Rupture of axillary artery and neuropraxis as complications of recurrent traumatic shoulder dislocation: case report

Axillary Artery Transection and Brachial Plexus Injury After Open Inferior Glenohumeral Dislocation: A Case Report

CASE

A judo athlete presented with an open inferior shoulder dislocation that occurred during competition. Examination revealed a transection of the axillary artery and neuropraxia of the posterior cord. Neuropraxia was resolved within 2 weeks. The axillary artery was repaired with a femoral vein graft. He regained full strength, range of motion, and function at 8 months.

CONCLUSION

Inferior glenohumeral dislocations are rare, and their management can be complicated by vascular and neurological injuries. We emphasize the importance of examination, diagnosis, and treatment of neurovascular pathologies to avoid catastrophic outcomes.

Brachial plexus injury after shoulder dislocation: a literature review

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.

Subclavian-axillary arterial thrombosis and distal embolisation after traumatic anterior glenohumeral dislocation

Arterial vascular injury associated with anterior dislocation of the shoulder is a rare but potentially devastating complication, often seen in the context of high-energy trauma or penetrating injury. It is a medical emergency that can compromise both the viability and functionality of the limb, as well as the patient's life if it is not identified early and treated properly. However, its diagnosis can be difficult, since it requires a high index of suspicion. The presence of an axillary artery thrombosis after shoulder dislocation resulting from low-energy trauma is extremely rare, even more so with subacute clinical presentation associated with embolism to the radial artery.

Axillary artery laceration after anterior shoulder dislocation reduction

Introduction

Glenohumeral dislocation is the most commonly encountered dislocation in the emergency department. The most frequent complications of glenohumeral dislocation are rotator cuff tears and an increase in the risk of recurrent dislocation. Less common acute complications include fractures, neurological complications and vascular injuries. The incidence of axillary artery injury associated with shoulder dislocation is reported to be about 1–2%.

Case

An 81-year-old male presented to the emergency department with pain in the right shoulder after a fall. On physical examination, the shoulder was in slight abduction and external rotation. Shoulder movements were painful and there was a swelling in the axillary region which was tender to palpation. There was no sensory or motor deficit and the peripheral pulses were equal and palpable. Following the administration of analgesics, shoulder reduction was performed using the flexion-adduction-external rotation method. After reduction, the patient started complaining of axillary pain. On control examination, the patient did not have any motor or sensory deficits, but peripheral pulses were not palpable on the right arm. The right upper extremity computed tomography angiography, which was performed with the suspicion of vascular injury, revealed a right axillary artery rupture.

Conclusion

Axillary artery injury accompanying anterior shoulder dislocation is a rare but serious condition which may result in limb loss and death.

Axillary Artery Injury Following Closed Reduction of an Age-Indeterminate Anterior Glenohumeral Dislocation

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.

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

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

Double traction method-an easy and safe reduction method for anterior shoulder dislocations, even for non-orthopedic surgeons

Cases

Forty-three male and 27 female patients with anterior shoulder dislocation, with an average age of 45 years, were treated with the "double traction method". The reduction is carried out by two operators, with the patient in a supine position. The first operator holds the patient's wrist and pulls gently longitudinally. After the patient's muscle spasm adequately subsides, the second operator tows the humerus head laterally by using a towel wrapped around the proximal arm.

Outcome

Reduction was successful in 63 patients (90%). No iatrogenic fracture or neurovascular deficit occurred.

Conclusion

Movement of the patient's arm position causes pain-related muscle spasm. The double traction method is distinctive compared to other manual relocation maneuvers in that the patient's arm is kept at the same position throughout the whole procedure. This maneuver is an easy and safe reduction method for anterior shoulder dislocations, even for non-orthopedic surgeons. It should be an option worth considering for closed reduction in shoulder dislocations.

Double level arterial injury with neuropraxia following anterior shoulder dislocation

Vascular and nervous complications are rare after shoulder dislocation. We report the case of a double level arterial injury with neuropraxia following anterior shoulder dislocation that was diagnosed by MultiDetector-row Computed Tomographic (MDCT) angiography and treated by surgical bypass graft and embolectomy. Our case is original, not only because of the rarity of these complications, but also because of the thromboembolism of brachial artery which could be undiagnosed and could compromise prognosis.

Percutaneous Transluminal Angioplasty for Axillary Artery Dissection After Open Reduction of Shoulder Fracture-Dislocation: A Case Report

CASE

Injury of the axillary artery after shoulder-joint fracture or dislocation is uncommon. We describe the clinical outcome of an elderly patient with a dissecting aneurysm of the axillary artery following open reduction of a fracture-dislocation of the shoulder. The arterial dissection was successfully managed with percutaneous transluminal balloon angioplasty.

