Axillary Artery Injuries Associated With Proximal Humerus Fractures: A Literature Review and a Proposal of a Novel Multidisciplinary Surgical Approach

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.

Acute-on-Chronic Axillary Artery Thrombus After Reverse Total Shoulder Arthroplasty for Failed Proximal Humerus Open Reduction and Internal Fixation: A Case Report

CASE

A 71-year-old woman presented with post-traumatic arthritis 11 months after open reduction and internal fixation for a left proximal humerus fracture (PHF) dislocation. After revision to reverse total shoulder arthroplasty (rTSA), the patient's left upper extremity was found to be avascular. An emergent thrombectomy was performed with restoration of arterial flow after removal of an acute-on-chronic axillary artery thrombus.

CONCLUSION

Although rare, as rTSA becomes more common for management of PHF, incidence of associated vascular injuries is likely to rise. Screening methods and clinical vigilance in diagnosis are advised for patients with anterior PHF dislocations and arterial injury risk factors.

The spectrum of computed tomography findings in blunt trauma of the subclavian/axillary artery: a pictorial essay

Traumatic injuries of the subclavian and axillary arteries are uncommon but have high morbidity and mortality. In contrast to penetrating injuries, which are often lethal, blunt injuries present a wide and heterogeneous spectrum of imaging findings. If a vessel tear or transsection is a life-threatening circumstance, minor injuries might be overlooked in an emergency setting but could cause or aggravate the functional loss of a limb. The aim of this pictorial essay is to acquaint radiologists with the spectrum of imaging findings that could be encountered during the radiological evaluation of the subclavian/axillary artery (SAA) in trauma patients and offer tips and tricks to improve the diagnostic workup of patients with suspected blunt SAA injuries.

Analysis of Traumatic Axillo-Subclavian Vessel Injuries: Endovascular Management is a Viable Option to Open Surgical Reconstruction

BACKGROUND

In traumatic axillo-subclavian vessel injuries, endovascular repair has been increasingly described, despite ongoing questions regarding infection risk and long-term durability. We sought to compare the clinical and safety outcomes between endovascular and surgical treatment of traumatic axillo-subclavian vessel injuries.

METHOD

A search query of the prospectively maintained PROOVIT registry for patients older than 18 years of age with a diagnosis of axillary or subclavian vessel injury between 2014-2019 was performed at a Level 1 Trauma Center. Patient demographics, severity of injury, Mangled Extremity Severity Score (MESS), Injury Severity Score (ISS), procedural interventions, complications, and patency outcomes were collected and analyzed.

RESULTS

Twenty-three patients with traumatic axillo-subclavian vessel injuries were included. There were similar rates of penetrating and blunt injuries (48% vs. 52%, respectively). Eighteen patients (78%) underwent intervention: 11 underwent endovascular stenting or diagnostic angiography; 7 underwent open surgical repair. There was similar severity of arterial injuries between the endovascular and open surgical groups: transection (30% vs. 40%, respectively), occlusion (30% vs. 40%, respectively). The open surgical group had worse initial clinical comorbidities: higher ISS scores (17.0 vs 13.5, p = 0.034), higher median MESS scores (6 vs. 3.5, P = 0.001). The technical success for the endovascular group was 100%. The endovascular group had a lower estimated procedural blood loss (27.5 mL vs. 624 mL, P = 0.03). The endovascular arterial group trended toward a shorter length of hospital stay (5.6 days vs. 27.6 days, P = 0.09) and slightly reduced procedural time (191.0 min vs. 223.5 min, P = 0.165). Regarding imaging follow up (average of 60 days post-discharge), 7 patients (54%) underwent surveillance imaging (5 with duplex ultrasound, 2 with computed tomography angiography CTA) that demonstrated 100% patency. Regardless of ISS or MESS scores, at long term clinical follow up (average of 214 days), there were no limb losses, graft infections or vascular complications in either the endovascular or open surgical group.

CONCLUSIONS

Endovascular treatment is a viable option for axillo-subclavian vessel injuries. Preliminary results demonstrate that endovascular treatment, when compared to open surgical repair, can have similar rates of technical success and long-term outcomes in patency, infection and vascular complications.

Endovascular Treatment of a Traumatic Axillary Artery Rupture Using the Dual Bull's-Eye Technique

BACKGROUND

Our purpose is to report a case of an axillary artery rupture treated by endovascular means using the dual bull's-eye technique. An 83-year-old woman with multiple comorbidities was diagnosed with axillary artery rupture after the reduction of a shoulder dislocation.

