PROXIMAL HUMERUS FRACTURE-DISLOCATION WITH LACERATION OF THE AXILLARY ARTERY: A CASE REPORT Steven J. Cotman1, MD, Thai Q. Trinh1, MD, Stephen Vincent1, MD, Jeffrey R. Backes1, MD
ABSTRACT 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 twopart 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.
Affiliation: 1 Mount Carmel Medical Center 793 West State Street Columbus, Ohio 43222. Corresponding Author: Jeffrey R. Backes MD Mount Carmel Health System Department of Orthopaedics, Columbus, Ohio Phone: 614-234-5000, Fax: 614-234-2772 Email: [email protected] Disclosures: None of the authors received payments or services, either directly or indirectly, from a third party in support of any aspect of this work.
INTRODUCTION Proximal Humerus fractures account for 4-6% of all fractures.1 Concomitant neurovascular injury to the surrounding brachial plexus and axillary artery have previously been reported in 6.2% 2 and 0.09% 3 of patients respectively. The current evidence reporting the diagnosis and management of axillary artery injuries in the setting of proximal humerus fractures is limited.4-7 The current paper details the presentation, diagnosis and management of a patient presenting with a brachial plexopathy and axillary artery laceration following a low energy proximal humerus fracture. Verbal consent was obtained from the patient prior to submission for publication. CASE REPORT A 79-year-old male presented with a chief complaint of right upper extremity pain with associated subjective weakness and paresthesias. The patient had sustained a mechanical fall from standing height while intoxicated approximately one hour prior to presentation. Physical exam findings included a hemodynamically stable patient with acute swelling and pain about the right shoulder. Dense paresthesias and a lack of motor function distal to the elbow were noted. Sensation in the axillary nerve distribution appeared grossly intact. The patient’s right hand appeared pale with no appreciable pulses on palpation or doppler examination. Plain radiographs demonstrated an intra-articular two-part fracture-dislocation of the proximal humerus (Figure 1). A CT angiogram was notable for laceration of the axillary artery with the displaced humeral shaft located adjacent to the zone of injury (Figure 2). A closed reduction was not attempted given the presumed tamponade effect exerted by the displaced fracture fragment. The patient was emergently taken to the operating room by both the orthopedic and vascular surgery teams. Operative Procedure The patient was placed supine on an operative table with both the right upper and right lower extremities prepped into the surgical field. Utilizing an extended infra-clavicular approach, the vascular surgery team isolated the first and second portions of the axillary artery. No injuries were noted in these regions and proximal control was obtained. The initial approach was extended Volume 37 53
S.J. Cotman, T.Q. Trinh, S. vincent, J.R. Backes
Figure 1: AP (A.) and Scapular Y (B) projections demonstrating a two-part proximal humerus fracture dislocation
Figure 2: CT- Angiogram demonstrating traumatic transection of the axillary artery by the displaced humeral shaft
Figure 3: Intra-operative fluoroscopic image following open reduction internal fixation of the displaced proximal humerus fracture (A.). Postoperative images at 3 (B.) and 6 months (C.).
