rev bras ortop.2015;50(1):110–113
w w w . r b o . o r g . b r
Case
report
Axillary
artery
lesion
secondary
to
fracturing
of
the
proximal
third
of
the
humerus:
case
report
夽
Alberto
Naoki
Miyazaki,
Marcelo
Fregoneze,
Pedro
Doneux
dos
Santos,
Luciana
Andrade
da
Silva
∗,
Guilherme
do
Val
Sella,
Sergio
Luiz
Checchia,
Sílvia
Helena
Cavadinha
Cândido
dos
Santos,
Fábio
Araujo
Fernandes
DepartmentofOrthopedicsandTraumatology,SchoolofMedicalSciences,SantaCasadeSãoPaulo,SãoPaulo,SP,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received30December2013 Accepted6February2014 Availableonline22January2015
Keywords:
Axillaryartery Humeralfractures Shoulderfractures
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b
s
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c
t
Lesionsoftheaxillaryarteryarerareinpatientswithfracturingoftheproximalthirdof thehumerusandmayhavegreatlyvaryingclinicalmanifestations.Theyareresponsiblefor 15%and20%ofupper-limbarteryinjuriesandthecommonestmechanismisafalltothe ground,whichaccountsfor79%ofsuchinjuries.Insomecases,thesignsonlyappearlater on.Itisimportanttobearthisassociationinmind,soastomakeanearlydiagnosisand avoidseriouscomplications.Wereportonacaseoftraumaticinjuryoftheaxillaryartery secondarytofracturingoftheproximalthirdofthehumerusinan84-year-oldpatient,with lateevolutionofclinicalsignsofischemiainthelimbaffected.Theaimherewastodiscuss thediagnosticdifficultiesandtreatment.
©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.
Lesão
da
artéria
axilar
secundária
a
fratura
do
terc¸o
proximal
de
úmero:
relato
de
caso
Palavras-chave:
Artériaaxilar Fraturasdoúmero Fraturasdoombro
r
e
s
u
m
o
Aslesõesdaartériaaxilarsãorarasempacientescomfraturasdoterc¸oproximaldoúmero epodemtermanifestac¸õesclínicasbastantevariadas.Sãoresponsáveispor15%a20%das lesõesarteriaisdosmembrossuperioreseomecanismomaiscomuméaquedaaosolo,que representa79%dostraumas.Emalgunscasosossinaissóaparecemtardiamente.É impor-tantelembraressaassociac¸ão,afimdediagnosticá-laprecocementeeevitarcomplicac¸ões graves.Relatamosumcasodelesãotraumáticadaartériaaxilarsecundáriaàfraturado terc¸oproximaldoúmeroemumapacientede84 anos,comevoluc¸ãotardia dossinais
夽
WorkdevelopedintheShoulderandElbowGroupoftheDepartmentofOrthopedicsandTraumatology,SchoolofMedicalSciences, SantaCasadeSãoPaulo,FernandinhoSimonsenWing,SãoPaulo,SP,Brazil.
∗ Correspondingauthor.
E-mail:[email protected](L.A.daSilva).
http://dx.doi.org/10.1016/j.rboe.2015.01.002
rev bras ortop.2015;50(1):110–113
111
clínicosdeisquemiadomembroacometido.Oobjetivoédiscutirasdificuldadesdo diag-nósticoedotratamento.
©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Todososdireitosreservados.
Introduction
Injuriestothebrachialplexusandaxillaryarteryarerarein patientswithfracturesoftheproximalthirdofthehumerus (FPTH),despitetheanatomicalproximityofthesestructures.1
Injuriestotheaxillaryarteryare responsiblefor15–20% ofthearterialinjuriesoftheupperlimbs2:94%ofthemare
causedbypenetrating woundsand theremainder (6%) are duetodislocatedfractures oftheshoulder. Themost com-monmechanismforthelatterisfallingtotheground,which accountsfor79%ofsuchinjuries.3
Theaimofthisarticlewastoreportonacaseofinjurytothe axillaryarterythatoccurredasaconsequenceofFPTH,along withthedifficultiesinmakingthediagnosisandperforming thetreatment.
Clinical
case
Thepatientwas an84-year-old womanwho was admitted tothe emergencyserviceafterhavingsuffered afalltothe ground,withright-sideFPTHandcranialinjury.
