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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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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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3
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Derakhshanfar A, Bazrafshan M. Axillary Artery Pseudoaneurysm due to Bullet Injury: Open Surgery of Lesion. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02717-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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4
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Endoscopic brachial plexus neurolysis in the management of infraclavicular nerve injuries due to glenohumeral dislocation. Injury 2020; 51:2592-2600. [PMID: 32778326 DOI: 10.1016/j.injury.2020.08.005] [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: 04/20/2020] [Revised: 07/30/2020] [Accepted: 08/02/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Infraclavicular brachial plexus (BP) injury secondary to glenohumeral joint (GHJ) dislocation is a rather common complication, which may be accountable for long-lasting deficits. The purpose of this study was to assess the potential benefits of BP neurolysis in such presentation, using an endoscopic approach. MATERIALS AND METHODS All patients who underwent endoscopic BP neurolysis in the setting of infraclavicular BP palsy due to GHJ dislocation were included. Preoperative physical examination was conducted to classify the observed motor and sensitive deficits into nerves and/or cord lesions. Six weeks after the trauma, examination was repeated and endoscopic BP neurolysis was elected if no significant improvements were observed. If nerve ruptures and/or severe damages were identified during surgery, nerve reconstructions were conducted within a month; in other cases, follow-up examinations were conducted at 6 weeks, 3 and 6 months to assess the course of postoperative recovery. RESULTS Eleven patients were included, including 6 men and 5 women, with a mean age of 43 ± 23 years (16;73). Six patients had at least one cord involved, four patients had isolated axillary nerve palsy, and one patient had a complete BP palsy. In 7 patients with cord lesions and/or isolated axillary nerve palsy, at least grade-3 strength, according to the British Medical Research Council grading system, was noted in all affected muscles within 6 weeks following the neurolysis; after 3 months of follow-up, grade-4 strength was observed in all muscles, and all but patients but one had fully recovered within 6 months. In 3 patients with isolated axillary nerve palsy, complete nerve ruptures (n=2) and severe damages (n=1) were identified under scopic magnification; secondary nerve transfers were conducted to reanimate the axillary nerve, and all patients fully recovered within a year. In one patient with complete BP palsy, improvements started after 6 months of follow-up, and full recovery was yielded after 2 years. No intra- and/or postoperative complications were noted. CONCLUSIONS At the cost of minimal additional morbidity, endoscopic BP neurolysis appears to be a safe and reliable procedure to shorten recovery delays in most patients presenting with BP palsy due to GHJ dislocation.
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Gutkowska O, Martynkiewicz J, Urban M, Gosk J. Brachial plexus injury after shoulder dislocation: a literature review. Neurosurg Rev 2020; 43:407-423. [PMID: 29961154 PMCID: PMC7186242 DOI: 10.1007/s10143-018-1001-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 05/17/2018] [Accepted: 06/21/2018] [Indexed: 12/01/2022]
Abstract
Brachial plexus injuries are among the rarest but at the same time the most severe complications of shoulder dislocation. The symptoms range from transient weakening or tingling sensation of the upper limb to total permanent paralysis of the limb associated with chronic pain and disability. Conflicting opinions exist as to whether these injuries should be treated operatively and if so when surgery should be performed. In this review, available literature dedicated to neurological complications of shoulder dislocation has been analysed and management algorithm has been proposed. Neurological complications were found in 5.4-55% of all dislocations, with the two most commonly affected patient groups being elderly women sustaining dislocation as a result of a simple fall and young men after high-energy injuries, often multitrauma victims. Infraclavicular part of the brachial plexus was most often affected. Neurapraxia or axonotmesis predominated, and complete nerve disruption was observed in less than 3% of the patients. Shoulder dislocation caused injury to multiple nerves more often than mononeuropathies. The axillary nerve was most commonly affected, both as a single nerve and in combination with other nerves. Older patient age, higher energy of the initial trauma and longer period from dislocation to its reduction have been postulated as risk factors. Brachial plexus injury resolved spontaneously in the majority of the patients. Operative treatment was required in 13-18% of the patients in different studies. Patients with suspected neurological complications require systematic control. Surgery should be performed within 3-6 months from the injury when no signs of recovery are present.
