Embolisation of a traumatic aneurysm of the posterior circumflex humeral artery in a volleyball player

Upper-limb neurovascular compression, pectoralis minor and quadrilateral space syndromes: A narrative review of current literature

Pectoralis minor syndrome (PMS) and quadrilateral space syndrome (QSS) are uncommon neurovascular compression disorders affecting the upper extremity. PMS involves compression under the pectoralis minor muscle, and QSS results from compression in the quadrilateral space-both are classically observed in overhead-motion athletes. Diagnosing PMS and QSS may be challenging due to variable presentations and similarities with other, more common, upper-limb pathologies. Although there is no gold standard diagnostic, local analgesic muscle-block response in a patient with the appropriate clinical context is often all that is required for an accurate diagnosis after excluding more common etiologies. Treatment ranges from conservative physical therapy to decompressive surgery, which is reserved for refractory cases or severe, acute vascular presentations. Decompression generally yields favorable outcomes, with most patients experiencing significant relief and restored baseline function. In conclusion, PMS and QSS, although rare, can cause debilitating upper-extremity symptoms; accurate diagnosis and appropriate treatment offer excellent outcomes, alleviating pain and disability.

Axillary and musculocutaneous neuropathies

This chapter covers axillary and musculocutaneous neuropathies, with a focus on clinically relevant anatomy, electrodiagnostic approaches, etiologic considerations, and management principles. Disorders of the lateral antebrachial cutaneous nerve, a derivative of the musculocutaneous nerve, are also reviewed. We emphasize the importance of objective findings, including the physical examination and electrodiagnostic evaluation in confirming the isolated involvement of each nerve which, along with the clinical history, informs etiologic considerations. Axillary and musculocutaneous neuropathies are both rare in isolation and most frequently occur in the setting of trauma. Less commonly encountered etiologies include external compression or entrapment, neoplastic involvement, or immune-mediated disorders including neuralgic amyotrophy, postsurgical inflammatory neuropathy, multifocal motor neuropathy, vasculitic neuropathy, and multifocal chronic inflammatory demyelinating polyradiculoneuropathy.

Posterior circumflex humeral artery pathological lesions with digital ischemia in an elite volleyball player: A case report and literature review

The posterior circumflex humeral artery, a branch of the axillary artery, is compressed by the humeral head during repeated abduction and external rotation of the shoulder joint owing to its anatomical structure. This damages the vascular endothelium, resulting in thrombi, arterial dissection, and aneurysms, a condition known as posterior, circumflex humeral artery pathological lesions. A thrombus may form at the site and becomes a peripheral embolus, resulting in peripheral arterial occlusion.A 21-year-old right-handed elite man college volleyball player noticed coldness and pain in his right hand during a game. Cyanosis was present except in the middle finger, and the beating radial artery was palpable; however, the ulnar artery was not. Doppler ultrasound examination revealed thrombus occlusion of the ulnar artery and common palmar artery of the index finger. Peripheral arterial occlusion was diagnosed due to embolization of a thrombus from this site. The patient stopped practicing volleyball immediately after the onset of symptoms and was started on cilostazol 200 mg and rivaroxaban 15 mg. Subjective coldness of the fingers improved one week after the start of treatment. The patient resumed practice four weeks after the start of treatment and participated in a game by the seventh week.Posterior circumflex humeral artery pathological lesions are caused by overhead motions such as pitching. They are most commonly reported in athletes playing volleyball, although rare, and many cases of aneurysm formation have been reported.Observing a cold sensation in the periphery after practice is necessary for screening.

Capillaroscopic Evidence of Microvascular Damage in Volleyball Players

Volleyball players experience repetitive stress that involves their hands and, in particular, their fingers. Literature reports that repetitive trauma can lead to local vascular abnormalities, such as reduced capillarization and lower resting blood flow. These anomalies could be related to the presence of dysfunctional endothelium. The aim of this study is to correlate the capillaroscopic findings by nailfold video capillaroscopy (NVC) to volleyball practice in order to early detect possible anomalies and perform an adequate follow-up to avoid damages that could negatively affect sport practice and the players' health status. In this study, 38 subjects were enrolled, 19 volleyball players and 19 healthy non-players as a comparison group. In almost all the players, we found capillaroscopic alterations of the "aspecific pattern" type without substantial gender differences. We may assume that the repeated traumas involving players' fingers can negatively modify their microcirculation. Based on these observations, it could be a desirable clinical practice to screen professional volleyball players with NVC in order to implement preventive strategies aimed at protecting the health of athletes.

Clinico-radiological review of peripheral entrapment neuropathies - Part 1 upper limb

PURPOSE

This article aims to review the pertinent anatomy, etiopathogenesis, current clinical and radiological concepts and principles of management in case of upper limb entrapment neuropathies.

METHODS

The review is based on critical analysis of the existing literature as well as our experience in dealing with entrapment neuropathies.

RESULTS

Entrapment neuropathies of the upper limb peripheral nerves are common conditions that are often misdiagnosed because of their varying clinical presentations and lack of standardized diagnostic methods. Clinical assessment and electrodiagnostic studies have been the mainstay; however, imaging techniques have provided newer insights into the pathophysiology of these entities, leading to a paradigm shift in their diagnosis and management. The current best practice protocols for entrapment syndromes are constantly evolving with increasing emphasis on the role high-resolution ultrasound and magnetic resonance imaging. Many imaging criteria are described and we have tried to present the most validated measurements for diagnosing entrapment neuropathies.