METHODS

An endovascular repair attempt was made, but, despite the use of a double approach (antegrade and retrograde), reconnecting both ends of the severed artery was deemed not possible. 5-mm Amplatz GooseNeck snares were advanced from each access and superposed in a perpendicular plane. A percutaneous infraclavicular puncture with a lumbar needle was made through both snares, and a V14 guidewire was subsequently introduced. The guidewire was recovered through femoral and brachial accesses, and a 7 × 100 mm covered self-expandable stent was deployed.

RESULTS

The final angiographic control did not show further hemorrhage, and the patient recovered radial pulse. Follow-up showed complete patency and no complications at 9 months after the procedure.

CONCLUSIONS

The dual bull's-eye technique can be used as a resource tool in cases of arterial rupture, when the arterial continuity cannot be re-established by conventional approaches.

Axillary Artery Injury In Blunt Shoulder Trauma - An Uncommon Association With Proximal Humerus Fracture

Axillary artery injury along with proximal humerus fracture as a result of blunt trauma is a rare incidence. We present a 65-year-old male with a pulseless cold hand, who had blunt trauma 3 days ago, leading to fracture of proximal end of humerus along with axillary artery injury. Surgical intervention revealed contusion of axillary artery with intravascular thrombosis causing complete occlusion. Internal fixation of fracture along with excision of contused axillary artery was done followed by interposition venous graft. The diagnostic modalities and treatment options for such a case are discussed.

Through Thick or Thin: Disparities in Perioperative Anticoagulant Use in Trauma Patients

Although vascular surgery guidelines recommend immediate anticoagulation for acute occlusion of a peripheral artery, it is unclear whether trauma surgeons follow this practice. A survey regarding the use of perioperative anticoagulation was sent to surgeons who perform their own peripheral arterial repairs after traumatic injury to define contemporary practice patterns. This survey demonstrated minimal consensus opinion regarding the management of extremity vascular injuries, strongly suggesting the need for a consensus conference, meta-analysis, and prospective studies to guide further care.

Critical errors in infrequently performed trauma procedures after training

BACKGROUND

Critical errors increase postoperative morbidity and mortality. A trauma readiness index was used to evaluate critical errors in 4 trauma procedures. In comparison to practicing and expert surgeon benchmarks, we hypothesized that pretraining trauma readiness index including both vascular and nonvascular trauma surgical procedures can identify residents who will make critical errors.

METHODS

In a prospective study, trained evaluators used a standardized script to evaluate performance of brachial, axillary, and femoral artery exposure and proximal control and lower-extremity fasciotomy on unpreserved cadavers. Forty residents were evaluated before and immediately after Advanced Surgical Skills for Exposure in Trauma training, and 38 were re-evaluated 14 months later. Residents were compared to 34 practicing surgeons evaluated once 30 months after training, and 10 experts.

RESULTS

Resident trauma readiness index increased with training (P < .001), remained unchanged 14 month later and was higher, with lower variance than practicing surgeons (P < .05). Expert trauma readiness index was higher than residents (P < .004) and practicing surgeons (P < .001). Resident training decreased critical errors when evaluated immediately and 14 months after Advanced Surgical Skills for Exposure in Trauma training. Practicing surgeons had more critical errors and performance variability than residents or experts. Experts had 5 to 7 times better error recovery than practicing surgeons or residents. Trauma readiness index area under the receiver operating curve with Youden Index <0.60 or <6 decile in their cohort, predicts a surgeon will make a critical error.

CONCLUSION

Low trauma readiness index was associated with critical errors occurring in all surgeon cohorts and can identify surgeons in need of remedial intervention.

[A man with a painful shoulder and numb hand]

A 57-year-old man suffered from an anterior luxation of the left shoulder with a dislocated fracture of the greater humeral tubercle after a fall. His left hand was cold, numb and no arterial pulsations could be detected. After shoulder reposition, the hand became warmer and the numbness disappeared. The next morning, pulsations of the hand were absent again. CT angiography showed a dissection of the axillary artery with thrombosis.

A Comparative Analysis of Open versus Endovascular Techniques for Management of Non-Aortic Cervicothoracic Arterial Injuries

The objective of this study is to describe the contemporary management of proximal upper extremity and neck arterial injuries by comparing open and endovascular repair at a single institution. This is a retrospective study of 22 patients that sustained subclavian, axillary, and carotid artery injuries from 2011 to 2016 that were managed with open or endovascular repair. There were nine subclavian, eight axillary, and five carotid artery injuries of which 10 (45.5%) underwent endovascular repair and 12 (54.5%) underwent open repair. There was no statistically significant difference between the groups including injury severity score or preoperative hypotension. There were no deaths in the endovascular group, and three (25.0%) deaths in the open group. All patients in the endovascular group were discharged home. In the open group, seven (58.3%) patients had at least one inpatient complication with a mean of 1.1 (standard deviation 1.4) complications per patient. In the endovascular group, there were three (30.0%) patients with inpatient complications and a mean of 0.4 (standard deviation 0.7) complications per patient (P = 0.18). Endovascular management of nonaortic cervicothoracic arterial injuries was successfully performed in hypotensive patients and patients with other life threatening traumatic injuries. Further studies are warranted to look at long-term patency of these repairs and to help develop a protocol to guide decision-making in the management of cervicothoracic injuries.