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Affiliation(s)
- Olga Gutkowska
- Department of Traumatology, Clinical Department of Traumatology and Hand Surgery, Wroclaw Medical University, ul. Borowska 213, 50-556 Wroclaw, Poland
| | - Jacek Martynkiewicz
- Department of Traumatology, Clinical Department of Traumatology and Hand Surgery, Wroclaw Medical University, ul. Borowska 213, 50-556 Wroclaw, Poland
| | - Maciej Urban
- Department of Traumatology, Clinical Department of Traumatology and Hand Surgery, Wroclaw Medical University, ul. Borowska 213, 50-556 Wroclaw, Poland
| | - Jerzy Gosk
- Department of Traumatology, Clinical Department of Traumatology and Hand Surgery, Wroclaw Medical University, ul. Borowska 213, 50-556 Wroclaw, Poland
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Middleton AH, Roffers J, Ziegler DW. Complete brachial plexus palsy following shoulder dislocation due to sneeze: a case report. Int J Emerg Med 2019; 12:28. [PMID: 31519168 PMCID: PMC6743164 DOI: 10.1186/s12245-019-0245-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 08/27/2019] [Indexed: 11/16/2022] Open
Abstract
Background Traumatic shoulder dislocation is a frequent condition presenting to the emergency department. Due to the anatomy of the shoulder, associated neurovascular damage is not uncommon. Although clinical intuition may suggest that a higher-energy mechanism is required to produce neurovascular sequelae, the existing literature does not support this supposition. Case presentation A 55-year-old woman presented to the emergency department with a complete brachial plexus palsy from an acute anterior shoulder dislocation following a violent sneeze. The shoulder was reduced without difficulty in the emergency department within 90 min of dislocation, and the patient was discharged. Her neurologic deficits gradually improved through a program of supervised therapy and orthopedic care. Follow-up at 1 year revealed marked improvement of motor and sensory function of the affected extremity with mild residual weakness and paresthesias in the affected hand. Conclusion Neurovascular injuries in the setting of shoulder dislocation may be present despite low-energy injury mechanisms.
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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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Rasulić L, Savić A, Lepić M, Puzović V, Karaleić S, Kovačević V, Vitošević F, Samardžić M. Epidemiological characteristics of surgically treated civilian traumatic brachial plexus injuries in Serbia. Acta Neurochir (Wien) 2018; 160:1837-1845. [PMID: 30056518 DOI: 10.1007/s00701-018-3640-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 07/20/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND Traumatic brachial plexus injuries are generally severe, and in many cases associated with surrounding tissue injuries, which makes them hard to diagnose at the right time. This paper presents etiological and epidemiological characteristics of surgically treated civilian traumatic brachial plexus injuries. METHODS This retrospective study included 68 patients, operated due to the traumatic brachial plexus injuries at Clinic for Neurosurgery, Clinical Center of Serbia, during the 11-year period. RESULTS The vast majority of injured patients were men in full working maturity. In our study, there were seven different etiological factors. The road traffic accidents were the most common-41 (60.3%), while the motorcycle accidents were the most dominant subtype (53.7%) of all road traffic accidents, and also representing 32.4% of all causes of trauma. Supraclavicular elements of the brachial plexus were injured in more than 80% of patients. A total of 49 (72.1%) patients from our study had one or more associated injuries. The most common associated injuries were bone fractures, brain contusions, and vascular injuries. CONCLUSION Although rare, non-war-related severe brachial plexus injuries represent a group of patients carrying high risk of insufficient functional recovery regardless of treatment modality, or surgical technique. Epidemiological and etiological data are therefore very important to identify the groups in risk and to induce preventive actions aimed at these patients.
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Abstract
Axillary nerve injury is a well-recognized complication of glenohumeral dislocation. It is often a low-grade injury which progresses to full recovery without intervention. There is, however, a small number of patients who have received a higher-grade injury and are less likely to achieve a functional recovery without surgical exploration and reconstruction. Following a review of the literature and consideration of local practice in a regional peripheral nerve injury unit, an algorithm has been developed to help identification of those patients with more severe nerve injuries. Early identification of patients with high-grade injuries allows rapid referral to peripheral nerve injury centres, allowing specialist observation or intervention at an early stage in their injury, thus aiming to maximize potential for recovery.