CONCLUSION

It is imperative for a clinical radiologist to be familiar with the etiopathogenesis and clinical features of these conditions, in addition to being thorough with the anatomy and the latest imaging strategies.

Management of upper extremity aneurysms: a systematic review

INTRODUCTION

The aim of this paper is to provide recommendations for diagnosis and management of arterial or venous aneurysms of the upper extremity.

EVIDENCE ACQUISITION

A systematic review of the Medline and Cockrane databases was performed from 1988 to 2019 by a combined strategy of MeSh terms.

EVIDENCE SYNTHESIS

One-hundred-forty-four publications were identified: 111 addressing arterial aneurysms and 33 addressing venous aneurysms. A total of 162 cases of arterial aneurysms, mostly brachial aneurysms (34.0% of cases) and 40 cases of venous aneurysms, mostly located in the forearm (60.0% of cases) were reported. For both types of aneurysms, most common presentation was the perception of a mass (56.3% for arterial one and 87.5% for venous one), but thromboembolic complication (46.7%), paresthesia (16.5%) or rupture (6.4%) could be observed in the setting of arterial aneurysms, while arm swelling (27.5%), neurological symptoms (12.5%), pulmonary embolism (10.0%) or rupture (2.5%) could occur in the setting of venous aneurysms. DUS was performed as first imaging modality for both settings, followed but CTA and MRA, especially in arterial aneurysms, to evaluate distal emboli and surrounding vasculature. Surgical treatment was mostly based on excision of the aneurysms with revascularization for arterial aneurysms (77.2%) and resection without reconstruction for the venous one (85.0%). Complications occurred in 10.5% of the cases of arterial aneurysms, none occurred after venous aneurysm resection.

CONCLUSIONS

Prompt diagnosis and appropriate preoperative imaging are mandatory in order to offer the best treatment modality. Open resection with revascularization seems to be the treatment of choice for arterial aneurysms, although endovascular procedures became more popular. Venous aneurysms require excision without revascularization.

Asymmetry in glenohumeral muscle strength of sitting volleyball players: an isokinetic profile of shoulder rotations strength

BACKGROUND

Sitting volleyball (SV) is a popular Paralympic game, in which shoulders of SV players are overloaded continuously during play. Nevertheless, shoulder girdle muscle function has never been measured in this population yet. The objective of this study was to investigate the dominant and non-dominant strength profile of male and female elite SV players on a glenohumeral level.

METHODS

A total of 13 Brazilian SV national team players volunteered to participate in this study (male: N.=6, age 32.8±4.1 years, body mass 83.2±19.4 kg, seated height 1.47±0.04 m; female: N.=7, age 32.8±4.1 years, body mass 80.1±17.9 kg, seated height 1.36±0.05 m). A Biodex dynamometer was used to measure internal rotation (IR) and external rotation (ER) of the glenohumeral muscle strength at 60°/s and 180°/s velocities in a concentric/concentric mode.

RESULTS

It was observed that male SV players were stronger than the female players at both upper limbs. Concerning the side effects, significant differences were found for IR at 60°/s velocity (F=7.55, P=0.02) and ER at 180°/s velocity (F=5.91, P=0.03), with higher values on the dominant limb in comparison to the non-dominant limb for both the male and female players. There were significant gender differences for the IR inter-limb asymmetry at 180°/s velocity, with a greater asymmetry between both shoulders in the male players compared to the female players, preference for the dominant side in both groups.

CONCLUSIONS

The SV players have an asymmetrical rotational strength profile. As muscular imbalance is a common injury pattern among overhead players. The findings of this study may assist the SV coaches and physiotherapists for evaluation and training of strength of the ER and IR shoulders of these players.

A systematic review on posterior circumflex humeral artery pathology: sports and professions at risk and associated risk factors

INTRODUCTION

Posterior circumflex humeral artery (PCHA) aneurysm formation and thrombosis as overuse injury in the dominant shoulder can result in ischemia of the forearm, hand and digits due to arterial embolisms. Increased awareness among physicians is necessary as PCHA pathology (PCHAP) might be underdiagnosed. Knowledge of sports and professions at risk and risk-factors for obtaining PCHAP is essential for the development of future preventive measures. This study aims to identify sports and professions at risk as well as risk factors for PCHAP.

EVIDENCE ACQUISITION

The databases of MEDLINE, EMBASE, BIOSIS, CINAHL and SPORTDiscus were systematically searched.

EVIDENCE SYNTHESIS

Twenty-seven papers fulfilled the inclusion criteria and described 67 patients with PCHAP involved in seven sports and three professions. The sports (number of cases) were volleyball (41), baseball (13), swimming (1), tennis (3), American football (2), canoeing (1) and yoga (1) (2 unknown). The professions included a baseball coach, a circus trapeze artist and a mechanic. Apart from expert opinions, no studies have identified risk factors for PCHAP. An anatomic variation of the PCHA origin is suggested to be protective for PCHAP.