Proximal Humerus Fracture-Dislocation with Laceration of the Axillary Artery: A Case Report

BACKGROUND

Proximal humerus fractures account for approximately 4-6% of all fractures. While the majority of these fractures are treated non-operatively, the amount of fracture displacement, concomitant injuries, and patient factors often result in the need for surgical stabilization. Although concomitant neurovascular injury in the setting of low-energy trauma is rare, injury to the surrounding neurovascular structures have previously been reported.

METHODS

We report a case of a 79-year-old male who sustained a low energy fall resulting in a two-part fracture dislocation of the proximal humerus with an associated brachial plexopathy and axillary artery laceration. The patient underwent emergent open reduction internal fixation of his fracture in addition to an axillary-brachial artery bypass using a reverse-saphenous vein graft. The current article reports the presentation, management and prognosis of this rare injury.

RESULTS

At 6 months, the patient demonstrated limited active shoulder abduction with no observed motor function at this elbow, wrist or hand. Radiographic follow up demonstrated a reduced glenohumeral joint with evidence avascular necrosis of the humeral head.

CONCLUSION

Fracture-dislocations of the proximal humerus may be associated with significant neurovascular injury in the setting of low energy trauma. Despite early treatment, the prognosis of patients with this constellation of injuries is guarded.

Determination of Functional Outcome Following Upper Extremity Arterial Trauma

Upper extremity arterial trauma may lead to significant disability with a poor functional outcome. This study represents a retrospective review of all trauma patients presenting to a university-affiliated medical center. Patients suffering from upper extremity arterial injuries requiring treatment were identified. The injured vessels were identified along with the mechanism of injury and method of repair. The degree of functional disability was evaluated by using a previously validated questionnaire, the Disabilities of the Arm, Shoulder, and Hand (DASH) Outcome Measure. Between September 1999 and December 2004, 17 patients presented with traumatic arterial injury to the upper extremity, with 9 and 8 patients suffering from blunt and penetrating traumas, respectively. One patient required amputation representing a limb salvage rate of 94%. The mean length of hospitalization was significantly shorter for penetrating trauma (5.1 vs 12 days, P = .03), with blunt trauma victims being more prone to coexisting orthopedic injuries ( P = .009). Length of follow-up did not differ between the 2 groups and ranged from 1-60 months. Patients with blunt trauma tended, although not statistically significant, to have higher DASH scores (61.8 vs 22.8, P = .08), indicating a greater degree of disability. By utilizing a validated disability questionnaire, this study confirms that patients suffering from blunt injuries to upper extremity arteries are more likely to have greater degrees of disability affecting everyday activities.

Endovascular Management of Traumatic Axillary Artery Dissection

A 43-year-old man was admitted to this hospital with a cool, slightly numb, left upper extremity after trauma. Physical examination revealed a cool left forearm and hand, with no distal pulses. An intraoperative angiogram demonstrated short-segment dissection and occlusion of the left axillary artery. A 10 mm x 40 mm self-expanding stent was placed across the intimal flap to reinstitute peripheral flow. Early postoperative duplex scanning showed normal flow through the axillary artery.

Outcome comparison between open and endovascular management of axillosubclavian arterial injuries

BACKGROUND

Endovascular repair (ER) of axillosubclavian arterial injuries is a minimally invasive alternative to open repair (OR). The purpose of this study was to compare the outcomes of ER vs OR.

METHODS

A retrospective study was performed of patients who sustained axillosubclavian arterial injuries admitted to two high-volume academic trauma centers between 2003 and 2013. Patients undergoing ER and OR were matched according to 25 different demographic and clinical variables in a 1:3 ratio using propensity scores. The primary outcome was in-hospital mortality. Secondary outcomes were complications and length of stay.

