Axillary Artery Injury Accompanying Humeral Neck Fracture

Abstract

Fractures of the proximal humerus account for approximately 5% of all long bone fractures.1 Arterial injuries resulting from proximal humeral fractures are even less common. The world literature contains 66 instances where proximal humeral fractures cause arterial injuries documented in case reports 1-29 or small series with less than 10 cases. 30-38These are important injuries because delayed diagnosis and treatment may result in serious sequelae including functional impairment, Volkmann ischemic contractures, and even limb loss. We report a case of axillary arterial injury resulting from a proximal humeral fracture and discuss the management of this uncommon disorder. Case ReportA 68-year-old woman fell from a staircase at a height of 8 ft from the ground. She fell onto the left shoulder and immediately experienced severe incapacitating left shoulder pain. She sought attention at a community clinic. The shoulder was tender and swollen and mobility was impaired secondary to pain. Plain radiographs confirmed a fracture of the humeral neck (►Fig. 1). The shoulder was immobilized with a plaster of paris cast and the patient transferred to a tertiary referral hospital for care.She was stabilized in the emergency room and referred to the orthopedic service for a fractured neck of humerus. Although the ipsilateral upper limb was warm and pink, the radial and ulnar pulses were reduced in volume. The junior orthopedic resident removed the cast to examine the limb, but documented no further clinical information in the patient's clinical record. Postimmobilization radiographs were requested.Four hours later, she was evaluated by the senior orthopedic resident who recognized clinical findings suggestive of limb ischemia: cool limb and reduced ipsilateral pulses. The cast was immediately removed and the vascular surgery team urgently summoned.A duplex Doppler scan confirmed the absence of arterial flow at the ipsilateral brachial and radial arteries, but the axillary artery could not be assessed properly due to tenderness and edema at the area. The patient was taken emergently to the operating room for exploration, arterial repair, and joint stabilization.Intraoperatively, a contused segment of the distal axillary artery was encountered, just as it continued to form the brachial artery (►Fig. 2). There were no pulsations within the vessel at this point and no distal flow was detected.The shoulder joint was fixated with a short rod and wires and vessel exploration followed. The contused segment of axillary artery was excised after proximal and distal control. A large intimal flap was found to be obstructing the lumen in the injured segment. A 10-cm segment of proximal great saphenous vein was harvested from the ipsilateral thigh. The reversed vein was used to restore continuity as an AbstractInjuries to the axillary artery from proximal humeral fractures are uncommon. There are only 66 such injuries reported across the world literature to date. We report an additional case of axillary artery injury. This case highlights the...

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