Cite this article: EFORT Open Rev 2018;3:70-77. DOI:10.1302/2058-5241.3.170003.
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Giannakakis S, Sachmpazidis I, Papapetrou A, Galyfos G, Sachsamanis G, Papacharalampous G, Maltezos C. A Rare Case of Axillary Artery Pseudoaneurysm Due to Shoulder Dislocation Treated With Percutaneous Thrombin Injection. Vasc Endovascular Surg 2018. [DOI: 10.1177/1538574418762653] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The incidence of combined neurovascular injuries among patients with high-energy shoulder trauma ranges from 27% to 44%. However, the presentation of an axillary artery pseudoaneurysm (PSA) due to shoulder dislocation without an associated osseous fracture is a very rare condition. Moreover, treatment of combined neurologic and vascular injuries of the shoulder remains controversial. Additionally, minimally invasive treatments such as thrombin injection have been mainly evaluated in patients with iatrogenic femoral artery PSAs. Therefore, we aim to report a rare case of axillary artery PSA associated with brachial plexus injury after shoulder dislocation treated with percutaneous thrombin injection.
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Affiliation(s)
| | | | | | - George Galyfos
- Department of Vascular Surgery, KAT General Hospital, Athens, Greece
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11
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Liska F, Lacheta L, Imhoff AB, Schmitt A. [Paresis of the brachial plexus after anterior shoulder luxation : Traumatic damage or compression due to hematoma?]. Unfallchirurg 2018; 121:419-422. [PMID: 29500507 DOI: 10.1007/s00113-018-0475-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
After traumatic anterior shoulder dislocation and self-reduction, the patient initially showed an inconspicuous clinical course. At the time of presentation in the emergency room the upper limb neurological status was reported to be normal. After discharge, paresis of the brachial plexus of the left arm occurred within 8 h. A subsequently performed computed tomography (CT) scan revealed a hematoma close to the brachial plexus, which was treated by surgical decompression and resulted in symptom relief. This case report describes a rare but significant complication after anterior shoulder dislocation, which should not be underestimated in the setting of a surgical emergency admission.
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Affiliation(s)
- F Liska
- Klinik für Orthopädie und Sportorthopädie, Klinikum Rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland.
| | - L Lacheta
- Klinik für Orthopädie und Sportorthopädie, Klinikum Rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
| | - A B Imhoff
- Klinik für Orthopädie und Sportorthopädie, Klinikum Rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
| | - A Schmitt
- Klinik für Orthopädie und Sportorthopädie, Klinikum Rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
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12
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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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Bucci G, Lucar-López G, Sanchez-Gonzalez J, Malagelada F, Palencia Lopez J, Guevara-Noriega KA. Axillary artery injury and brachial plexus palsy as a complication of proximal humerus fractures. J Orthop 2017; 14:340-341. [PMID: 28706376 DOI: 10.1016/j.jor.2017.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 06/21/2017] [Indexed: 12/15/2022] Open
Affiliation(s)
- G Bucci
- Hospital de Mataro, Carretera de Cirera, 230, Traumatology Department. 08304 Mataró, Barcelona, Spain
| | - G Lucar-López
- Hospital de Mataro, Carretera de Cirera, 230, Traumatology Department. 08304 Mataró, Barcelona, Spain
| | - J Sanchez-Gonzalez
- Hospital de Mataro, Carretera de Cirera, 230, Traumatology Department. 08304 Mataró, Barcelona, Spain
| | - F Malagelada
- Hospital de Mataro, Carretera de Cirera, 230, Traumatology Department. 08304 Mataró, Barcelona, Spain
| | - J Palencia Lopez
- Hospital de Mataro, Carretera de Cirera, 230, Traumatology Department. 08304 Mataró, Barcelona, Spain
| | - K A Guevara-Noriega
- Hospital de Mataro, Carretera de Cirera, 230, Traumatology Department. 08304 Mataró, Barcelona, Spain
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Monem M, Iskandarani MK, Gokaraju K. Axillary artery pseudoaneurysm resulting in brachial plexus injury in a patient taking new oral anticoagulants. BMJ Case Rep 2016; 2016:bcr-2016-216976. [PMID: 27535738 DOI: 10.1136/bcr-2016-216976] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We discuss the case of an independent 80-year-old Caucasian woman, being treated with new oral anticoagulants for a previous deep vein thrombosis, who had fallen on her right shoulder. She made a delayed presentation to the emergency department with a wrist drop in her right dominant hand. She had right arm bruising with good distal pulses but had a global neurological deficit in the hand. Plain radiographs of the shoulder, humerus, elbow, forearm and wrist demonstrated no fractures. MRI showed a significant right axillary lesion distorting the surrounding soft tissues, including the brachial plexus, and CT with contrast confirmed this to be a large axillary pseudoaneurysm. This was treated with an endovascular stent resulting in slightly improved motor function, but the significant residual deficit required subsequent rehabilitation to improve right upper limb function.
