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COpynghl
Thrombosis
by The Journal
1987
of the Axillary
Proximal
EDWARD
V.
A.
LIM,
M.D.t,
From
Fractures
for about
of the proximal
S per cent
It is a common
such
fractures
around
contributing
as a fall
the San
factor.
osteoporosis
In large
Francisco
series
Fractures
THREE
J.
General
Complicating
CASES*
DAY,
M.D4,
Hospital,
SAN
San
FRANCISCO,
Case
slipped
Like
fell at home
and
hospital.
Physical
were
about
ulnar,
the
not
examination
palpable
and
white
approximately
part of the left shoulder.
to be a strong
Reports
1 . A ninety-one-year-old
CASE
population.
has a minor
on fractures
CALIFORNIA
Francisco
account
extremity.
appears
OF
Incorporated
Artery
LORRAINE
of the humerus
on an outstretched
the hip,
REPORT
AND
of all fractures
in the general
in the elderly
patient
who
injury
accident
end
Surger.
Humeral
A
BY
of Bone and Joint
median
revealed
The
in the
woman
four
left
nerves
were
of the
surgical
a large
upper
brachial,
who
hours
intact.
or
warm,
but
arteries.
Radiographs
to the
on the anterior
was
ulnar
dementia
admission
hematoma
extremity
radial,
had senile
before
pulses
The
showed
radial,
a comminuted
FIG. 1-A
Case
I
.
A
ninety-one-year-old
woman
who
had
a severely
displaced
fracture
humerus
did not return.
An arteriogram
demonstrated
occlusion
is rare4’78.
just
to the
and
circumflex
We
treated
at the
8
are reporting
the cases
of three
been
in the sixth
patients
within
the last three years on the orthopaedic
San Francisco
General
Hospital.
No benefits
in any form
have
been
received
or will
who
were
service
be received
.
778
Gentle
traction
proximal
was
There
long
deltopectoral
and
(Fig.
the
1-C).
which
extended
verse
arteriotomy
also
was
with
a displaced
bounding
severe
developed.
posterior
axillary
artery
Because
osteopenia,
a Neer
a loose
screw,
The
applied.
radial
and
hypertension,
Four
days
of
a rotated
intertrochanteric
were
the
strip
then
were
of
Postoperatively,
arterial
the patient
died
a
of
the
replacement
was
the
left
but
and
was
thrombus,
through
hip
pulses,
fibrillation,
1-B).
through
comminution
removed
the
artery
(Fig.
explored
the surrounding
fracture
ulnar
artery
humeral
and
but the pulses
of the axillary
severe
distally,
atrial
later
extremity
proximal
intimal
centimeters
incision.
had strong
to the left upper
incision.
four
hip
failure
and
Then,
compression
operatively,
applied
anterior
The site of the fracture
done
a commercial
party related
directly
or indirectly
to the subject
ofthis
article.
No funds were received
in support
of this study.
t Department
of Orthopaedic
Surgery,
University
of Cincinnati
Mcdical Center,
231 Bethesda
Avenue,
Cincinnati,
Ohio 45267.
t Department
of Orthopaedic
Surgery
San Francisco
General
Hospital,
1001 Potrero
Avenue,
San Francisco,
California
941 10.
1-A).
fracture.
fracture
from
(Fig.
of
the
fracture
fragment
have
neck
humerus.
proximal
of the patients
surgical
left
displaced
the majority
the
of the
and seventh
decades
of life6, but neurovascular
injuries
are
not commonly
associated
with fractures
and dislocations
about the shoulder
and acute thrombosis
ofthe axillary
artery
shoulder
of
neck
a trans-
reduced
upper
three
days
congestive
of a massive
and
extremity
postheart
myocardial
infarction.
THE JOURNAL
OF BONE AND JOINT SURGERY
a
THROMBOSIS
who
had
admission
radial
chronic
to the
pulse
noted,
neck
done
were
for
a long
fixation.
securely
in spite
revealed
an intimal
thrombosed
cised,
medium.
The
saphenous
was
cold
and
a stretch
defect
of
graft
embolism,
diagnosed
scan,
loss
of fixation
twenty-eight
successfully
of the
days
humeral
was
it was
after
had no pain
sufficiency
involving
the arm
was
CASE
Hospital.
and
was
the initial
replacement.
the patient
stairs
fracture
At
final
the
had an acute
on
evident
follow-up
right
upper
the
basis
with
After
a
On
admission
VOL. 69-A, NO. 5, JUNE
upper
the
the artery
mottled
episode
of pul-
of a ventilation-
on follow-up
had a Neer
months
no problems
extremity.