into a traditional deltopectoral approach for exposure of the fracture site. The humeral shaft was identified resting against the third portion of the axillary artery. A reduction maneuver was performed and a complex tear of the anteroinferior wall of the axillary artery was noted just proximal to the anterior and posterior humeral circumflex vessels. Despite the presence of a simple intra-articular split of the humeral head, it was elected to proceed with placement of a proximal humeral locking plate for fracture stabilization given the need for vascular bypass. Following stabilization of the fracture, an axillary-brachial arterial bypass was performed using a reverse-saphenous vein graft. Following completion of the bypass, prophylactic fasciotomies of the arm and forearm were performed. Post-Operative Course The patient was discharged from the hospital on postoperative day 21. At three months, the patient was unable to demonstrate any active shoulder, elbow, wrist 54 The Iowa Orthopedic Journal
or hand motion. Radiographs demonstrated inferior subluxation of the humeral head and increased subchondral sclerosis of the proximal humerus. At six months, the patient was able to demonstrate 30 degrees of active shoulder abduction. He did not regain any active motion of the elbow, wrist or hand and possessed only limited sensation to light touch along the ulnar border of his fifth digit. Postoperative films at six months demonstrated improved seating of his humeral head with signs of avascular necrosis including humeral head collapse and resorption of the greater tuberosity (Figure 3). DISCUSSION Neurovascular injury following low-energy fractures of the proximal humerus is a rare but important entity with both therapeutic and prognostic implications.3 Although the injury can occur anywhere along the course of the artery, previous reports have documented a high rate of injury to the third segment of the artery in those patients presenting with isolated fractures of the proximal
Proximal Humerus Fracture-Dislocation with Laceration of the Axillary Artery: A Case Report humerus.8 The current case highlights the importance of identifying a potential vascular injury prior to any attempt at closed reduction. Based on intraoperative findings, a closed reduction may have removed the tamponade effect exerted by the displaced humeral shaft and potentially resulted in hemodynamic instability or death. The authors were unable to identify a reported case of a patient experiencing hemodynamic instability or death as a result of a closed reduction. In a retrospective case series of 3 patients with proximal humerus fractures and concomitant axillary artery injury, Thorsness et al.7 highlighted the need for early vascular surgery involvement, especially in patients presenting on a delayed basis as the displaced fracture fragments may have scarred to the adjacent neurovascular structures. Although the current patient presented with obvious signs of involvement of both the brachial plexus and axillary artery, the presence of a palpable pulse does not always exclude the presence of a vascular injury secondary to extensive collateral blood flow.9 In a retrospective population-based study, Menendez et al.3 reported that males, patients with atherosclerotic disease, and those patients with concomitant injuries to either the scapula, ribs or brachial plexus were more likely to present with injury to the axillary artery. The authors recommended that all patients presenting with a proximal humerus fracture with signs and symptoms of a brachial plexus injury undergo vascular testing to rule out involvement of the axillary artery.3 The long-term prognosis of patients presenting with brachial plexus and vascular injuries remains guarded.8 In a retrospective review of twenty-one patients, neurologic recovery was universally poor with 86% of patients possessing neurologic deficits at final follow up.8 The role of acute brachial plexus exploration and nerve repair remains unknown. Major orthopedic complications included a high rate of AVN (15%), delayed union (10%) A and delayed shoulder arthrodesis (10%) secondary to inferior subluxation of the humeral head. Twenty-four percent of patients underwent secondary amputation between 4 days and 18 months.8
REFERENCES 1. McLaughlin, J.A., R. Light, and I. Lustrin, Axillary artery injury as a complication of proximal humerus fractures. J Shoulder Elbow Surg. 1998; 7(3): p. 292-294. 2. Stableforth, P.G., Four-part fractures of the neck of the humerus. J Bone Joint Surg Br. 1984; 66(1): p. 104-108. 3. Menendez, M.E., D. Ring, and M. Heng, Proximal humerus fracture with injury to the axillary artery: a population-based study. Injury. 2015; 46(7): p. 13671371. 4. Gorthi, V., et al., Life-threatening posterior circumflex humeral artery injury secondary to fracturedislocation of the proximal humerus. Orthopedics. 2010; 33(3). 5. Inui, A., et al., Shoulder fracture dislocation associated with axillary artery injury: a case report. J Shoulder Elbow Surg. 2009; 18(2): p. e14-16. 6. Papaconstantinou, H.T., et al., Endovascular repair of a blunt traumatic axillary artery injury presenting with limb-threatening ischemia. J Trauma. 2004; 57(1): p. 180-183. 7. Thorsness, R., et al., Proximal humerus fractures with associated axillary artery injury. J Orthop Trauma. 2014; 28(11): p. 659-663. 8. Ng, A.J., et al., Axillary Artery Injury Associated with Proximal Humeral Fractures: Review of LongTerm Vascular, Orthopedic, and Neurologic Outcomes. Ann Vasc Surg. 2016. 9. Gallucci, G., et al., Late onset of axillary artery thrombosis after a nondisplaced humeral neck fracture: a case report. J Shoulder Elbow Surg. 2007; 16(2): p. e7-8.
SUMMARY The high association of brachial plexus and vascular injuries should reinforce the need for a detailed neurovascular exam in the setting of a proximal humerus fracture. Non-invasive vascular studies and early vascular consultation is recommended for any patient presenting with concerns for vascular injury. We recommend against performing a closed reduction in patients presenting with vascular injury in which the OR is immediately available. Despite early treatment, the prognosis of patients with this constellation of injuries is guarded.