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Affiliation(s)
- Mohammed Monem
- Trauma & Orthopaedic Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, UK
| | | | - Kishan Gokaraju
- Trauma & Orthopaedic Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, UK
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Miyazaki AN, Fregoneze M, Santos PDD, da Silva LA, Sella GDV, Checchia SL, Santos SHCCD, Fernandes FA. Lesão da artéria axilar secundária a fratura do terço proximal de úmero: relato de caso. Rev Bras Ortop 2015. [DOI: 10.1016/j.rbo.2014.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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16
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Miyazaki AN, Fregoneze M, dos Santos PD, da Silva LA, do Val Sella G, Checchia SL, dos Santos SHCC, Fernandes FA. Axillary artery lesion secondary to fracturing of the proximal third of the humerus: case report. REVISTA BRASILEIRA DE ORTOPEDIA (ENGLISH EDITION) 2015; 50:110-3. [PMID: 26229901 PMCID: PMC4519588 DOI: 10.1016/j.rboe.2015.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Accepted: 02/06/2014] [Indexed: 11/29/2022]
Abstract
Lesions of the axillary artery are rare in patients with fracturing of the proximal third of the humerus and may have greatly varying clinical manifestations. They are responsible for 15% and 20% of upper-limb artery injuries and the commonest mechanism is a fall to the ground, which accounts for 79% of such injuries. In some cases, the signs only appear later on. It is important to bear this association in mind, so as to make an early diagnosis and avoid serious complications. We report on a case of traumatic injury of the axillary artery secondary to fracturing of the proximal third of the humerus in an 84-year-old patient, with late evolution of clinical signs of ischemia in the limb affected. The aim here was to discuss the diagnostic difficulties and treatment.
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Fatic N, Radojevic N, Obadovic J, Juskovic A. Axillary Arterial Thrombosis Secondary to Re-Fracture of the Humerus. Open Access Maced J Med Sci 2014. [DOI: 10.3889/oamjms.2014.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
In the presented case report, we evaluated mechanism of axillary artery thrombosis in cases of repeated fracture of the shoulder. A 73-year-old female fell down on an outstretched hand. Radiographs demonstrated a Neer’s 2-part displaced fracture of the proximal humerus and open fracture of the acromion. Forty years ago, in a car accident, fractures of the same proximal humerus and clavicle occurred and were surgically treated. Two hours after fixation with Kirschner wires, thrombosis of the axillary artery was quickly diagnosed and rapid treatment allowed revascularisation of the arm without any consequences.