The
was
with
Progressive
radiographs,
the patient
eighteen
he had
1987
white
emergency
decreased
The
was
after
and
three
years
insufficiency.
proximal
surgery,
of vascular
range
a Rush
room
radial
man
to 60 degrees,
in-
of motion
fell down
at San
and
Francisco
brachial
rod
Postoperatively
of
a flight
The
axillary
and
and
of
while
the
bluish
and
neck of the
traction
pulses
and
a cut-off
hu-
in the
line
the extremity
the
con-
brachial
systolic
blood
artery
pressure
with
resected
The
proximal
inserted
through
range
then
after
the greater
immobilizer
had
of the
to 60 degrees,
to
on
the
and
it was
circumflex
found
vessels
A one-centimeter
section
a primary
anastomosis
flow
of the humerus
was
then
fixed
final
follow-up
tuberosity.
was
no symptoms
ofthe
distal
traction
explored,
thrombus.
and
fragment
ofmotion
abduction
was
medium
despite
At the region
filled
was
of contrast
remained
artery
site.
the patient
The
gentle
pulse,
occlusion
a shoulder
later,
using
Doppler
of mercury,
fracture
artery
re-established.
cold
the radial
The
demonstrated
artery.
in the
A
was
of the surgical
of mercury.
to be trapped
defect.
artery distally.
components.
extremity
reduction
cold.
millimeters
extremity.
The
brachial
cemented
fracture
to restore
and
millimeters
subscapular
used.
On
of vascular
shoulder
internal
claudication
was painless
rotation
with
or
flexion
to 90 degrees,
and external
rotation to 20 degrees.
There was some pain on overhead
because of impingement
of the proximal
end of the Rush rod
motion
underneath
to the
failed
An arteriogram
the
hand.
manipulative
pale
forty
150
in the
of the
using
a displaced
had been cx-
heparin.
and
3. A seventy-seven-year-old
brought
to be
fixed
functional.
was
deformity
tinued
was
segment
media.
of the
measured
screws
to be
artery
to bridge
treated
shoulder
of
of the axillary
operation,
in the
thought
was
used
the patient
which
and
An initial
merus.
of the fracture
a plate
in the tunica
was
perfusion
fracture
reduction
the axillary
monary
A weak
of the thrombosed
segment
postoperatively.
and
1-C
with reconstitution
humeral
replacement
good capillary
blush
radiographs
showed
On
a three-centimeter
and
fragment
shoulder
immobilizer
was used
Four days postoperatively
clammy.
a displaced
An open
artery run-off,
Neer proximal
alcoholic
intoxicated.
revealed
Exploration
vein
a chronic
while
incision,
fracture
with
was
fell
revealed
deltopectoral
three-centimeter
a reversed
who
and
An angiogram
of the osteopenia.
tear
arm
radiographs
of contrast
through
used
and
right
of the humerus.
in the column
was
man
slipped
the
779
ARTERY
FIG.
showing
a block distal to the subscapular
made after removal
of the thrombus
and
dementia
hospital,
was
the surgical
defect
Arteriogram
Radiograph
2. A seventy-nine-year-old
CASE
and
1-B:
1 -C:
AXILLARY
1-B
FIG.
Fig.
Fig.
OF THE
the acromion,
of
but
otherwise
the patient
was
doing
well.
Discussion
General
pulses
but
To our knowledge,
there have been only isolated
case
780
E.
reports
The
of injury
to the axillary
complication
is much
artery
more
V.
A.
LIM
after
humeral
fracture.
common
after
clavicular
AND
L.
J.
DAY
The
persistence
shoulder
may
of collateral
mask
a lesion
circulation
of the
axillary
about the
artery, but in
fractures
or dislocation
of the should&.
Weile
and Fjeldborg suggested
that the predilection
of the artery to injury
our three
amination.
patients
the diagnosis
Although
the circulation
is caused
by its fixation
proximally
by the thoraco-acromial
branch
and distally
by the anterior
and posterior
humeral
circumflex
arteries.
This predilection
is combined
with the
loss of elasticity
of the arteries
in the elderly.