On physical examination, edema, hematoma and pain whenmovingtheright shoulderwere observed. Neurologi-calexaminationoftherightupperlimbshowedparesisinthe handandelbow,butthisexaminationwasimpairedbecause oftheloweredconsciousnesslevelassociatedwiththecranial injury.Onvascularexamination,palpationofthedistalpulse and measurement of peripheral perfusion were normal. A radiographontherightshouldershowedaFPTHwithmarked medializationofthe metaphysis(Fig. 1).Surgicaltreatment wasproposed,butbecauseofthecranialinjuryand comor-bidities,itwasnotpossibletooperateonthepatientasan emergency.
Onthethirddayofthehospitalstay,itwasobservedthat thetemperatureoftherightupperlimbhaddecreased,the distalperfusionhaddiminishedandtherewasnodistalpulse. Emergencysurgicalexplorationwasindicated,withthe sus-picionofthrombosisoftheaxillaryartery.Therewasnoneed forpreoperativearteriography,sincetheclinicalconditionof ischemiawasself-evidentandthissupplementary examina-tionwouldhavepostponedtheoperationandaddedgreater damagetothelimb.
Bymeansofthedeltopectoralroute,arthroplastywas per-formedinordertoresectthehumeralepiphysis,becauseofthe severityofthesituationandthepatient’spoorclinical condi-tion.Thevascularsurgeryteamperformeddissectionofthe axillaryarteryand foundthat itwas intact,but withpulse presentintheregionproximaltothefractureandabsent dis-tally.Thromboendarterectomywasperformed(Fig.2)usinga Fogarty®catheterinordertocompletelyremovethe
obstruc-tionofthearteriallumen.Intraoperativearteriography(Fig.3)
showedanotherobstructionattheleveloftheelbow,which wasalsodealtwithinordertoachievelimbreperfusion.
Inexploringthebrachialplexus,weonlyobservedsigns of contusion of the median, ulnar and musculocutaneous nerves.
Thepatient died afterthe operation,10h aftershewas takentoanintensivecareunit,whereshehadarrived intu-batedandpresentinghemodynamicinstability.Hercondition progressedtobradycardia,followedbyasystole,whichcould not bereversed.Thecause ofdeath wasidentified as pul-monarythromboembolism.
Discussion
Traumaticinjurytotheaxillaryartery,asacomplicationof FPTH,israre.Yagubtanand Panneton3 onlyfound24cases
ofinjurytotheaxillaryarterysubsequenttoFPTHdescribed intheEnglish-languageliterature.Aneurologicaldeficitwas observedin46%ofthepatientsand54%hadinjuriesofthe intimalayeroftheartery,whichledsecondarilytothrombosis. Vascularrepairwasperformedinallthecases,withan upper-limbsalvagerateofmorethan89%.
Fig.1–Radiographicimageoftherightshoulderin
anteroposteriorviewshowingfractureoftheproximalthird
ofthehumerus:notemedialdisplacementofthehumeral
112
rev bras ortop.2015;50(1):110–113Fig.2–Intraoperativeimageshowingdissectionofthe
axillaryarteryandarteriotomy:noteexitofthrombusfrom
theaxillaryarterythroughtheopening(whitearrow).
Fig.3–Imageofarteriographyoftherightupperlimb
showingarterialobstructionattheleveloftheelbow(white
arrow).
Thebrachialplexuspresentsacloserelationshipwiththe axillary artery, inside acommon fascialsheath. Therefore, anydamagetothearterythatcausesmildedemamaylead tonervecompression.4Sukeietal.5emphasizedthat
pares-thesiaisprobablythemostreliablesymptomofinadequate peripheralcirculation. Thus,vascularinjuryshould be sus-pectedwhenthereisaneurologicaldeficitassociatedwiththe fracture.
AccordingtoMatheietal.,6suspectingarterialinjuryisthe
firstandmostimportantsteptowardmakingthediagnosis. Whenclinicalsignsofischemiaofthelimbarepresent,the diagnosisbecomeseasy,althoughinsomecasesthesignsof ischemiamaynotbeevidentjustaftertheinjuryandmayonly appearlateron,withsevereconsequencesforthelimb.