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Chen L, Peng F, Wang T, Chen D, Yang J. Traumatic pseudoaneurysm of axillary artery combined with brachial plexus injury. PLoS One 2014; 9:e113099. [PMID: 25412426 PMCID: PMC4239043 DOI: 10.1371/journal.pone.0113099] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2014] [Accepted: 10/19/2014] [Indexed: 11/19/2022] Open
Abstract
Traumatic pseudoaneurysm of the axillary artery combined with brachial plexus injury is extremely rare. The factors that influence the symptoms and functional recovery related to this condition are unclear. Nine patients who had sustained this trauma were surgically treated at our unit between June 1999 and November 2010. The cause of trauma, symptoms, signs and examinations of neurological and vascular deficits, and the surgical findings of the involved nerves and vessels were recorded in detail. The functional recovery of vessels and nerves, as well as the extent of pain, were evaluated, respectively. The average length of patient follow-up was 4.5 years (range, 24 months to 11.3 years). After vessel repair, whether by endovascular or operative treatment, the distending, constant, and pulsating pain was relieved in all patients. Furthermore, examination of the radial artery pulse on the repaired side appeared normal at last follow-up. All patients showed satisfactory sensory recovery, with motor recovery rated as good in five patients and fair in four patients. The symptom characteristics varied with the location of the damage to the axillary artery. Ultrasound examination and computed tomography angiography are useful to evaluate vascular injury and provide valuable information for operative planning. Surgical exploration is an effective therapy with results related to the nerve injury condition of the brachial plexus.
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Affiliation(s)
- Lin Chen
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China
- Key Laboratory of Hand Reconstruction, Ministry of Health, Shanghai, China
- Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Feng Peng
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China
- Key Laboratory of Hand Reconstruction, Ministry of Health, Shanghai, China
- Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
- * E-mail:
| | - Tao Wang
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China
- Key Laboratory of Hand Reconstruction, Ministry of Health, Shanghai, China
- Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Desong Chen
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China
- Key Laboratory of Hand Reconstruction, Ministry of Health, Shanghai, China
- Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Jianyun Yang
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China
- Key Laboratory of Hand Reconstruction, Ministry of Health, Shanghai, China
- Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
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Abstract
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.
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Sinha S, Patterson BO, Ma J, Holt PJ, Thompson MM, Carrell T, Tai N, Loosemore TM. Systematic review and meta-analysis of open surgical and endovascular management of thoracic outlet vascular injuries. J Vasc Surg 2013; 57:547-567.e8. [DOI: 10.1016/j.jvs.2012.10.077] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Revised: 09/26/2012] [Accepted: 10/04/2012] [Indexed: 10/27/2022]
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Zhang Q, Wang S, Tang C, Chen W, Zhang Y, Chen L. Axillary artery lesions from humeral neck fracture: A study in relation to repair. Exp Ther Med 2012; 5:328-332. [PMID: 23251293 PMCID: PMC3524089 DOI: 10.3892/etm.2012.775] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Accepted: 10/22/2012] [Indexed: 11/28/2022] Open
Abstract
Whether axillary artery injuries associated with proximal humeral fractures must be repaired is uncertain. The present study reports three cases treated with various approaches. In case 1, the left humeral surgical neck was broken, the radial pulse disappeared and the arm temperature was significantly reduced. Computerized tomography angiography (CTA) revealed a 3-cm filling deficiency in the axillary artery. The injured artery was reconstructed with a segment of the greater saphenous vein after the fracture was reduced and fixed with a plate. In case 2, the axillary artery was compressed by the broken humeral segment, which caused the right hand to become cool. The fracture was fixed but the axillary artery embolism was not treated. In case 3, the humeral neck was broken with injury to the brachial plexus, although the patient’s hand remained warm. Digital subtraction angiography (DSA) revealed that the axillary artery was injured badly but there was extensive collateral circulation. The proximal humeral fracture was reduced and fixed without artery reconstruction. The three cases all resulted in a good outcome with the bone healed and limb alive. No ischemic necrosis occurred. However, the neurapraxia did not dissappear completely. Axillary artery injury resulting from humeral neck fracture is a rare but disabling traumatic event. Early diagnosis based on signs of acute ischemia of the arm enables early treatment and a favourable outcome. An angiogram is the best way to diagnose the artery injury and evaluate the condition of the collateral circulation. The injured artery in a cold arm should be repaired, while in a warm arm reconstruction is unnecessary due to rich collateral circulation.