The sclerotic
vessels
may tear, rupture,
or sustain
intimal
damage,
after
obviously
compromised,
the radial and ulnar pulses may be
They should
always
be checked
and compared
in the contralateral
extremity.
On admission,
two
which
thrombosis
may occur.
Actual
or brachial
comitantes,
of laceration
to the
axillary
with
plexus
can occur
ends
of a fracture
of a fracture
artery
directly
associated
is controversial.
with
as the result
those
of the normal
operative
fragment.
been
even
with vascular
Earlier
those
of our patients
had warm extremities
with good capillary
refill,
but the Doppler
pulses
in the antecubital
fossa and
radial artery were diminished
significantly
when compared
Avulsion
of some branches
of the axillary
artery,
venae
by the jagged
The management
injury
supervenes.
transection
attenuated.
treatment
Immediate
studies
of the fracture
fixation.
brachial
Anatomical
of the humerus
reduction
and maintaining
alignment
by closed
means,
various
internal
fixation
have been
comminution
and osteopenia
humeral
replacement
of fractures
is not necessary,
may
ofdisplaced
methods
of the
and because
elderly,
occur,
The
adverse
exploration
is our
effects
and the high risk
been emphasized.
of non-
artery
of the axillary
has
of patchy
or
of the artery
after stabilization
regimen
as soon as an
recommended
arteriogram
is made.
In all of our patients,
a segmental
defect in the artery was noted although
reconstitution
of the
surgical
reducing
artery
noted
fragments
is difficult
of open reduction
and
used.
In the
commonly
side.
of thrombosis
noted in past reports5’7,
complete
gangrene
has
suggested
that rigid fixation
of the fracture
is necessary
to
protect
the site of vascular
repai?.
More recent
studies
indicated
that good results
can be obtained
without
internal
neck
was made
on initial
cxof the limb may not be
as well.
operatively
in our
artery
axillary
in whom
proximal
distally
was
Reconstitution
reverse
patients,
found
vein
circulation
was
findings
were confirmed
and in one of them (Case
the collateral
intra3) the
to be caught
of the primary
by thrombectomy,
be necessary.
through
Angiographic
excision
vessel
in the
may
and primary
fracture
site.
be accomplished
repair,
or use
of a
graft.
References
I
.
C. S. ; CONFORTY,
B. ; ENGELBERG,
M. ; and REISS,
13: 564-566, 1973.
HENSON,
0. F. : Vascular
Complications
of Shoulder
Injuries.
JARDON,
0. M. ; Hooo,
L. 1. ; and LYNCH,
R. D. : Complete
and Joint Surg. , 55-A: 189-192, Jan. 1973.
LINSON,
M. A.: Axillary
Artery Thrombosis
after Fracture
of
MCQUILLAN,
W. M. , and NOLAN,
B. : Ischaemia
Complicating
492, 1968.
NEER, C. S., II: Displaced
Proximal
Humerus
Fractures.
Part
ANTAL,
R. : Injuries
to the
Axillary
Artery
due
to Anterior
Dislocation
of the Shoulder.
J.
Trauma,
2.
3.
4.
5.
6.
J. Bone
Avulsion
and Joint Surg.
of the Axillary
,
38-B(2):
528-531,
1956.
Artery
as a Complication
of Shoulder
Dislocation.
J. Bone
the Humerus.
A Case Report.
J. Bone and Joint Surg. , 62-A:
1214-1215,
Oct.
Injury.
A Report
of Thirty-seven
Cases.
J. Bone and Joint Surg. , SO-B(3):
I. Classification
and
Evaluation.
J. Bone
and Joint
Surg.
.
52-A:
1077-1089,
1980.
482-
Sept.
1970.
7.
E. H. J. : Major Arterial
Injury in Closed
Fracture
of the Neck of the Humerus.
Report of a Case. J. Bone and Joint Surg. , 51-B(3):
5081969.
THEODORIDES,
1. , and DE KEIZER,
G.: Injuries
of the Axillary
Artery Caused
by Fractures
of the Neck of the Humerus.
injury,
8: 120-123,
1976.
WEILE, F. , and FJELDBORG, 0. : Lesions
of the Axillary
Artery
Associated
with Dislocation
of the Shoulder.
Acta Chir.
Scandinavica,
137: 279281, 1971.
SMYTH,
510,
8.
9.
ThE JOURNAL
OF BONE
AND
JOINT
SURGERY
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