a Departamento de Ortopedia, Santa Casa de São Paulo, São Paulo, SP, Brasil
b Serviço de Ortopedia e Traumatologia, Hospital Israelita Albert Einstein, Universidade Federal de São Paulo (Unifesp), São Paulo, SP,Brasil
c Instituto de Ortopedia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, SP, Brasil
d Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brasil
Introduction
Injuries to the brachial plexus and axillary artery are rare inpatients with fractures of the proximal third of the humerus(FPTH), despite the anatomical proximity of these structures.
Injuries to the axillary artery are responsible for 15-20%of the arterial injuries of the upper limbs2: 94% of them arecaused by penetrating wounds and the remainder (6%) aredue to dislocated fractures of the shoulder. The most com-mon mechanism for the latter is falling to the ground, whichaccounts for 79% of such injuries.
The aim of this article was to report on a case of injury to theaxillary artery that occurred as a consequence of FPTH, alongwith the difficulties in making the diagnosis and performingthe treatment.
Clinical case
The patient was an 84-year-old woman who was admittedto the emergency service after having suffered a fall to theground, with right-side FPTH and cranial injury.
On physical examination, edema, hematoma and painwhen moving the right shoulder were observed. Neurologi-cal examination of the right upper limb showed paresis in thehand and elbow, but this examination was impaired becauseof the lowered consciousness level associated with the cranialinjury. On vascular examination, palpation of the distal pulseand measurement of peripheral perfusion were normal. Aradiograph on the right shoulder showed a FPTH with markedmedialization of the metaphysis (Fig. 1). Surgical treatmentwas proposed, but because of the cranial injury and comor-bidities, it was not possible to operate on the patient as anemergency.
On the third day of the hospital stay, it was observed thatthe temperature of the right upper limb had decreased, thedistal perfusion had diminished and there was no distal pulse.Emergency surgical exploration was indicated, with the sus-picion of thrombosis of the axillary artery. There was no needfor preoperative arteriography, since the clinical condition ofischemia was self-evident and this supplementary examina-tion would have postponed the operation and added greaterdamage to the limb.
By means of the deltopectoral route, arthroplasty was per-formed in order to resect the humeral epiphysis, because of theseverity of the situation and the patient's poor clinical condi-tion. The vascular surgery team performed dissection of theaxillary artery and found that it was intact, but with pulsepresent in the region proximal to the fracture and absent dis-tally. Thromboendarterectomy was performed (Fig. 2) using aFogarty®catheter in order to completely remove the obstruc-tion of the arterial lumen. Intraoperative arteriography (Fig. 3) showed another obstruction at the level of the elbow, whichwas also dealt with in order to achieve limb reperfusion.
In exploring the brachial plexus, we only observed signsof contusion of the median, ulnar and musculocutaneousnerves.
The patient died after the operation, 10 h after she wastaken to an intensive care unit, where she had arrived intu-bated and presenting hemodynamic instability. Her conditionprogressed to bradycardia, followed by asystole, which couldnot be reversed. The cause of death was identified as pul-monary thromboembolism.
Discussion
Traumatic injury to the axillary artery, as a complication ofFPTH, is rare. Yagubtan and Panneton3only found 24 casesof injury to the axillary artery subsequent to FPTH describedin the English-language literature. A neurological deficit wasobserved in 46% of the patients and 54% had injuries of theintima layer of the artery, which led secondarily to thrombosis.Vascular repair was performed in all the cases, with an upper-limb salvage rate of more than 89%.
The brachial plexus presents a close relationship with theaxillary artery, inside a common fascial sheath. Therefore,any damage to the artery that causes mild edema may leadto nerve compression.4Sukei et al.5emphasized that pares-thesia is probably the most reliable symptom of inadequateperipheral circulation. Thus, vascular injury should be sus-pected when there is a neurological deficit associated with thefracture.
According to Mathei et al.,6suspecting arterial injury is thefirst and most important step toward making the diagnosis.When clinical signs of ischemia of the limb are present, thediagnosis becomes easy, although in some cases the signs ofischemia may not be evident just after the injury and may onlyappear later on, with severe consequences for the limb.
Vascular injuries associated with fractures of the proxi-mal region of the humerus are more common among elderlypatients. The pathogenesis of these injuries consists of a com-bination of osteoporosis and atherosclerosis.
The injury mechanisms include direct trauma due to bonespicules or excessive stretching of the artery with the armin hyperabduction with avulsion or rupturing of the originof one of the branches. The acute injuries range from lac-eration of the artery to damage only to the intima layer,which leads to occlusion of the lumen of the vessel. Injuriesseen later on include pseudoaneurysm, arteriovenous fistulaor thrombosis.7,8Thus, the vascular clinical state should beassessed regularly on the days following the injury.
In the case presented here, the injury mechanism wasprobably arterial contusion resulting from direct contact withthe bone spicule, which led to injury of the intima layerand evolved with subsequent clinical manifestation of totalobstruction of the vessel.
The clinical condition of axillary artery injury is oftencomplex and variable. Physical examination is an excellentpredictor for detecting arterial injury, with sensitivity of 96%.3In some cases, greater signs are present, such as active hemor-rhage, absence of radial pulse, altered brachial artery pressureand pulsatile hematoma.6,10In other cases, only signs of riskmay be present, such as alterations of the distal pulse, painafter reduction and stabilization of the fracture, muscle weak-ness, numbness, paralysis, stiffness, pallor or one extremitycolder than that of the opposite limb.4In our case, the physicalexamination was somewhat impaired because of the loweringof the patient's level of consciousness due to the associatedcranial injury.
Modi et al.7recommended that all patients with FPTHwith significant medial displacement of the diaphysis or amedial bone spicule should routinely undergo ultrasonogra-phy in order to rule out vascular injuries. In our opinion, giventhat this examination may be inconclusive in the acute phase,because of not ruling out injury of the intima layer of the ves-sel, we do not agree with the indication of performing it on allpatients with displaced fractures who do not present clinicalsigns.
This article draws attention to the association betweentraumatic injury of the axillary artery and cases of FPTH. Eventhough this association is uncommon, it may lead to disas-trous complications when present. In some cases, like ours,the signs only appear later on. It is important to bear this association in mind, so as to diagnose it early and avoid com-plications of greater severity.
Conflicts of interest
The authors declare no conflicts of interest.
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