RESULTS

Among 153 patients (79.7% male; mean age, 32.7 ± 15.9 years) who sustained axillosubclavian arterial injuries, 18 (11.8%) underwent ER and 135 (88.2%) had OR. Matched cases (ER, n = 18) and controls (OR, n = 54) had similar demographic and clinical data, such as age, gender, admission systolic blood pressure and Glasgow Coma Scale score, body Abbreviated Injury Scale scores, Injury Severity Score, and transfusion requirements. Patients undergoing ER had significantly lower in-hospital mortality compared with patients undergoing OR (5.6% vs 27.8%; P = .040; odds ratio, 0.7; 95% confidence interval, 0.6-0.9). Similarly, patients undergoing ER had substantially lower rates of surgical site infections and a trend toward lower rates of sepsis. Outpatient follow-up was available in 88.2% (n = 15) of the patients at a median time of 8 months (1-30 months). Two ER patients required open reintervention for stent-related complications (one for a type Ia endoleak and another for stent thrombosis).

CONCLUSIONS

In our experience with axillosubclavian arterial injuries, ER was associated with improved mortality and lower complication rates. Patient follow-up demonstrates an acceptable reintervention rate after ER. Further multicenter prospective evaluation is warranted to determine long-term outcomes.

Blunt trauma of thorax with subclavian and axillary artery lesion--case report

We report a rare case of blunt trauma of the axillary artery in a 20-year-old man who was injured as a motorcycle rider and received severe body injuries. Injuries included severe trauma of the left lower leg with contusion and extensive soft tissue and bone trauma of these regions with poor general condition and with the presence of clinical signs of traumatic shock. Upon arrival, we found that in addition to earlier clearly visible trauma to the leg, there was a hematoma of the medial side of the left supraclavicular region and the absence of the radial artery pulse with paralysis of the left arm. Given the clinical findings, emergency radiological examination was made to the patient (X-ray, US, CDFI, MSCT-angiography) and we found out that there was trauma of axillary artery with clear signs of thrombosis of extra thoracic part of subclavian artery due to its transition into the axillary artery. After hemodynamic stabilization, above knee amputation of the left leg was performed and emergency exploration of earlier mentioned arteries. Bypass of the damaged arteries with synthetic graft 6 mm in diameter was made. Control MSCT angiography showed normal flow in the arterial tree of the whole left hand and the MRI of the cervical spine and shoulder girdle did not found lesions of the brachial plexus. SSEP demonstrated the absence of pulses on the left hand. Patient on regular check-ups showed normal general condition, with adequate passable graft and pronounced paralysis on the left hand. In the process of rehabilitation physiotherapy was also included. Blunt trauma to the axillary artery is an extremely rare example of trauma of blood vessels which makes only 0.03% of all vascular injuries.

Pseudoaneurysm after arthroscopic subacromial decompression and distal clavicle excision

Arthroscopic shoulder surgery is considered a safe and effective method of treating a variety of shoulder pathologies and is associated with a low complication rate. The type and rate of complications can vary, depending on the procedure, positioning, surgical time, and anesthesia. Fortunately, neurovascular injuries occur infrequently. Numerous studies have described the proximity of neurovascular structures to portals placed in shoulder arthroscopy, in both the beach chair and the lateral decubitus positions. Accurate portal placement is important to avoid damage to adjacent neurovascular structures. Inaccurate placement of portals can lead to inadvertent damage to these structures and create more difficulty with visualization and angle of instrumentation, possibly compromising the success of the procedure. This article describes a 50-year-old man who underwent arthroscopic subacromial decompression and distal clavicle excision for persistent subacromial impingement and acromioclavicular arthritis. During postoperative follow-up, the patient had a small, bulging area located near the anterior portal site. Examination showed a well-healed anterior portal site with a small (approximately 2×2 cm), nontender, immobile mass located within the deep soft tissues just below the anterior portal incision. Ultrasound evaluation showed a pseudoaneurysm of a branch off the axillary artery. The patient underwent successful embolization of the pseudoaneurysm, with complete resolution of symptoms.

[Judgment of defect length of extremities artery trauma and reconstruction]

OBJECTIVE

To study the influence of actual defect length and gap width of the limbs main artery on the method selection of repairing and reconstruction.

METHODS

Retrospective study was carried out for 32 patients with extremity main artery injury from 1996 to 2009, including 30 males and 2 females; 30 adults with an average age of 36 years old ranging from 18 to 51 years, 2 children of 4 and 5 years old respectively. Injured body parts involved axillary artery in 4 cases,brachial artery in 7 cases,radial artery in 2 cases, femoral artery in 4 cases, popliteal artery in 13 cases, posterior tibial artery in 2 cases. Main arterial injury defect gap width of all cases were observed and the reasons were analyzed. All cases were repaired by the method of end to end anastomosis after vessels stretch.