CONCLUSIONS

PCHAP is reported in seven overhead sports and three professions. No risk factors for PCHAP were identified. An anatomic variant of the PCHA origin was found to be a potential protective factor for PCHAP. Physicians should be cautious for distal embolization as a result of PCHAP in athletes and workers, both adult and adolescent, involved in repetitive powerful overhead movements.

Quadrilateral space syndrome: a review

Quadrilateral space (QS) syndrome (QSS) is a relatively rare condition in which the axillary nerve and the posterior humeral circumflex artery are compressed within the QS. Fibrous bands are most commonly implicated as the cause, with true space-occupying lesions being less common. QSS is characterized by poorly localized shoulder pain and paresthesia over the lateral aspect of the shoulder and arm in a nondermatomal pattern. These symptoms are aggravated by shoulder abduction and external rotation. Point tenderness is typically present over the QS; however, diagnosis on physical examination can be difficult. Pain relief after lidocaine block of the axillary nerve within the QS is a useful finding in the evaluation of patients with suspected QSS. No definitive diagnostic imaging exists, making diagnosis difficult, although radiographs and magnetic resonance imaging are recommended to rule out other pathology. Nonoperative treatment, including nonsteroidal anti-inflammatory drugs, activity modification, and physical therapy, for at least 6 months is recommended before pursuing operative intervention. Small case series have shown that surgical decompression of the QS has good outcomes, with resolution of pain and return to sport.

Quadrilateral Space Syndrome: Diagnosis and Clinical Management

Quadrilateral space syndrome (QSS) is a rare disorder characterized by axillary nerve and posterior humeral circumflex artery (PHCA) compression within the quadrilateral space. Impingement is most frequently due to trauma, fibrous bands, or hypertrophy of one of the muscular borders. Diagnosis can be complicated by the presence of concurrent traumatic injuries, particularly in athletes. Since many other conditions can mimic QSS, it is often a diagnosis of exclusion. Conservative treatment is often first trialed, including physical exercise modification, physical therapy, and therapeutic massage. In patients unrelieved by conservative measures, surgical decompression of the quadrilateral space may be indicated.

Posterior circumflex humeral artery pathology and digital ischemia in elite volleyball: Symptoms, risk factors & suggestions for clinical management

OBJECTIVES

To assess the association between posterior circumflex humeral artery (PCHA) pathology (PCHAP), symptoms and associated risk factors, in elite volleyball players, and to suggest profiles for clinical management and monitoring.

DESIGN

Cross-sectional study.

METHODS

A questionnaire assessed symptoms of digital ischemia (DI) in the dominant hand and risk factors among 278 elite indoor and beach volleyball players of whom 6.1% (17/278) was diagnosed with PCHAP using ultrasound. Odds Ratios (OR) including 95% confidence intervals (95%CI) were calculated using binary logistic regression.

RESULTS

All 278 players completed the questionnaire. Three participants with PCHAP were symptomatic (18%). Ninety-three of 96 symptomatic participants had no PCHAP (OR=0.39; 95% CI 0.13-1.13). Total years playing volleyball (OR 1.14; 95% CI 1.03-1.25) and age (OR 1.17; 95% CI 1.00-1.29) were dose-response related risk factors: a volleyball career of ≥17 years and age of ≥27 years were associated with a 9-fold and 14-fold increased risk of PCHAP, respectively.

CONCLUSIONS

The volleyball career duration and age are dose-response related risk factors for PCHAP among elite indoor and beach volleyball players. DI symptoms are prevalent in a minority of athletes with PCHAP (3/17; 18%). To enable worldwide standardized care for these athletes at risk, four profiles for clinical management and monitoring have been suggested based on questionnaire and ultrasound outcomes.

Diagnostic properties of the SPIQuestionnaire to detect Posterior Circumflex Humeral Artery Disease in elite volleyball players: a cross-sectional study

OBJECTIVES

Sports related aneurysmal degeneration and thrombosis of the Posterior Circumflex Humeral Artery (PCHA) has been known to cause symptoms of digital ischemia (DI) in elite volleyball players. Studies have reported symptoms of DI in as much as 28% of the elite indoor volleyball players. The purpose of this study was to determine the diagnostic value of the Shoulder PCHA Pathology and digital Ischemia - Questionnaire (SPI-Q) for detection of sports related PCHA disease using ultrasound data as the standard of reference.

METHODS

The SPI-Q was completed by elite indoor volleyball players from the highest and single highest Dutch volleyball division and by elite beach volleyball players participating in the 2014 Grand Slam Beach Tournament The Hague (GSBTH). Ultrasound assessment of the dominant shoulder was performed on-site using the SPI-US protocol. The SPI-Q sensitivity, specificity, positive - and negative predictive value and positive - and negative likelihood ratios, and the diagnostic odds ratio were calculated for detection of sports related PCHA disease, using ultrasound as the standard of reference.

