Department of Orthopaedics, University of Virginia, Charlottesville, Virginia, USA
| | - Andrew Bridgforth
- Department of Orthopaedics, University of Virginia, Charlottesville, Virginia, USA
| | - Seth Yarboro
- Department of Orthopaedics, University of Virginia, Charlottesville, Virginia, USA
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15
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Kakazu R, Wyrick JD. Management of Complex Proximal Humerus Fractures: What Is the Role of Open Reduction and Internal Fixation? CURRENT GERIATRICS REPORTS 2018. [DOI: 10.1007/s13670-018-0261-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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16
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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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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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Schumaier A, Grawe B. Proximal Humerus Fractures: Evaluation and Management in the Elderly Patient. Geriatr Orthop Surg Rehabil 2018; 9:2151458517750516. [PMID: 29399372 PMCID: PMC5788098 DOI: 10.1177/2151458517750516] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 09/29/2017] [Accepted: 11/23/2017] [Indexed: 12/20/2022] Open
Abstract
Introduction: Proximal humerus fractures are common in the elderly. The evaluation and management of these injuries is often controversial. The purpose of this study is to review recent evidence and provide updated recommendations for treating proximal humerus fractures in the elderly. Methods: A literature review of peer-reviewed publications related to the evaluation and management of proximal humerus fractures in the elderly was performed. There was a focus on randomized controlled trials and systematic reviews published within the last 5 years. Results: The incidence of proximal humerus fractures is increasing. It is a common osteoporotic fracture. Bone density is a predictor of reduction quality and can be readily assessed with anteroposterior views of the shoulder. Social independence is a predictor of outcome, whereas age is not. Many fractures are minimally displaced and respond acceptably to nonoperative management. Displaced and severe fractures are most frequently treated operatively with intramedullary nails, locking plates, percutaneous techniques, or arthroplasty. Discussion: Evidence from randomized controlled trials and systematic reviews is insufficient to recommend a treatment; however, most techniques have acceptable or good outcomes. Evaluation should include an assessment of the patient’s bone quality, social independence, and surgical risk factors. With internal fixation, special attention should be paid to medial comminution, varus angulation, and restoration of the calcar. With arthroplasty, attention should be paid to anatomic restoration of the tuberosities and proper placement of the prosthesis. Conclusion: A majority of minimally displaced fractures can be treated conservatively with early physical therapy. Treatment for displaced fractures should consider the patient’s level of independence, bone quality, and surgical risk factors. Fixation with percutaneous techniques, intramedullary nails, locking plates, and arthroplasty are all acceptable treatment options. There is no clear evidence-based treatment of choice, and the surgeon should consider their comfort level with various procedures during the decision-making process.
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Affiliation(s)
- Adam Schumaier
- Department of Orthopaedics and Sports Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Brian Grawe
- Department of Orthopaedics and Sports Medicine, University of Cincinnati, Cincinnati, OH, USA
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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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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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Delayed Axillary Artery Occlusion after Reverse Total Shoulder Arthroplasty. Case Rep Orthop 2016; 2016:5463514. [PMID: 27555975 PMCID: PMC4983348 DOI: 10.1155/2016/5463514] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Accepted: 07/03/2016] [Indexed: 12/02/2022] Open
Abstract
Axillary artery injury has been associated with shoulder dislocation and surgery. We describe a case of delayed axillary artery occlusion after reverse total shoulder arthroplasty. The injury was confirmed by Doppler and angiography and was treated with angioplasty and stenting. Early recognition and treatment of this injury are mandatory for patients' recovery.
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Menendez ME, Ring D, Heng M. Proximal humerus fracture with injury to the axillary artery: a population-based study. Injury 2015; 46:1367-71. [PMID: 25986664 DOI: 10.1016/j.injury.2015.04.026] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 04/18/2015] [Accepted: 04/20/2015] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Mariano E Menendez
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - David Ring
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Marilyn Heng
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Chen YX, Zhu Y, Wu FH, Zheng X, Wangyang YF, Yuan H, Xie XX, Li DY, Wang CJ, Shi HF. Anatomical study of simple landmarks for guiding the quick access to humeral circumflex arteries. BMC Surg 2014; 14:39. [PMID: 24970300 PMCID: PMC4099027 DOI: 10.1186/1471-2482-14-39] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2013] [Accepted: 06/17/2014] [Indexed: 11/21/2022] Open
Abstract
Background The posterior and anterior circumflex humeral artery (PCHA and ACHA) are crucial for the blood supply of humeral head. We aimed to identify simple landmarks for guiding the quick access to PCHA and ACHA, which might help to protect the arteries during the surgical management of proximal humeral fractures. Methods Twenty fresh cadavers were dissected to measure the distances from the origins of PCHA and ACHA to the landmarks (the acromion, the coracoid, the infraglenoid tubercle, the midclavicular line) using Vernier calipers. Results The mean distances from the origin of PCHA to the infraglenoid tubercle, the coracoid, the acromion and the midclavicular line were 27.7 mm, 50.2 mm, 68.4 mm and 75.8 mm. The mean distances from the origin of ACHA to the above landmarks were 26.9 mm, 49.2 mm, 67.0 mm and 74.9 mm. Conclusion Our study provided a practical method for the intraoperative identification as well as quick access of PCHA and ACHA based on a series of anatomical measurements.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Hong-fei Shi
- Department of Orthopaedics, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No, 321 Zhongshan Road, Nanjing China.
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