RESULTS

The artery defect width was 3 cm to 7 cm with an average of (4.375 +/- 1.200) cm. Defect width of the upper extremity brachial artery and axillary artery group was (5.73 +/- 0.63) cm,the lower extremity femoral and popliteal artery group (3.80 +/- 0.73) cm, the posterior tibial artery group (3.25 +/- 0.35) cm, the radial artery group (3.00 +/- 0.00) cm. Defect width of upper extremity brachial artery and axillary artery group was larger than that of the other three groups (P < 0.01). End to end anastomosis was performed successfully in all cases. Blood supply recovered well. Because of the severe limb infection 2 patients had amputation in the late. All patients received follow-up. The patients without fracture were followed up to 2 weeks postoperatively, all patients with fractures were followed up to 1 year at least. Limb blood supply was good in all patients during the follow-up.

CONCLUSION

Blood vessel defect gap width is different from the actual vessel defect, but is larger than the actual vessel defect. Misjudgment of the vascular defect length will lead to more vascular transplantation. The vast majority of vascular defect can be directly repaired by the method of end to end anastomosis after the vessel free and stretch.

Avulsive axillary artery injury in reverse total shoulder arthroplasty

In addition to neurologic injuries such as peripheral nerve palsy, axillary vessel injury should be recognized as a possible complication of reverse total shoulder arthroplasty. Limb lengthening associated with Grammont-type reverse total shoulder arthroplasty places tension across the brachial plexus and axillary vessels and may contribute to observed injuries. The Grammont-type reverse total shoulder arthroplasty prosthesis reverses the shoulder ball and socket, shifts the shoulder center of rotation distal and medial, and lengthens the arm. This alteration of native anatomy converts shearing to compressive glenohumeral joint forces while augmenting and tensioning the deltoid lever arm. Joint stability is enhanced; shoulder elevation is enabled in the rotator cuff–deficient shoulder. Arm lengthening associated with reverse total shoulder arthroplasty places a longitudinal strain on the brachial plexus and axillary vessels. Peripheral nerve palsies and other neurologic complications of reverse total shoulder arthroplasty have been documented. The authors describe a patient with rotator cuff tear arthropathy and a history of radioulnar synostosis who underwent reverse total shoulder arthroplasty complicated by intraoperative injury to the axillary artery and postoperative radial, ulnar, and musculocutaneous nerve palsies. Following a seemingly unremarkable placement of reverse shoulder components, brisk arterial bleeding was encountered while approximating the incised subscapularis tendon in preparation for wound closure. Further exploration revealed an avulsive-type injury of the axillary artery. After an unsuccessful attempt at primary repair, a synthetic arterial bypass graft was placed. Reperfusion of the right upper extremity was achieved and has been maintained to date. Postoperative clinical examination and electromyographic studies confirmed ongoing radial, ulnar, and musculocutaneous neuropathies.

[Application of the device for local compression of injured magistral arteries of the extremities]

External hemorrhage of extremities wounds is the leading cause of soldiers' death on the battlefield. In these cases control of massive arterial bleeding require not only prompt and effective measures, but also safety procedure. We assessed on volunteers the effectiveness, application time and pain intensity during the use of construction powerful quick-grip one-handed bar clamp. In results we found that the use of improvised quick-grip clamp for hemorrhage control in axillary and popliteal areas stops arterial blood flow in an extremity in all cases proven by Doppler ultrasound examination. Application time in axillary zone was 15.3 +/- 5.2 sec, in popliteal area--27.3 +/- 8.0 sec. In the groin area, the use of this improvised device was not effective due to technical characteristics (small distance between the main frame and the pressure surfaces). There do appear to be sufficient reasons to design the universal clamp for hemorrhage control from the wounds of junctional zones as well as proximal segments of extremities on Advanced Trauma Management stage and also for civilian prehospital emergency care.

Management of axillo-subclavian arterial injuries and predictors of outcome

AIM

Although incidence of subclavian and axillary artery injury account for less than 9% of all vascular injuries, trauma to these vessels presents a surgical challenge particularly with high mortality and morbidity rates. The aim of the study was to review our experience on subclavian and axillary vessels injury and to analyze factors that may influence results of reconstructive surgery.

METHODS

Data of 35 patients have been recorded between January 2000 and June 2010. Mean age was 24.86 ± 8.99 years and most were males (88.57%). Regression analysis was performed to find out factors affecting outcome. The mean follow-up time was 60 months. The artery was injured in 32 of the 35 cases (91.43%) and the vein was injured in nine cases (25.71%).