RESULTS

Two hundred twenty-four elite male indoor volleyball players from the Dutch division were included in this study and 62 elite male and female beach volleyball players participating in the GSBTH: a total of 278 players. Thirty-five percent of the players reported symptoms of DI. The prevalence of PCHA disease was 6.1%. For the SPI-Q we found a sensitivity of 18% (95% CI 4-43), specificity of 64% (95% CI 58-70), positive predictive value of 3% (95% CI 0.7-8.9) and negative predictive value of 92% (95% CI 87-96), positive likelihood ratio of 0.50 (95% CI 0.18-1.40), negative likelihood ratio of 1.28 (95% CI 1.01-1.62) and a diagnostic odds ratio of 0.39 (95% CI 0.11-1.38).

CONCLUSION

The diagnostic value of the SPI-Q to detect PCHA disease in elite volleyball players is poor, which makes it unsuitable as a diagnostic instrument for sports related PCHA disease specifically. However, it can be used to assess all-cause symptoms of DI and raise awareness within athletes and sports physicians, which is important for preventing ischemic complications.

Test-retest reliability and agreement of the SPI-Questionnaire to detect symptoms of digital ischemia in elite volleyball players

The Shoulder posterior circumflex humeral artery Pathology and digital Ischemia - questionnaire (SPI-Q) has been developed to enable periodic surveillance of elite volleyball players, who are at risk for digital ischemia. Prior to implementation, assessing reliability is mandatory. Therefore, the test-retest reliability and agreement of the SPI-Q were evaluated among the population at risk. A questionnaire survey was performed with a 2-week interval among 65 elite male volleyball players assessing symptoms of cold, pale and blue digits in the dominant hand during or after practice or competition using a 4-point Likert scale (never, sometimes, often and always). Kappa (κ) and percentage of agreement (POA) were calculated for individual symptoms, and to distinguish symptomatic and asymptomatic players. For the individual symptoms, κ ranged from "poor" (0.25) to "good" (0.63), and POA ranged from "moderate" (78%) to "good" (97%). To classify symptomatic players, the SPI-Q showed "good" reliability (κ = 0.83; 95%CI 0.69-0.97) and "good" agreement (POA = 92%). The current study has proven the SPI-Q to be reliable for detecting elite male indoor volleyball players with symptoms of digital ischemia.

Ultrasound assessment of the posterior circumflex humeral artery in elite volleyball players: Aneurysm prevalence, anatomy, branching pattern and vessel characteristics

Objectives

To determine the prevalence of posterior circumflex humeral artery (PCHA) aneurysms and vessel characteristics of the PCHA and deep brachial artery (DBA) in elite volleyball players.

Methods

Two-hundred and eighty players underwent standardized ultrasound assessment of the dominant arm by a vascular technologist. Assessment included determination of PCHA aneurysms (defined as segmental vessel dilatation ≥150 %), PCHA and DBA anatomy, branching pattern, vessel course and diameter.

Results

The PCHA and DBA were identified in 100 % and 93 % (260/280) of cases, respectively. The prevalence of PCHA aneurysms was 4.6 % (13/280). All aneurysms were detected in proximal PCHA originating from the axillary artery (AA). The PCHA originated from the AA in 81 % of cases (228/280), and showed a curved course dorsally towards the humeral head in 93 % (211/228). The DBA originated from the AA in 73 % of cases (190/260), and showed a straight course parallel to the AA in 93 % (177/190).

Conclusions

PCHA aneurysm prevalence in elite volleyball players is high and associated with a specific branching type: a PCHA that originates from the axillary artery. Radiologists should have a high index of suspicion for this vascular overuse injury. For the first time vessel characteristics and reference values are described to facilitate ultrasound assessment.

Key Points

• Prevalence of PCHA aneurysms is 4.6 % among elite volleyball players.

• All aneurysms are in proximal PCHA that originates directly from AA.

• Vessel characteristics and reference values are described to facilitate US assessment.

• Mean PCHA and DBA diameters can be used as reference values.

• Radiologists need a high index of suspicion for this vascular overuse injury.

B-Mode Sonographic Assessment of the Posterior Circumflex Humeral Artery: The SPI-US Protocol-A Technical Procedure in 4 Steps

Elite overhead athletes are at risk of vascular injury due to repetitive abduction and external rotation of the dominant arm. The posterior circumflex humeral artery (PCHA) is prone to degeneration, aneurysm formation, and thrombosis in elite volleyball players and baseball pitchers. The prevalence of PCHA-related thromboembolic complications is unknown in this population. However, the prevalence of symptoms associated with digital ischemia is 31% in elite volleyball players. A standardized noninvasive imaging tool will aid in early detection of PCHA injury, prevention of thromboembolic complications, and measurement reproducibility. A standardized vascular sonographic protocol for assessment of the proximal PCHA (SPI-US protocol [Shoulder PCHA Pathology and Digital Ischemia-Ultrasound protocol]) is presented.

Reproducibility of the SPI-US protocol for ultrasound diameter measurements of the Posterior Circumflex Humeral Artery and Deep Brachial Artery: an inter-rater reliability study

OBJECTIVES

Elite overhead athletes are at risk of posterior circumflex humeral artery (PCHA) degeneration, aneurysm formation and thrombosis. Identification of the proximal PCHA and the nearby originating deep brachial artery (DBA) can be a challenge, even among experienced sonographers. The aim of this study was to assess the accuracy and precision of a newly designed standardized ultrasound (US) protocol (SPI-US) for assessment of the PCHA and DBA.

