Case report

A 75 year old woman was admitted to the accident and emergency (A&E) department after a history of a fall on the outstretched right hand. This had resulted from her being “blown over” by a strong gust of wind. On arrival to A&E she complained of pain in the right shoulder. Clinical examination revealed swelling and tenderness in the area of the right axilla and shoulder. On further examination her radial pulse was present but was noted to be somewhat weaker then that on the left side. The right arm was also felt to be colder then the left. Neurological examination revealed a complete motor and sensory deficit affecting the right arm. Radiography was urgently carried out which showed no evidence of fracture or dislocation to the shoulder or humerus.

The swelling in the axilla continued to increase and the lady became hypotensive. Despite the presence of a radial pulse a clinical diagnosis of a vascular injury to the axillary artery was made in addition to a presumed injury to the brachial plexus. After successful resuscitation by volume replacement angiography was carried out, which showed leaking of contrast material from a branch of the axillary artery (fig 1).

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Figure 1

Angiogram showing contrast material leaking from the axillary artery.

At formal exploration in the operating theatre a side branch of the axillary artery was found to be avulsed from the axillary artery itself. Haemostasis was readily secured. No evidence of injury to the exposed parts of the brachial plexus was apparent at operation. Postoperatively the neurological deficit persisted. Nerve conduction studies were carried out that confirmed avulsion of the roots of the brachial plexus that was not amenable to surgical treatment.

Discussion

Damage to the axillary artery after blunt injury usually occurs as a consequence of severe trauma. Arterial injury is well described in association with fracture of the upper humerus^{1, 2} or dislocation of the shoulder.^{3, 4} Our case shows that arterial injury in the axilla can occur with low impact as well as high impact injuries and that severe vascular and neurological injury can occur in the absence of fracture or dislocation. This case also confirms the close association between arterial injury to the axillary artery and damage to the brachial plexus.

BRACHIAL PLEXUS INJURY

Neurological injury to the brachial plexus is usually caused by severe traction to the nerve roots that occurs at the time of injury. As in our case these injuries are most often not amenable to surgical treatment. Volume loss into the axilla as a result of associated arterial injury can be considerable in these cases and was sufficient to cause hypotension in the case described. The tamponade effect of the haematoma being contained in the axilla delays exsanguination. We have identified only one case in the medical literature where damage to the axillary artery itself was the cause of death in the absence of associated injury.⁵ The high axillary pressures caused by the tamponade effect can, however, cause a compression neuropathy to the brachial plexus. Prompt evacuation of the haematoma may significantly reduce the subsequent neurological deficit in such cases. The long term outcome of neurovascular injury to the axillary structures is not dependent on the vascular injury, which can usually be successfully managed, but upon the recognition, treatment, and outcome of the associated nerve injuries.⁶

Conclusion

This case highlights the importance of performing a full, detailed neurovascular examination in all patients with an upper limb injury. This case also confirms that a significant vascular injury can be present even when the distal pulse is present and that vascular injury can occur in the elderly with lesser degrees of force because of atherosclerotic rigidity of the artery. In cases where a vascular injury is suspected and the patient is stable angiography should be rapidly carried out to delineate the anatomy of the injury allowing surgical access to be planned. Although a coordinated vascular and orthopaedic approach and prompt surgical treatment will optimise post-injury upper limb function the long term results of these complex injuries are usually determined by the presence and severity of associated nerve injuries.