RESULTS

Seven of 24 reconstructions with saphenous graft failed as a result of thrombosis, whereas all of seven prosthetic grafts were patent during the long-term follow-up period. Except one, all surgical interventions followed by warfarin administration were patent while seven repair failures occurred among the anticoagulation-free interventions.

CONCLUSION

Autologous vein graft must be the first choice; however, in case of size discrepancy, prosthetic graft usage may be an alternative approach and postoperative administration of anticoagulants may be considered at least in the presence of certain risk factors such as native artery-graft diameter discrepancy, thrombus history and prosthetic graft.

Axillary artery thrombosis after humeral resurfacing arthroplasty

Shoulder arthroplasty is a very successful procedure that places significant technical demands on the surgeon. Complications, such as neural injury and postoperative fracture, have been reported in the literature. In this article, I describe 2 cases of axillary artery thrombosis that occurred after humeral resurfacing arthroplasty. Case 1 involved a 59-year-old woman who underwent humeral resurfacing arthroplasty. In the immediate postoperative period, a vascular insult was diagnosed by decreased radial pulse and perfusion. Immediate retrograde angiography revealed occlusion of the axillary artery near the level of the prosthesis. Retrograde balloon thrombectomy removed an arterial thrombus and circulation was restored. Case 2 involved a 64-year-old woman with a latent decrease in radial pulse amplitude after humeral resurfacing. Unsuccessful balloon thrombectomy necessitated a reverse saphenous vein bypass graft. Axillary artery injury that occurs after anterior shoulder dislocation is well documented. Shoulder position during humeral resurfacing reproduces anterior glenohumeral dislocation and may tense the axillary artery against the edge of the pectoralis minor. Elderly patients are predisposed to vascular injury because of loss of arterial elasticity. Meticulous neurovascular examination is crucial throughout the postoperative period, as collateral circulation may conceal perfusion deficits. Prompt recognition of vascular injury may prevent circulatory compromise.

[Proximal humeral fracture complicated by axillary artery lesion--a case review]

Although proximal humeral fractures are common diagnosis in emergency, cases of axillary artery injuries are rare. Authors present a patient, who underwent high energy trauma during a traffic accident like a pedestrian. Comminuted proximal humeral fracture was complicated with an occlusion of the third part of the axillary artery. There was necessary an urgent surgery, ostesynthesis with locking plate and reconstruction of the axillary artery by interposition of expanded polytetrafluoroethylene (ePTFE) graft. Postoperative course was uncomplicated, patient had no symptoms of ischaemia of extremity or claudication and started physiotherapy. In review of the literature authors present possible reasons of arterial injuries, possibilities of treatments to minimize risk of amputation. Axillary artery injury from proximal humeral fracture is rare, but every surgeon must be aware of this entity in order to avoid fatal complications.

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.

[A woman with a painful shoulder and cold hand]

A 65-year-old woman presented with a left-sided humeral fracture and a cold hand, caused by a dissection of her axillar artery. She was treated conservatively and perfusion recovered spontaneously.

[Trauma of the brachial plexus and associated vascular injury--a case report]

Acute vascular trauma in the axillary region is usually associated with brachial plexus injury and presents a great challenge to surgeon and formidable obstacle to restore a useful limb function. Interdisciplinary operative and postoperative approach is mandatory providing an optimal care of these severe patients. Here we present a case of neurovascular trauma that affected axillary artery and vein, complete transection associated with complete transection of the brachial plexus. Immediately after admission emergency surgery was performed and in postoperative follow up, after several operations and rehabilitation that continued for 24 months, entire functional recovery was achieved without any disabling consequences.

[Axillary wound with complete vasculo-nervous section. Functional outcomes]

Axillary wound with complete vasculonervous section are rare in adults, males between 20 and 30 years being more affected. In children these lesions are even more rarely encountered. Immediate surgical repair of vascular and nervous sections is recommended. Neurological impalement may be severe when all nervous trunks in the axilla are affected. Recovery of the motor and sensitive deficit is a long process and is often partial, good functional outcome being rare. Recovery in children is supposed to be better due to a more rapid regenerative capacity of the nerves. We present the case of a 9-year-old boy with axillary wound and complete section of axillary artery, median, ulnar, radial and musculocutaneous nerves and medial cutaneous nerve of arm. Vascular reconstruction with venous graft and epiperineural nerve reconstruction was done. Kinetotherapy and physiotherapy was part of recovery treatment. Follow up at 15 months confirmed very good functional outcomes with almost complete motor and sensitive function of the limb.