METHODS

Two experienced sonographers determined diameters of the PCHA and DBA using the SPI-US protocol. Inter-observer agreement was evaluated using intra-class correlation coefficient (ICC), standard error of measurement (SEM), minimal detectable change (MDC), Bland-Altman (BA) analysis, and variance component (VARCOMP) analysis.

RESULTS

Thirty-three healthy volunteers participated. The ICC for diameter measurement of the PCHA and DBA were 0.70 (95 %CI 0.50-0.83) and 0.60 (95 %CI 0.30-0.80), respectively. The SEM for the PCHA and DBA was 0.32 mm and 0.29 mm and MDC was 0.90 mm and 0.80 mm, respectively. The BA and VARCOMP analyses showed no systematic and only marginal sonographer bias.

CONCLUSIONS

The SPI-US protocol is accurate and precise for PCHA and DBA diameter assessment in cases where they originate from the axillary artery. PCHA and DBA diameter measurements are sonographer-independent using the SPI-US-protocol.

KEY POINTS

• PCHA & DBA diameter assessment is accurate and reliable using the SPI-US protocol • PCHA & DBA diameter measurements are sonographer-independent using the SPI-US protocol • The SPI-US protocol minimal detectable change is 0.90 mm for PCHA diameter measurement • This minimal detectable change enables detection of PCHA aneurysms • First step towards international periodic surveillance of athletes at risk of PCHA-injury.

Self-reported symptoms and risk factors for digital ischaemia among international world-class beach volleyball players

The prevalence of ischaemia-related symptoms is remarkably high among elite indoor volleyball players. Since the exposure to sport-specific demands may be higher in beach volleyball compared to indoor volleyball, the aim of this study was to assess the prevalence of ischaemia-related symptoms and associated risk factors among world-class beach volleyball players. Therefore, a questionnaire survey was performed among beach volleyball players active during the 2013 Grand Slam Beach Volleyball in the Netherlands. In total, 60 of the 128 beach volleyball players (47%) participated: 26 males and 34 females from 17 countries. The self-reported prevalence of cold or blue or pale digits in the dominant hand during or immediately after practice or competition was 38% (n = 23). Two risk factors were independently associated with symptoms of blue or pale digits: more than 14 years playing volleyball (odds ratio (OR) 4.42, 90% confidence interval (90% CI) 1.30-15.07) and sex (female) (OR 4.62, 90% CI 1.15-18.57). In conclusion, the prevalence of symptoms associated with digital ischaemia is high among international world-class beach volleyball players. Female sex and the length of the volleyball career were independently associated with an increased risk of ischaemia-related symptoms. The high prevalence of these seemingly innocuous symptoms and possible associated risk factors warrant regular monitoring since early detection can potentially prevent thromboembolic complications and irreversible tissue damage.

Quadrilateral space syndrome: the Mayo Clinic experience with a new classification system and case series

Quadrilateral space syndrome (QSS) arises from compression or mechanical injury to the axillary nerve or the posterior circumflex humeral artery (PCHA) as they pass through the quadrilateral space (QS). Quadrilateral space syndrome is an uncommon cause of paresthesia and an underdiagnosed cause of digital ischemia in overhead athletes. Quadrilateral space syndrome can present with neurogenic symptoms (pain and weakness) secondary to axillary nerve compression. In addition, repeated abduction and external rotation of the arm is felt to lead to injury of the PCHA within the QSS. This often results in PCHA thrombosis and aneurysm formation, with distal emboli. Because of relative infrequency, QSS is rarely diagnosed on evaluation of athletes with such symptoms. We report on 9 patients who presented at Mayo Clinic with QSS. Differential diagnosis, a new classification system, and the management of QSS are discussed, with a comprehensive literature review. The following search terms were used on PubMed: axillary nerve, posterior circumflex humeral artery, quadrilateral space, and quadrangular space. Articles were selected if they described patients with symptoms from axillary nerve entrapment or PCHA thrombosis, or if related screening or imaging methods were assessed. References available within the obtained articles were also pursued. There was no date or language restriction for article inclusion; 5 studies in languages besides English were reported in German, French, Spanish, Turkish, and Chinese.

Risk factors associated with self-reported symptoms of digital ischemia in elite male volleyball players in the Netherlands

One in every four elite male volleyball players in the Netherlands reported blue or pale digits in the dominant hand. Little is known about risk factors. To assess whether personal-, sports-, and work-related risk factors are associated with these symptoms in these volleyball players, a survey was performed among elite male volleyball players in the Dutch national top league and in the Dutch beach volleyball team. The questionnaire assessed the presence of symptoms and risk factors. Binary logistic regression was performed to calculate odds ratios (ORs). A total of 99 of the 107 athletes participated - a response rate of 93%. Two sports-related risk factors were associated with symptoms of blue or pale digits: 18-30 years playing volleyball [OR = 6.70; 95% confidence interval (CI) 1.12-29.54] and often/always performing weight training to increase dominant limb strength (OR = 2.70; 95% CI 1.05-6.92). No significant other sports-, personal-, or work-related risk factors were found. Playing volleyball for more than 17 years and often/always performing weight training to increase dominant limb strength were independently associated with an increased risk on ischemia-related complaints of the dominant hand in elite male volleyball players.