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ABSTRACT 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 twopart 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.
Affiliation: 1 Mount Carmel Medical Center 793 West State Street Columbus, Ohio 43222. Corresponding Author: Jeffrey R. Backes MD Mount Carmel Health System Department of Orthopaedics, Columbus, Ohio Phone: 614-234-5000, Fax: 614-234-2772 Email: [email protected] Disclosures: None of the authors received payments or services, either directly or indirectly, from a third party in support of any aspect of this work.
INTRODUCTION Proximal Humerus fractures account for 4-6% of all fractures.1 Concomitant neurovascular injury to the surrounding brachial plexus and axillary artery have previously been reported in 6.2% 2 and 0.09% 3 of patients respectively. The current evidence reporting the diagnosis and management of axillary artery injuries in the setting of proximal humerus fractures is limited.4-7 The current paper details the presentation, diagnosis and management of a patient presenting with a brachial plexopathy and axillary artery laceration following a low energy proximal humerus fracture. Verbal consent was obtained from the patient prior to submission for publication. CASE REPORT A 79-year-old male presented with a chief complaint of right upper extremity pain with associated subjective weakness and paresthesias. The patient had sustained a mechanical fall from standing height while intoxicated approximately one hour prior to presentation. Physical exam findings included a hemodynamically stable patient with acute swelling and pain about the right shoulder. Dense paresthesias and a lack of motor function distal to the elbow were noted. Sensation in the axillary nerve distribution appeared grossly intact. The patient’s right hand appeared pale with no appreciable pulses on palpation or doppler examination. Plain radiographs demonstrated an intra-articular two-part fracture-dislocation of the proximal humerus (Figure 1). A CT angiogram was notable for laceration of the axillary artery with the displaced humeral shaft located adjacent to the zone of injury (Figure 2). A closed reduction was not attempted given the presumed tamponade effect exerted by the displaced fracture fragment. The patient was emergently taken to the operating room by both the orthopedic and vascular surgery teams. Operative Procedure The patient was placed supine on an operative table with both the right upper and right lower extremities prepped into the surgical field. Utilizing an extended infra-clavicular approach, the vascular surgery team isolated the first and second portions of the axillary artery. No injuries were noted in these regions and proximal control was obtained. The initial approach was extended Volume 37 53
S.J. Cotman, T.Q. Trinh, S. vincent, J.R. Backes
Figure 1: AP (A.) and Scapular Y (B) projections demonstrating a two-part proximal humerus fracture dislocation
Figure 2: CT- Angiogram demonstrating traumatic transection of the axillary artery by the displaced humeral shaft
Figure 3: Intra-operative fluoroscopic image following open reduction internal fixation of the displaced proximal humerus fracture (A.). Postoperative images at 3 (B.) and 6 months (C.).
into a traditional deltopectoral approach for exposure of the fracture site. The humeral shaft was identified resting against the third portion of the axillary artery. A reduction maneuver was performed and a complex tear of the anteroinferior wall of the axillary artery was noted just proximal to the anterior and posterior humeral circumflex vessels. Despite the presence of a simple intra-articular split of the humeral head, it was elected to proceed with placement of a proximal humeral locking plate for fracture stabilization given the need for vascular bypass. Following stabilization of the fracture, an axillary-brachial arterial bypass was performed using a reverse-saphenous vein graft. Following completion of the bypass, prophylactic fasciotomies of the arm and forearm were performed. Post-Operative Course The patient was discharged from the hospital on postoperative day 21. At three months, the patient was unable to demonstrate any active shoulder, elbow, wrist 54 The Iowa Orthopedic Journal
or hand motion. Radiographs demonstrated inferior subluxation of the humeral head and increased subchondral sclerosis of the proximal humerus. At six months, the patient was able to demonstrate 30 degrees of active shoulder abduction. He did not regain any active motion of the elbow, wrist or hand and possessed only limited sensation to light touch along the ulnar border of his fifth digit. Postoperative films at six months demonstrated improved seating of his humeral head with signs of avascular necrosis including humeral head collapse and resorption of the greater tuberosity (Figure 3). DISCUSSION Neurovascular injury following low-energy fractures of the proximal humerus is a rare but important entity with both therapeutic and prognostic implications.3 Although the injury can occur anywhere along the course of the artery, previous reports have documented a high rate of injury to the third segment of the artery in those patients presenting with isolated fractures of the proximal