CONCLUSION

This case report highlights the need for careful vascular examination of all elderly patients with a fracture or dislocation of the shoulder and the possible use of percutaneous transluminal angioplasty for the management of arterial dissection prior to proceeding with surgical exploration.

Proximal humerus fractures with associated axillary artery injury

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

Neurovascular complications due to the Hippocrates method for reducing anterior shoulder dislocations

In spite of the fact that the Hippocrates method hardly has been evaluated in a scientific manner and numerous associated iatrogenic complications have been reported, this method remains to be one of the most common techniques for reducing anterior shoulder dislocations. We report the case of a 69-year-old farmer under coumarin anticoagulant therapy who sustained acute first time anterior dislocation of his dominant right shoulder. By using the Hippocrates method with the patient under general anaesthesia, the brachial vein was injured and an increasing hematoma subsequently caused brachial plexus paresis by pressure. After surgery for decompression and vascular suturing, symptoms declined rapidly, but brachial plexus paresis still was not fully reversible after 3 mo of follow-up. The hazardousness of using the Hippocrates method can be explained by traction on the outstretched arm with force of the operator’s body weight, direct trauma to the axillary region by the physician’s heel, and the topographic relations of neurovascular structures and the dislocated humeral head. As there is a variety of alternative reduction techniques which have been evaluated scientifically and proofed to be safe, we strongly caution against the use of the Hippocrates method as a first line technique for reducing anterior shoulder dislocations, especially in elder patients with fragile vessels or under anticoagulant therapy, and recommend the scapular manipulation technique or the Milch technique, for example, as a first choice.

Axillary artery transection after shoulder dislocation

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

Endovascular management of an axillary arterial injury post shoulder dislocation

Axillary arterial injury is a rare complication of non-recurrent glenohumeral joint dislocation. Previously this type of injury would have required open exploration of the axillary artery with associated risk of iatrogenic injury to the axillary vein or brachial plexus. We present the case of a 75-year-old lady, who following a fall in her own home, sustained a dislocation of her right shoulder joint complicated by avulsion of a branch of her axillary artery. We describe the successful endovascular management of the injury using a self-expanding stent and propose this as the preferred surgical option where the artery is not completely transected.

[Rupture of axillary artery and brachial plexus paralysis as complications of recurrent anterior glenohumeral dislocation: a case report]

The authors report a case of transection of the axillary artery and brachial plexus paralysis following recurrent anterior glenohumeral dislocation. Subsequent vascular reconstruction was performed using a venous interposition graft. The brachial plexus was explored at the same time and found to be in continuity. Neurological recovery was complete within a few months.

Endovascular Treatment of an Axillary Pseudoaneurysm Following a Traumatic Shoulder Dislocation

A pseudoaneurysm following a shoulder dislocation is considered rare. We report here a case of an 82-yearold man who suffered from vascular and neurological injury due to an axillary pseudoaneurysm following anterior dislocation of the left shoulder. An emerging swelling in the shoulder region was caused by a hematoma and a slowly bleeding pseudoaneurysm in combination with reactive swelling of the soft tissues. Neurological damage occurred due to local compression. A minimally invasive technique was used to treat the pseudoaneurysm. Embolization was initially attempted, but this treatment failed. A stent was subsequently inserted to eliminate the axillary pseudoaneurysm from the circulation. Early imaging and an aggressive endovascular treatment should be considered in all patients suffering from an axillary artery (pseudo)aneurysm.

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

Background

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

Methods

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

Results

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

Conclusion

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

A singular case of iatrogenic axillofemoral bypass disruption: a dramatic event treated by a lucky combined approach

Proximal disruption of an axillofemoral bypass is a catastrophic event rarely caused by a posttraumatic anterior dislocation of the shoulder. Herein, we present a 74-year-old man with a painful dislocation of the right shoulder that was successfully reduced. Three hours later he had hemodynamic shock with an expanding and pulsating hematoma at the level of the right shoulder, pectoral and infraclavicular region. Surgical exposure of the right brachial artery was carried out, and intraoperative angiography revealed a proximal anastomotic leakage. The distal ballooning improved the hemodynamic status, and by a redo infraclavicular incision the hematoma was drained. The arterial leak was repaired by an 8 mm polytetrafluoroethylene interposed graft between the axillary artery and existing graft. The utility of a combined approach (endovascular + open surgical) is discussed.