High prevalence of self-reported symptoms of digital ischemia in elite male volleyball players in the Netherlands: a cross-sectional national survey

BACKGROUND

In the past 3 years, 6 volleyball players with ischemic digits and small microemboli in the digital arteries of the dominant hand presented themselves in our hospital. These complaints were caused by an aneurysmatic dilation of the posterior circumflex humeral artery (PCHA) with distal occlusion and digital emboli in the isolateral limb. All were elite male volleyball players active in the national top league. Little is known about the exact symptoms associated with PCHA pathological lesions with digital emboli (PCHAP with DE) and its prevalence in elite volleyball players. If vascular injury can be identified at an early stage, thromboembolic complications and irreversible damage to the digits might be prevented.

PURPOSE

To assess the prevalence of symptoms that are consistent with digital ischemia and may be caused by PCHAP with DE in elite male volleyball players in the Netherlands.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A questionnaire survey was performed among elite volleyball players in the Dutch national top league and the Dutch beach volleyball team. The questionnaire was constructed using literature-based data on symptoms associated with PCHAP with DE, together with data retrieved from medical files.

RESULTS

A total of 99 of the 107 athletes participated, with a response rate of 93%. The most frequently reported symptoms associated with PCHAP with DE were cold, blue, or pale digits in the dominant hand during or immediately after practice or competition. The prevalence of these symptoms ranged from 11% to 27%. The prevalence of cold digits during practice and competition was 27%. The prevalence of cold, blue, and pale digits during or immediately after practice and competition was 12%.

CONCLUSION

An unexpectedly high percentage of elite volleyball players reported symptoms that are associated with PCHAP with DE in the dominant hand. Because these athletes are considered potentially at risk for developing critical digital ischemia, further analysis of the presence of digital ischemia and PCHA injury is warranted.

Posterior circumflex humeral artery injury with distal embolisation in professional volleyball players: a discussion of three cases

Presented are three cases of volleyball players with ischaemia of the hand due to arterial emboli originating from an injured posterior circumflex humeral artery (PCHA). An operative treatment with ligation of the PCHA was performed in all patients because of the proximity of the occlusion to the axillary artery. After a rehabilitation programme, all patients could return to their previous level of competition. During overhead motion, the PCHA is prone to injury in its position overlying the humeral head and its course through the quadrilateral space. Recognition of the vascular origin of these symptoms in athletes is important to prevent serious ischaemic complications. Signs of ischaemia might be subtle and may be misdiagnosed as musculoskeletal injuries. Therefore, the examining physician must have a high index of suspicion and awareness about these injuries is important.

Percutaneous treatment of traumatic upper-extremity arterial injuries: a single-center experience

PURPOSE

To assess the feasibility and effectiveness of emergency percutaneous treatment of traumatic injuries of upper-extremity arteries.

MATERIALS AND METHODS

Between January 2000 and December 2007, 11 patients (mean age, 49.9 years) with traumatic injuries of upper-extremity arteries were observed: three had pseudoaneurysms, four had dissections, three had transections, and one had mural hematoma. Lesions involved the axillary (n = 6), subclavian (n = 3), or brachial artery (n = 2). Pseudoaneurysms and transections were treated with stent grafts, (n = 6) and dissections and mural hematomas were treated with bare stents (n = 2) or angioplasty (n = 3). Follow-up (mean, 45.1 months; range, 12-84 months) was performed with color Doppler ultrasonography at 1, 3, 6, and 12 months and then, yearly.

RESULTS

Immediate technical success was obtained in all cases. No major complications occurred; there was one asymptomatic occlusion of the interosseous artery and one case of incomplete thrombosis of the radial artery (with recanalization after 1 month with systemic medical therapy). During a mean follow-up of 45.1 months, one stent-graft occlusion occurred, which was treated with intraarterial pharmacologic thrombolysis (urokinase 60,000 IU/h for 12 hours). Overall primary clinical success rate was 95.2% and secondary clinical success rate was 100%.

CONCLUSIONS

Percutaneous treatment is a feasible and safe tool for injuries of upper-extremity arteries because it can provide a fast and definitive termination of bleeding or a resolution of acute ischemia. This approach, with its low invasiveness, can be proposed as first-line treatment in patients with traumatic lesions of upper-extremity arteries.

Positional compression of the axillary artery causing upper extremity thrombosis and embolism in the elite overhead throwing athlete

OBJECTIVES

To describe the spectrum of axillary artery pathology seen in high-performance overhead athletes and the outcomes of current treatment.

METHODS

A retrospective review of patients that had undergone management of axillary artery lesions in a specialized center for thoracic outlet syndrome (TOS). Treatment outcomes were assessed with respect to arterial pathology and operative management.