Endovascular treatment of axillary artery dissection following anterior shoulder dislocation

Injury to the axillary artery is a rare complication of anterior shoulder dislocation. Open surgical repair is technically demanding because of the anatomical position of the vessel and the propensity for concomitant injuries. Standard surgical exposure techniques involve extensive dissection, including a combination of supraclavicular or infraclavicular incision, median sternotomy, and thoracotomy causing significant morbidity and mortality rates. Endovascular techniques may offer an alternative to these surgically demanding procedures. We present a patient with a traumatic dissection of the axillary artery following anterior shoulder dislocation who was successfully managed with an endovascular stent.

[Angular approach in the surgical treatment of the axillary neurovascular bundle pathologies]

Different surgical approaches have been developed in the surgical treatment of various isolated and combined lesions of the axillary neurovascular bundle. The angular approach favorably differs from others and has a number of advantages. The angular approach was used to operate on 16 patients with varying abnormalities at this site, including 6 patients with traumatic lesion of the secondary trunks of the brachial plexus and 6 with space-occupying lesion, and 1 patient with the superior thoracic aperture; the remaining 6 patients with significant neurovascular compression syndrome, who had been operated on for various causes. The authors have made certain that the angular approach lightens a surgical intervention and shortens its duration substantially, by reducing the risk of postoperative pyoinflammatory complications, keloid cicatrices, and contractures. The surgical approach applied by the authors is universal and may be used in the treatment of pathology of the secondary trunks of the brachial plexus and vascular lesions, tumors, and pyoinflammatory processes of the axillary space.

Diagnosis and management of vascular injuries in the shoulder girdle of the overhead athlete

Vascular injuries represent a rare cause of shoulder pain and functional limitation among overhead athletes. Complaints of heaviness, fatigue, paresthesias, and effort-related pain should prompt the sports medicine clinician to consider vascular pathology as a possible cause of such symptoms. Position-dependent compression of the subclavian and axillary vessels within the thoracic outlet may result in functional limitation and a decline in overhead athletic performance, particularly when symptoms occur in the dominant upper limb. Treatment options include physical therapy and (in the case of thrombus) thrombolysis, but surgical decompression of the neurovascular bundle is generally advocated. This article reviews the diagnosis and management of effort thrombosis (also known as Paget-Schroetter syndrome), arterial thoracic outlet syndrome, and entrapment of the posterior circumflex humeral artery within the quadrilateral space. Familiarity with these conditions may help to minimize the risk of delayed diagnosis and associated morbidity.

Isolated axillary artery injury due to blunt trauma

The intimal damage of the axillary artery due to an acute, single blunt trauma is very rare without concomitant bone, brachial plexus, venous and soft tissue injuries. Early diagnosis and appropriate management of the arterial injury is essential to avoid permanent disability. The clinical signs are usually occult and do not become manifest until a long ischemic interval following injury, owing to the extensive collateral network. A twenty-year-old male patient had injured his left arm in a hyperabduction and hyperextension position while he was carrying a refrigerator with his arm. An increase in the intensity of pain and numbness reappeared in his left arm 1.5 months after the trauma. Digital subtraction angiography of the axillary artery performed after his hospitalization showed an occlusion of the axillary artery and no reconstitution of distal part of the occlusion via collateral vessels. During the operation, the axillary and brachial arteries were bypassed with a saphenous graft. As shown in this case report, in the early period after blunt trauma of the upper limb, progressive signs of vascular compromise may disappear because of collateral circulation even if the distal pulses are absent. Then an angiography of the upper limb becomes essential for correct diagnosis and treatment. This is our second experience. On the basis of our first experience that was reported, in such a chronic case, oral anticoagulation must be carried out at least six months whenever a graft thrombosis after revascularization is encountered.

Simultaneous bilateral anterior fracture dislocation of the shoulder with neurovascular injury: report of a case

This paper reports an unusual case of orthopedic trauma in a 29-year-old man who experienced concomitant bilateral anterior shoulder fracture dislocation with associated brachial plexus and axillary artery injury. We also highlight the mechanism underlying this rare workplace injury related to use of a forklift.

Fracture of the proximal humerus with injury to the axillary artery in a boy aged 13 years

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.

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

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

Iatrogenic axillary artery injury from humeral neck fracture repair. A rare and unusual event in which and aggressive strategy was mandatory to save a child limb

Humeral neck fracture is rarely associated with injury of the nearby axillary artery and in the English literature only 29 such cases have been reported. An injury of the distal axillary artery secondary to reduction and fixation of a humeral neck fracture is a very rare and unusual complication, to the best of our knowledge has never been reported in literature. In this paper we report the case of entrapment of the distal axillary artery in the humerus rhyme fracture in a 9-year-old child who suffered a nighttime car-accident with her father. At admission, the child presented a left humeral neck fracture with no other lesions and no neurologic problems in her limb; peripheral pulses present in her left hand at palpation. After closed reduction and pinning of the fracture with 2 K-wires, the left upper limb became ischemic and pulseless and the child was transferred at our Institution for diagnosis and treatment. In this paper we discuss the treatment to be adopted in this very unusual situation.