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22
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Halliday J, Hems T, Simpson H. Beware the painful nerve palsy; neurostenalgia, a diagnosis not to be missed. Strategies Trauma Limb Reconstr 2012; 7:177-9. [PMID: 23054745 PMCID: PMC3482437 DOI: 10.1007/s11751-012-0143-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Accepted: 09/24/2012] [Indexed: 11/28/2022] Open
Abstract
We present a case of painful radial nerve palsy following application of a humeral lengthening frame. At re-operation, the radial nerve was found to be compressed against a distal pin. This was re-sited providing immediate pain relief and a gradual resolution of the radial nerve palsy. Pain in association with a nerve palsy should alert the clinician to the possibility of nerve compression that may benefit from urgent decompression.
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Affiliation(s)
- Jane Halliday
- Department of Trauma and Orthopaedics, Edinburgh Royal Infirmary, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, UK,
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Hems TEJ, Mahmood F. Injuries of the terminal branches of the infraclavicular brachial plexus. ACTA ACUST UNITED AC 2012; 94:799-804. [DOI: 10.1302/0301-620x.94b6.28286] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We reviewed 101 patients with injuries of the terminal branches of the infraclavicular brachial plexus sustained between 1997 and 2009. Four patterns of injury were identified: 1) anterior glenohumeral dislocation (n = 55), in which the axillary and ulnar nerves were most commonly injured, but the axillary nerve was ruptured in only two patients (3.6%); 2) axillary nerve injury, with or without injury to other nerves, in the absence of dislocation of the shoulder (n = 20): these had a similar pattern of nerve involvement to those with a known dislocation, but the axillary nerve was ruptured in 14 patients (70%); 3) displaced proximal humeral fracture (n = 15), in which nerve injury resulted from medial displacement of the humeral shaft: the fracture was surgically reduced in 13 patients; and 4) hyperextension of the arm (n = 11): these were characterised by disruption of the musculocutaneous nerve. There was variable involvement of the median and radial nerves with the ulnar nerve being least affected. Surgical intervention is not needed in most cases of infraclavicular injury associated with dislocation of the shoulder. Early exploration of the nerves should be considered in patients with an axillary nerve palsy without dislocation of the shoulder and for musculocutaneous nerve palsy with median and/or radial nerve palsy. Urgent operation is needed in cases of nerve injury resulting from fracture of the humeral neck to relieve pressure on nerves.
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Affiliation(s)
- T. E. J. Hems
- Scottish National Brachial Plexus Injury
Service, Department of Orthopaedic Surgery, The
Victoria Infirmary, Langside Road, Glasgow
G42 9TY, UK
| | - F. Mahmood
- The Victoria Infirmary, Department
of Orthopaedic Surgery, Glasgow, G42
9TY, UK
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24
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Wenger JDA, Olsson CJ. Acute limb ischemia after a proximal humeral epiphyseal fracture: intraoperative findings of an illustrative vascular lesion. J Shoulder Elbow Surg 2011; 20:e1-3. [PMID: 21232985 DOI: 10.1016/j.jse.2010.10.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2010] [Revised: 10/01/2010] [Accepted: 10/08/2010] [Indexed: 02/01/2023]
Affiliation(s)
- J Daniel A Wenger
- Department of Orthopaedics, Skåne University Hospital, Malmö, Sweden.
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25
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Proximal humerus fracture with a pink, pulseless arm in a teenage boy and literature review. Eur J Trauma Emerg Surg 2010; 36:593-5. [PMID: 26816316 DOI: 10.1007/s00068-010-0036-7] [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: 06/08/2010] [Accepted: 06/22/2010] [Indexed: 10/19/2022]
Abstract
Proximal humeral fractures associated with vascular compromise are extremely rare in children. We describe the presentation, diagnosis and management of one such injury in a child.
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Abstract
Abstract
Forty-eight cases of causalgia are described. The syndrome was caused by missile injury in 33 patients. There was a major arterial injury in 22 patients. Sympathetic block followed by sympathectomy abolished the pain in 11 of the first 14 patients in the series. Causalgia was cured by correcting the lesion of the nerve and of the adjacent axial artery in the subsequent 32 patients. The concept of complex regional pain syndrome Type 1 and Type 2 is challenged.