RESULTS

Nine male athletes were referred for arterial insufficiency in the dominant arm between January 2000 and August 2010, representing 1.6% of 572 patients treated for TOS (19% of 47 patients treated for arterial TOS). Seven were elite baseball pitchers (six professional, one collegiate), and two were professional baseball coaches with practice pitching responsibilities, with a mean age of 30.9 ± 2.9 years. Presenting symptoms included arm fatigue (five), finger numbness (four), cold hypersensitivity/Raynaud's (two), rest pain (one), and cutaneous fingertip embolism (one). Three patients underwent transcatheter thrombolysis prior to referral, including one with angioplasty and stenting. At angiography and surgical exploration 2.5 ± 0.8 weeks after symptom presentation (range, 1-8 weeks), six patients had occlusion of the distal axillary artery opposite the humeral head either at rest (three) or with arm elevation (three), one had axillary artery dissection with positional occlusion, and two had thrombosis of circumflex humeral artery aneurysms. Five patients had embolic arterial occlusions distal to the elbow. Treatment included segmental axillary artery repair with saphenous vein (n = 7; five interposition bypass grafts and two patch angioplasties), ligation/excision of circumflex humeral artery aneurysms (n = 2), and distal artery thrombectomy/thrombolysis (n = 2). Mean postoperative hospital stay was 3.8 ± 0.5 days, and the time until resumption of unrestricted overhead throwing was 10.8 ± 2.7 weeks. At a median follow-up of 15 months (range, 3-123 months), primary-assisted patency was 89%, and secondary patency was 100%. All nine patients had continued careers in professional baseball, although one retired during long-term follow-up.

CONCLUSIONS

Repetitive positional compression of the axillary artery can cause a spectrum of pathology in the overhead athlete, including focal intimal hyperplasia, aneurysm formation, segmental dissection, and branch vessel aneurysms. Prompt recognition of these rare lesions is crucial given their propensity toward thrombosis and distal embolism, with positional arteriography necessary for diagnosis. Full functional recovery can usually be anticipated within several months of surgical treatment, consisting of mobilization and segmental reconstruction of the diseased axillary artery or ligation/excision of branch aneurysms, as well as concomitant management of distal thromboembolism.

Arterial compression during overhead throwing: a risk for arterial injury?

Case studies reporting aneurysm formation in the axillary artery have been described in overhead throwing athletes, possibly due to repetitive arterial compression by the humeral head that has been transiently observed during sonographic diagnostic arm manoeuvres. Whether compression negatively alters arterial health has not been investigated and was the focus of this study. The throwing arm of elite overhead athletes was screened for inducible axillary artery compression. Compressors (COMP, n = 11, mean age: 20 (SD: 2) year, 7 male, 4 female) were age and sex matched with noncompressing (NONCOMP) athlete controls. Four indices of arterial health (flow mediated dilation [FMD], conduit artery vasodilatory capacity [CADC], glyceryl-trinitrate [GTN]-induced vasodilation and intima-media thickness [IMT]) were assessed with high-resolution ultrasound at the brachial and the axillary, artery. No significant between-group differences were observed at the brachial, or axillary, artery for FMD (brachial: COMP: mean (SD) 6.2 (3.1)%, NONCOMP: 6.1 (3.5)%, p = 0.967, axillary: COMP: 8.0 (5.5)%, NONCOMP: 9.0 (3.6)%, p = 0.602), CADC (brachial: COMP: 10.4 (3.4)%, NONCOMP: 10.4 (5.4)%, p = 0.999, axillary: COMP: 9.6 (4.2)%, NONCOMP: 8.5 (3.2)%, p = 0.492), GTN-induced vasodilation (brachial: COMP: 17.9 (5.1)%, NONCOMP:14.1 (7.2)%, p = 0.173, axillary: COMP: 9.5 (4.3)%, NONCOMP: 7.7 (3.1)%, p = 0.302) or IMT (brachial: p = 0.084, axillary: p = 0.581). These results suggest that transient arterial compression, observed during diagnostic arm manoeuvres in overhead throwing athletes, is not associated with abnormal indices of artery function or structure and that other mechanisms must be responsible for the published cases of aneurysm formation in elite athletes performing overhead throwing actions.

Flow-mediated dilation and intima-media thickness of the brachial and axillary arteries in individuals with and without inducible axillary artery compression

The presence of axillary artery aneurysm and/or thrombus in overhead throwing athletes has been linked, theoretically, with the finding of compression by the humeral head induced by a diagnostic arm maneuver. However, whether this intermittent compression is incidental or of pathological significance has yet to be determined. Flow-mediated vasodilation (FMD), intima-media thickness (IMT) and maximum vasodilatory capacity were measured locally (3rd portion of the axillary artery) and downstream (brachial artery) in individuals previously tested for inducible axillary artery compression (compressor group [COMP]: n=8, mean (SD) age: 23 (4) y; "noncompressor" control group [NONCOMP]: n=8, 26 (4) y). A high-resolution ultrasound machine recorded arterial diameter and blood flow velocity. A rapid inflation/deflation pneumatic cuff placed distal to the site of measurement induced reactive hyperemia. Custom-designed wall tracking software with synchronized Doppler waveform analysis detected changes in arterial diameter, blood flow velocity and shear rate from baseline to 3min after cuff deflation. Glyceryl trinitrate and/or ischemic hand grip exercises were administered to induce maximum vasodilation. No significant differences in FMD, IMT or maximum vasodilator capacity were observed between groups at the axillary artery. However, the downstream brachial FMD response was significantly diminished in the COMP group (6.38 [3.28]%) compared with the NONCOMP group (10.38 [2.74]%; p=0.006) despite a comparable shear rate between groups (COMP: 81.92 (44.55) s(-1); NONCOMP: 83.18 (40.02) s(-1); p=0.961). Pooled data revealed a significant negative relationship (r=-0.52, p=0.038) between the FMD response and degree of arterial compression. These results suggest a chronic change in downstream vascular function in individuals demonstrating clinically significant inducible axillary artery compression.

