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Abstract
A case of transection of anterior circumference humeral artery, a branch of the 3rd part of the axillary artery is reported, after a simple anterior shoulder dislocation. This complication though rare could potentially result in catastrophic consequences for the patient. It should therefore be recognised early and a coordinated prompt vascular and orthopaedic surgical treatment given for better upper limb functional outcome.
- anterior shoulder dislocation
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A 91 year old man presented to the emergency department with severe right shoulder pain having tripped and fallen onto the shoulder about 40 minutes earlier.
He has had no previous injuries to this shoulder.
Although he had myocardial infarction nine years previously, he has no other past medical history. He was not on any medication and was fully independent.
He had normal triage observations, which were as follows; pulse rate 55/min; respiration rate 16/min; blood pressure 148/75 mm Hg ; oxygen saturation 98%.
His physical examination revealed an obvious anterior dislocation of the right shoulder with normal neurovascular examination.
After administration of intravenous analgesic (10 mg morphine sulphate), radiographs were obtained, which confirmed simple subcoracoid anterior glenohumeral dislocation.
This was easily relocated soon after under Entonox (a mixture of nitrous oxide and oxygen containing 50% of each gas) using Kocher's method and confirmed radiographically.
Within minutes of relocation, the patient began to experience increasing pain in the shoulder. Close observation revealed increasing deltopectoral swelling and bruising, which aroused a suspicion of internal haemorrhage despite having normal ipsilateral brachial and radial pulses. He remained haemodynamically normal and had normal full blood count and clotting screen.
The orthopaedic and vascular surgeons were called and elected to take the patient to theatre for urgent surgical exploration. They found a bleeding transected anterior circumference humeral artery with a massive tissue haematoma of approximately 300 ml within the axillary sheath. The haematoma was evacuated and haemostasis was achieved by ligation of the bleeding artery.
Although he recovered well from anaesthesia, he was left with a brachial plexus deficit and went on to suffer considerable morbidity including: wound infection with MRSA, septicaemia, acute renal failure, and stiff shoulder. Secondary closure of his surgical wound was carried out by plastic surgeons and he was finally discharged from the ward eight weeks later. He is currently making good progress with outpatient physiotherapy.
DISCUSSION
Simple anterior glenohumeral dislocation accounts for approximately 50% of all dislocations seen in emergency departments and tends to be most frequent in healthy men.1
It is rarely associated with vascular complications but the axillary artery or its branches may be damaged,2 often with serious consequences, as in this case. With the exception of the popliteal, the axillary artery is perhaps more frequently lacerated by violent movements than any other artery in the body.
The axillary artery is the continuation of the subclavian at the outer border of the first rib and nominally ends at the lower border of the teres major muscle where it becomes the brachial. The pectoralis minor crosses the vessel and divides it into three parts, the first part being proximal, the second posterior, and the third distal to the muscle. The first part is enclosed together with the axillary vein and the brachial plexus in the fibrous axillary sheath, continuous above with the prevertebral layer of the deep cervical fascia. This close relation, illustrated in figure 1 makes the brachial plexus vulnerable in axillary vascular injuries. The anterior circumflex humeral, a branch of the third part, is one of the six branches of the axillary artery.3
The close relation between the axillary artery and its six branches with the brachial plexus and the shoulder joint is illustrated.
Recognised predisposing factors are: recurrent dislocation (27% of cases) and age, (86% occur in patients older than 50)4 resulting from adhesion to the joint capsule and atherosclerosis rendering the vessels less compliant. A review of the litera-ture shows that the third part of the axillary artery and its branches are most commonly damaged however, there has not been a previously reported anterior circumference humeral artery injury, the smallest branch, as in this case.
This vascular injury may happen primarily at the time of dislocation or result directly during relocation. The primary injury may become evident after relocation because of loss of the tamponade effect exerted by the dislocated shoulder.
Because of the potential wide ranging consequences of this injury, which includes a reported fatal haemorrhage,5 it should be actively excluded by paying close attention to the injured shoulder and ipsilateral radial pulse in elderly patients who present in the emergency department with recurrent anterior shoulder dislocation.
Once suspected, selective axillary angiography should be performed urgently as delayed recognition of these lesions may lead to permanent neurological deficits despite adequate vascular repair of the affected artery.
A coordinated vascular and orthopaedic approach and prompt surgical treatment may assure full upper limb function.