Primary nerve repair in associated lesions of the axillary artery and brachial plexus

Diagnosis becomes more complex when there is an association of a brachial plexus injury with an arterial lesion. The principal clinical picture in most cases is acute ischemia that requires initial treatment in the emergency room, and the final results of nerve repair are generally poorer. Although delayed brachial plexus reconstruction is preferred by some authors, our experience leads us to the opinion that a combined repair presents several advantages. Immediately after trauma, the surgical field is free of scar tissue, and a precise evaluation of both the number and level of damaged nerves may be made. Vascular and nerve repair may be mutually agreed upon by both the vascular surgeon and microsurgeon, and simple sutures may often be used instead of grafts in early nerve repair. Even if the extent of nerve damage may sometimes be difficult to assess, the results of early, easier repairs can be observed in our series of 14 combined lesions. Our results indicate that collaboration between microsurgeons and vascular surgeons is a very important factor in providing a correct approach to these problematic patients.

Traumatic injuries to the subclavian and axillary arteries: a 13-year review

PURPOSE

By reviewing our experience, we evaluated the presentation, management, and long-term outcome of patients with subclavian and axillary artery injuries resulting from trauma.

METHODS

We retrospectively reviewed the data of 38 patients who received treatment for subclavian or axillary artery injuries in the Emergency and Trauma Department of Medical Faculty of Istanbul, Istanbul University between January 1989 and July 2002.

RESULTS

Arterial injuries were repaired with an end-to-end anastomosis in 10 (26.3%) patients, primary repair in 6 (15.7%), autologous vein graft interposition in 16 (42%), ligation in 5 (13.1%), and a proximal subclavian-brachial artery bypass in 1 (2.6%). One (2.6%) of the arterial reconstructions failed in the perioperative period. Fourteen (36%) patients presented with a neurological deficit, which recovered after the intervention in 2 (5.2%) patients. A wound infection developed in 8 (21%) patients and 2 (5.2%) patients died of concomitant injuries. Thirteen (36.1%) of the remaining 36 patients were followed up for a mean period of 7 months.

CONCLUSION

Successful management of subclavian and axillary artery injuries requires prompt diagnosis because the occult nature of these injuries necessitates a high index of suspicion. Although revascularization procedures are often successful, it is the associated neurological, orthopedic, and soft tissue injuries that affect the functional outcome of the limb.

Endovascular Repair of a Traumatic Axillary Pseudoaneurysm Following Anterior Shoulder Dislocation

Pseudoaneurysms due to musculoskeletal trauma are rare and comprise less than 2% of all pseudoaneurysms. We report a case of axillary pseudoaneurysm following anterior dislocation of the shoulder. The patient was successfully treated by endovascular intervention.

Techniques for reduction of anteroinferior shoulder dislocation

Dislocation of the shoulder joint is common. The shoulder is affected in up to 60% of all major joint dislocations, one study citing an incidence of 1.7% in the general population. The most common form is anteroinferior dislocation. A variety of techniques to reduce shoulder dislocation has been described. The key to successful relocation is a thorough understanding of the anatomy of both the enlocated and the dislocated shoulder joint.

[Acute vascular occlusion of the upper extremity after blunt trauma]

Intimal ruptures after blunt trauma without joint dislocation are rare. We report the case of a 62 year old male patient presenting with paraesthesia in the fingers I to III and a cool left hand after a blunt trauma of the upper arm. Non-invasive examination documented the thrombotic occlusion of the axillary artery. Due to a circular rupture of the intima surgical revascularization was performed with a vein graft.

Traumatic Axillary Artery Dissection with Radial Artery Embolism

This report describes a case of pathologically proven traumatic arterial dissection, presenting as complete occlusion of the axillary artery with radial artery embolism. Occlusion of the axillary artery by traumatic dissection mimicked transection and radial artery embolism mimicked congenital absence of the radial artery on the initial angiogram, but these were correctly diagnosed with the following sonogram.

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

Gleno-humeral dislocations are frequent, but associated complete transection of the axillary artery has only been reported sporadically. We present a case of complete rupture of the axillary artery associated with recurrent anterior dislocation of the shoulder, followed by a discussion of the likely mechanisms and the key learning points.