Anterior translation at the glenohumeral joint: a cause of axillary artery compression?

BACKGROUND

Lesions to the axillary artery are reported in overhead athletes. One speculated cause is repeated transient compression by the humeral head due to excessive laxity at the glenohumeral joint.

HYPOTHESES

(1) Anterior translation of the glenohumeral joint alters axillary artery diameter and blood flow characteristics, and (2) individuals demonstrating inducible axillary artery compression with the arm in an overhead position (as indicated by diameter and blood flow characteristics) will demonstrate greater magnitudes of anterior translation.

STUDY DESIGN

Descriptive laboratory study.

METHODS

After receiving ethical approval and screening for problematic conditions/injuries, 26 subjects were tested (10 men and 16 women; mean age [standard deviation], 25 years [4]). Axillary artery diameter and peak systolic velocity were measured with B-mode and Doppler ultrasound before, during, and after glenohumeral anterior translation at 90 degrees of abduction, 60 degrees of external rotation, and 30 degrees of horizontal flexion, and at baseline and a simulated overhead throwing position (120 degrees of abduction, 90 degrees of external rotation, and 30 degrees of horizontal extension). The magnitude of anterior translation was captured with B-mode ultrasound using a posterior transverse approach.

RESULTS

Application of the glide resulted in a significant (F(2,21) = 9.965, P = .001) reduction in axillary artery diameter and a significant increase in peak systolic velocity (F(2,21) = 5.286, P = .014). Subjects demonstrating clinically significant levels of axillary artery compression ( > 50% reduction in vessel diameter with the arm in the overhead throwing position) exhibited significantly (t = -2.260, P = .040) greater ranges of anterior translation at the glenohumeral joint than the 9 subjects who exhibited < 10% reduction in arterial diameter.

CONCLUSIONS

This investigation provides the first empirical support for the clinical opinion that glenohumeral anterior translation could be a mechanism for inducible axillary artery compression.

CLINICAL RELEVANCE

The response of axillary artery hemodynamics in normal, healthy individuals is the first step in the process of determining whether the finding of inducible axillary artery compression in overhead athletes with arterial pathology is related to glenohumeral translation.

Sonographic evaluation of the subclavian artery during thoracic outlet syndrome shoulder manoeuvres

Clinical tests for vascular thoracic outlet syndrome (vTOS) generally incorporate shoulder horizontal flexion/extension (HF/HE), abduction (ABD) and external rotation (ER). The effect of these clinical tests on blood flow characteristics and the most effective arm positions for detecting arterial compromise are, however, unknown. The aims of this study are to establish normative vascular responses in the subclavian artery (i.e. arterial diameter [D] and peak systolic blood flow velocity [PSV]) to various arm positions, and determine the incidence of abnormal physiological responses. Ten male and twenty-one female (mean age: 25 yr) healthy volunteers were rigorously screened prior to testing. With the subject seated the arm was passively supported in a randomised series of 12 standardised shoulder positions incorporating varying degrees of HF/HE, ABD and ER. Doppler ultrasound insonated the subclavian artery D (mm) and PSV (cms(-1)) in each position. Data comparisons were made using ANOVAs with bonferroni adjustment for multiple comparisons. Alpha level was set at p=0.01. Significant decreases (p=0.008) in PSV were recorded from 120 degrees , 90 degrees and 45 degrees ABD (92+/-10, 89+/-11 and 88+/-14 cm s(-1), respectively) to 180 degrees ABD (mean+/-95% CI: 52+/-16 cm s(-1)). Similarly, post-hoc comparisons revealed a significant decrease (p=0.008) in PSV from 120 degrees ABD (94+/-14 cm s(-1)) to 120 degrees ABD with 30 degrees HE and 90 degrees ER (69+/-12 cm s(-1)). Complete lack of blood flow was demonstrated by six subjects and two subjects at end of range ABD and combined end of range ER and HE, respectively. The heterogenous response of asymptomatic individuals with no past history of TOS symptoms raises uncertainty of the validity of positive test responses from extreme arm positions. Clinical decisions based on false positive outcomes have serious implications for mistreatment such as inappropriate surgical intervention; therefore it is imperative that clinical decision is not based on test outcomes alone. Further research is required to determine the cause of heterogenous responses in asymptomatics and discover means to improve test specificity.

Unusual origin of radial collateral artery noted in quadrangular space syndrome

In this paper, an unusual origin of the radial collateral artery of the arm is reported. The radial collateral artery in one of the cadavers dissected by us originated from the posterior circumflex humeral artery. The importance of this abnormal origin of the radial collateral artery from the posterior circumflex humeral artery in quadrangular space syndrome is discussed.