Proximal Humerus Fracture-Dislocation with Laceration of the Axillary Artery: A Case Report humerus.8 The current case highlights the importance of identifying a potential vascular injury prior to any attempt at closed reduction. Based on intraoperative findings, a closed reduction may have removed the tamponade effect exerted by the displaced humeral shaft and potentially resulted in hemodynamic instability or death. The authors were unable to identify a reported case of a patient experiencing hemodynamic instability or death as a result of a closed reduction. In a retrospective case series of 3 patients with proximal humerus fractures and concomitant axillary artery injury, Thorsness et al.7 highlighted the need for early vascular surgery involvement, especially in patients presenting on a delayed basis as the displaced fracture fragments may have scarred to the adjacent neurovascular structures. Although the current patient presented with obvious signs of involvement of both the brachial plexus and axillary artery, the presence of a palpable pulse does not always exclude the presence of a vascular injury secondary to extensive collateral blood flow.9 In a retrospective population-based study, Menendez et al.3 reported that males, patients with atherosclerotic disease, and those patients with concomitant injuries to either the scapula, ribs or brachial plexus were more likely to present with injury to the axillary artery. The authors recommended that all patients presenting with a proximal humerus fracture with signs and symptoms of a brachial plexus injury undergo vascular testing to rule out involvement of the axillary artery.3 The long-term prognosis of patients presenting with brachial plexus and vascular injuries remains guarded.8 In a retrospective review of twenty-one patients, neurologic recovery was universally poor with 86% of patients possessing neurologic deficits at final follow up.8 The role of acute brachial plexus exploration and nerve repair remains unknown. Major orthopedic complications included a high rate of AVN (15%), delayed union (10%) A and delayed shoulder arthrodesis (10%) secondary to inferior subluxation of the humeral head. Twenty-four percent of patients underwent secondary amputation between 4 days and 18 months.8
REFERENCES 1. McLaughlin, J.A., R. Light, and I. Lustrin, Axillary artery injury as a complication of proximal humerus fractures. J Shoulder Elbow Surg. 1998; 7(3): p. 292-294. 2. Stableforth, P.G., Four-part fractures of the neck of the humerus. J Bone Joint Surg Br. 1984; 66(1): p. 104-108. 3. Menendez, M.E., D. Ring, and M. Heng, Proximal humerus fracture with injury to the axillary artery: a population-based study. Injury. 2015; 46(7): p. 13671371. 4. Gorthi, V., et al., Life-threatening posterior circumflex humeral artery injury secondary to fracturedislocation of the proximal humerus. Orthopedics. 2010; 33(3). 5. Inui, A., et al., Shoulder fracture dislocation associated with axillary artery injury: a case report. J Shoulder Elbow Surg. 2009; 18(2): p. e14-16. 6. Papaconstantinou, H.T., et al., Endovascular repair of a blunt traumatic axillary artery injury presenting with limb-threatening ischemia. J Trauma. 2004; 57(1): p. 180-183. 7. Thorsness, R., et al., Proximal humerus fractures with associated axillary artery injury. J Orthop Trauma. 2014; 28(11): p. 659-663. 8. Ng, A.J., et al., Axillary Artery Injury Associated with Proximal Humeral Fractures: Review of LongTerm Vascular, Orthopedic, and Neurologic Outcomes. Ann Vasc Surg. 2016. 9. Gallucci, G., et al., Late onset of axillary artery thrombosis after a nondisplaced humeral neck fracture: a case report. J Shoulder Elbow Surg. 2007; 16(2): p. e7-8.
SUMMARY The high association of brachial plexus and vascular injuries should reinforce the need for a detailed neurovascular exam in the setting of a proximal humerus fracture. Non-invasive vascular studies and early vascular consultation is recommended for any patient presenting with concerns for vascular injury. We recommend against performing a closed reduction in patients presenting with vascular injury in which the OR is immediately available. Despite early treatment, the prognosis of patients with this constellation of injuries is guarded.
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