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Affiliation(s)
- Rolfe Birch
- Peripheral Nerve Injury Unit, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex, England
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27
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Modi CS, Nnene CO, Godsiff SP, Esler CNA. Axillary artery injury secondary to displaced proximal humeral fractures: a report of two cases. J Orthop Surg (Hong Kong) 2008; 16:243-6. [PMID: 18725681 DOI: 10.1177/230949900801600223] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We report 2 cases of axillary artery injury secondary to low-energy proximal humeral fractures. In case 1, early diagnosis based on signs of acute ischaemia of the arm enabled early treatment and a favourable outcome. In case 2, there were no signs of ischaemia or neurological deficit, resulting in delayed diagnosis and increased severity of the injury. The patient developed a false aneurysm and sepsis and eventually died. A high index of suspicion is necessary for diagnosing an axillary artery injury. We recommend that all patients with proximal humeral fractures with severe medial displacement of the shaft and a bone spike should routinely undergo Doppler ultrasound scanning to rule out vascular injuries and the presence of a false aneurysm.
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Affiliation(s)
- C S Modi
- Warwick Orthopaedics, University Hospitals Coventry and Warwickshire NHS Trust, United Kingdom.
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28
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Axillary artery injury combined with delayed brachial plexus palsy due to compressive hematoma in a young patient: a case report. J Brachial Plex Peripher Nerve Inj 2008; 3:9. [PMID: 18373866 PMCID: PMC2329636 DOI: 10.1186/1749-7221-3-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2007] [Accepted: 03/28/2008] [Indexed: 12/03/2022] Open
Abstract
Introduction Axillary artery injury in the shoulder region following blunt trauma without association with either shoulder dislocation or fracture of the humeral neck has been previously reported. Axillary artery injury might also be accompanied with brachial plexus injury. However, delayed onset of brachial plexus palsy caused by a compressive hematoma associated with axillary injury after blunt trauma in the shoulder region has been rarely reported. In previous reports, this condition only occurred in old patients with sclerotic vessels. We present a case of a young patient who suffered axillary artery injury associated with brachial plexus palsy that occurred tardily due to compressive hematoma after blunt trauma in the shoulder region without association of either shoulder dislocation or humeral neck fracture. Case presentation A 16-year-old male injured his right shoulder in a motorbike accident. On initial physical evaluation, the pulses on the radial and ulnar arteries in the affected arm were palpable. Paralysis developed later from 2 days after the injury. Functions in the right arm became significantly impaired. Angiography showed complete occlusion of the axillary artery. Magnetic resonance imaging demonstrated a mass measuring 4 × 5 cm that was suspected to be a hematoma compressing the brachial plexus in a space between the subscapular muscle and the pectoralis minor muscle. Surgery was performed on the third day after injury. In intraoperative observations, the axillary artery was occluded with thrombus along 5 cm; a subscapular artery was ruptured; the brachial plexus was compressed by the hematoma. After evacuation of the hematoma, neurolysis of the brachial plexus, and revascularization of the axillary artery, the patient had an excellent functional recovery of the affected upper limb, postoperatively. Conclusion Surgeons should be aware that axillary artery injuries may even occur in young people after severe blunt trauma in the shoulder region and can be associated with secondary brachial plexus injury due to a hematoma. For treatment in cases with progressive nervous deficit after trauma, not only reconstruction of the injured artery but also immediate evacuation of the hematoma, and exploration of the brachial plexus are necessary to avoid irreversible neurological damage.
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Gruson KI, Ruchelsman DE, Tejwani NC. Isolated tuberosity fractures of the proximal humeral: current concepts. Injury 2008; 39:284-98. [PMID: 18243203 DOI: 10.1016/j.injury.2007.09.022] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2007] [Revised: 07/12/2007] [Accepted: 09/24/2007] [Indexed: 02/02/2023]
Abstract
Despite the relatively common occurrence of fractures of the proximal humeral amongst the elderly, the subgroup of isolated greater and lesser tuberosity fractures have remained less well understood. While the majority of two-part fractures result from a standing-height fall onto an outstretched hand, isolated tuberosity fractures are also commonly associated with glenohumeral dislocations or direct impact to the shoulder region. Inasmuch as isolated greater tuberosity fractures are considered uncommon, isolated lesser tuberosity fractures are generally considered exceedingly rare. Non-operative treatment including a specific rehabilitation protocol has been advocated for the majority of non-displaced and minimally displaced fractures, with generally good outcomes expected. The treatment for displaced fractures, however, has included both arthroscopically assisted fixation and open or percutaneous reduction and internal fixation (ORIF). The choice of fixation and approach depends not only on fracture type and characteristics, but also on a multitude of patient-related factors. With an expected increase in the level of physical activity across all age groups and overall longer lifespans, the incidence of isolated tuberosity fractures of the proximal humeral is expected to rise. Orthopaedic surgeons treating shoulder trauma should be aware of treatment options, as well as expected outcomes.