Vascular injuriesassociatedwith fractures ofthe proxi-malregionofthehumerusaremorecommonamongelderly patients.Thepathogenesisoftheseinjuriesconsistsofa com-binationofosteoporosisandatherosclerosis.5
Theinjurymechanismsincludedirecttraumaduetobone spiculesor excessive stretchingofthe arterywiththe arm in hyperabduction withavulsionor rupturing ofthe origin ofone ofthebranches. Theacuteinjuries rangefrom lac-eration of the artery to damage only to the intima layer, whichleadstoocclusionofthelumenofthevessel.Injuries seenlateronincludepseudoaneurysm,arteriovenousfistula orthrombosis.7,8 Thus,thevascularclinicalstateshouldbe
assessedregularlyonthedaysfollowingtheinjury.9
In the case presentedhere, the injury mechanism was probablyarterialcontusionresultingfromdirectcontactwith the bone spicule, which led to injury of the intima layer andevolvedwithsubsequentclinicalmanifestationoftotal obstructionofthevessel.
The clinical condition of axillary artery injury is often complex andvariable.Physicalexaminationisanexcellent predictorfordetectingarterialinjury,withsensitivityof96%.3
Insomecases,greatersignsarepresent,suchasactive hemor-rhage,absenceofradialpulse,alteredbrachialarterypressure andpulsatilehematoma.6,10Inothercases,onlysignsofrisk
maybepresent,suchasalterationsofthedistalpulse,pain afterreductionandstabilizationofthefracture,muscle weak-ness,numbness,paralysis,stiffness,pallororoneextremity colderthanthatoftheoppositelimb.4Inourcase,thephysical
examinationwassomewhatimpairedbecauseofthelowering ofthepatient’slevelofconsciousnessduetotheassociated cranialinjury.
Modi et al.7 recommended that all patients with FPTH
with significant medialdisplacement ofthe diaphysisor a medialbonespiculeshouldroutinelyundergo ultrasonogra-phyinordertoruleoutvascularinjuries.Inouropinion,given thatthisexaminationmaybeinconclusiveintheacutephase, becauseofnotrulingoutinjuryoftheintimalayerofthe ves-sel,wedonotagreewiththeindicationofperformingitonall patientswithdisplacedfractureswhodonotpresentclinical signs.
rev bras ortop.2015;50(1):110–113
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associationinmind,soastodiagnoseitearlyandavoid com-plicationsofgreaterseverity.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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1. SuttieAS,MofidiR,HowdA,GriffithsGD.UseofaJavidTM
shuntinthemanagementofaxillaryarteryinjuryasa complicationoffractureofthesurgicalneckofthehumerus: acasereport.JMedCaseRep.2008;2:259.
2. ZhangQ,WangS,TangC,ChenW,ZhangY,ChenL.Axillary arterylesionsfromhumeralneckfracture:astudyinrelation torepair.ExpTherMed.2013;5(1):328–32.
3. YagubyanM,PannetonJM.Axillaryarteryinjuryfrom humeralneckfracture:ararebutdisablingtraumaticevent. VascEndovascSurg.2004;38(2):175–84.
4.StenningM,DrewS,BirchR.Low-energyarterialinjuryatthe shoulderwithprogressiveordelayednervepalsy.JBoneJoint SurgBr.2005;87(8):1102–6.
5.SuikeiM,VashistaG,ShaathN.Axillaryarterycompromisein aminimallydisplacedproximalhumerusfracture:acase report.CasesJ.2009;2:9308.
6.MatheïJ,DepuydtP,ParmentierL,OlivierF,HarakeR,Janssen A.Injuryoftheaxillaryarteryafteraproximalhumeral fracture:acasereportandoverviewoftheliterature.Acta ChirBelg.2008;108(5):625–7.
7.ModiCS,NneneCO,GodsiffSP,EslerCNA.Axillaryartery injurysecondarytodisplacedproximalhumeralfractures:a reportoftwocases.JOrthopSurg.2008;16(2):243–6.
8.JensenBV,JacobsenJ,AndreasenH.Lateappearanceof arterialinjurycausedbyfractureoftheneckofthehumerus. JTrauma.1987;27(12):1368–9.
9.GallucciG,RanallettaM,GallucciJ,CarliPD,MaignonG.Late onsetofaxillaryarterythrombosisafteranondisplaced humeralneckfracture:acasereport.JShoulderElbowSurg. 2007;16(2):e7–8.