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Affiliation(s)
- Konrad I Gruson
- NYU Hospital for Joint Diseases, Department of Orthopaedic Surgery, New York, NY 10021, United States.
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30
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Camp SJ, Milani R, Sinisi M. Intractable neurostenalgia of the ulnar nerve abolished by neurolysis 18 years after injury. J Hand Surg Eur Vol 2008; 33:45-6. [PMID: 18332019 DOI: 10.1177/1753193407087889] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
A 39 year-old farmer sustained a closed rupture of the left brachial artery, which was successfully managed by emergency vein graft repair of the artery. Adjacent nerve trunks were seen to be intact, but stretched. Burning pain in the distribution of the ulnar nerve started at day seven postoperatively, and worsened over the ensuing years. There was no response to membrane stabilising drugs, amitryptiline, nor to regional sympatholytic or local anaesthetic blocks. Neurolysis of the ulnar nerve, which was densely adherent to the dilated vein graft, abolished his pain.
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Affiliation(s)
- S J Camp
- Peripheral Nerve Injury Unit, Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK.
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32
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McCann PA, Barakat MJ, Wand JS. Delayed brachial plexus compression secondary to anterior shoulder dislocation—The late consequence of an axillary artery pseudoaneurysm: A case report. ACTA ACUST UNITED AC 2006. [DOI: 10.1016/j.injury.2006.06.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Wera GD, Friess DM, Getty PO, Armstrong DG, Lacey SH, Baele HR. Fracture of the proximal humerus with injury to the axillary artery in a boy aged 13 years. ACTA ACUST UNITED AC 2006; 88:1521-3. [PMID: 17075102 DOI: 10.1302/0301-620x.88b11.18164] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Fractures of the proximal humerus with concomitant vascular injury are rare in children. We describe the presentation, diagnosis, and treatment of a fracture of the proximal humerus in association with an axillary artery injury in a child.
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Affiliation(s)
- G D Wera
- Department of Orthopaedic Surgery, University Hospitals of Cleveland, USA.
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Kato N, Birch R. Peripheral nerve palsies associated with closed fractures and dislocations. Injury 2006; 37:507-12. [PMID: 16643920 DOI: 10.1016/j.injury.2006.02.044] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2005] [Revised: 02/22/2006] [Accepted: 02/22/2006] [Indexed: 02/02/2023]
Abstract
We have studied 178 consecutive cases of 203 patients admitted to this unit between 1999 and 2003 with diagnosis of peripheral nerve palsies associated with closed fractures and dislocations in the upper and lower limbs. Fifty-one nerves were explored, 25 of which were found partly or completely transected. Indications for surgery were high-energy transfer injury, severe neuropathic pain, failure to progress and a static Tinel's sign. Spontaneous recovery was good in only 25 of the 51 non-operated cases of high-energy transfer injury to the circumflex, radial and common peroneal nerves. Good spontaneous recovery is closely related to low-energy transfer injury, and is associated with an advancing Tinel's sign. Absence of the Tinel's sign indicates conduction block; neurophysiological investigation confirms it. We stress the particular value of the Tinel's sign, and note that severe neuropathic pain indicates continuing damage to the nerve and gives a strong reason for operation.
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Affiliation(s)
- Naoki Kato
- Peripheral Nerve Injury Unit, Royal National Orthopaedic Hospital, Stanmore, Middlesex HA7 4LP, UK.
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