Proximal humerus fractures account for 4-6% of 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 or anterior circumflex humeral artery injuries in the setting of proximal humerus fractures is limited.4-7 This current case report details the presentation, diagnosis and management of a patient presenting with an axillary nerve neuropraxia following a low energy proximal humerus fracture-dislocation, and an anterior circumflex humeral artery avulsion injury intraoperatively.
An 83-year-old female sustained a fall while pushing a supermarket cart, and landed on her right shoulder on September 3, 2017. She had no prior complaints or other injuries to her right shoulder. She was seen in the emergency department that night. X-rays were obtained demonstrating a four-part proximal humerus fracture-dislocation. (Figure 1) A closed reduction was not attempted, and she was sent home in a sling and came into our clinic on September 6, 2017 for further evaluation.
Her past medical history is significant for diabetes type II, coronary artery disease, atrial fibrillation, and congestive heart failure. Her medications include Digoxin, Lasix, Metformin, Glipizide, and Xarelto. She is a non-smoker and does not drink alcohol. On physical exam, her body mass index (BMI) is 42. She had significant ecchymosis in the right upper arm. She was cooperative on exam, demonstrating intact lateral shoulder and distal sensation. She had 4/5 motor intact of the posterior deltoid, but upon effort 0/5 motor of the middle and anterior deltoid. Her active and passive range of motion was painful and unable to be fully assessed.
The plan at this point was to achieve medical optimization with cardiology clearance. Further imaging, including a computed tomography (CT) scan of the right shoulder was obtained at an outside institution. She was consented for a reverse total shoulder arthroplasty with fracture specific implants.
Day of Surgery
The day of surgery September 12, 2017, an interscalene block was administered, as well as general endotracheal anesthesia.
The patient was placed supine, with the head of the table elevated approximately 30 degrees. A traditional deltopectoral approach was utilized for exposure. The biceps tendon was identified and traced to the glenoid. A subpectoral biceps tenodesis was done, and the greater and lesser tuberosities were identified and traction sutures were placed. The humeral head was palpated in the subcoracoid recess. An arterial pulsation was detected next to the humeral head. The humeral head was freed gently using finger dissection. With lifting the humeral head, brisk bleeding was encountered. The surgical dissection area was immediately packed, appropriate warning was given to the anesthesia and the operating room staff that we would need packed red blood cells, and cell saver was requested. A call was placed to vascular surgery intraoperatively. The incision was then extended proximally and the pectoralis minor and the conjoined tendon were taken down transversely 1 cm distal to the tip of the coracoid with a cuff of tissue for later repair. The pectoralis major was then released from its insertion on the humerus. These were tagged with heavy suture for easy identification. The axillary artery was carefully dissected from the brachial plexus and vessel loops were placed proximally and distally. An avulsed branch, the anterior circumflex humeral artery, was identified and using 5-0 nylon suture figure of eight sutures were placed at the base which stopped the bleeding. Vascular surgery recommended to attempt palpation of a distal pulse. We were able to palpate a radial pulse distally and doppler an ulnar pulse distally. The area was packed with thrombin soaked foams. Since the patient was stable and bleeding was under control we felt it was safe to continue with her procedure. A reverse total shoulder arthroplasty was implanted with no difficulty, and the tuberosities were reduced to the implant. (Figure 2)
The patient was extubated and transferred to the post anesthesia care unit, and from there to the telemetry floor. She remained stable during her post-operative stay. An arterial doppler exam was obtained of her right upper extremity, which showed normal flow distally of her bilateral upper extremities. (Figure 3) Xarelto was resumed on post-operative day one. She worked with physical therapy and was discharged on post-operative day two to a skilled rehab facility in stable condition.
Neurovascular injury following low energy fractures of the proximal humerus is rare but an important entity with both therapeutic and prognostic implications.3 The current case highlights the importance of identifying possible vascular injury prior to attempt at any closed reduction. Based on the intraoperative findings, a closed reduction may have removed a possible tamponade effect exerted by the displaced humeral head. This case also highlights the need for heightened awareness of a pre-operative injury or increased risk of intraoperative vascular injury, when there is a neurologic injury suspected based on preoperative exam findings. Some authors recommend that all patients presenting with a proximal humerus fracture with signs and symptoms of a brachial plexus injury undergo vascular testing pre-operatively to rule out involvement of the axillary artery or its branches. 3 The long-term prognosis of patients presenting with brachial plexus and vascular injuries remains guarded,10 however there is little literature regarding the prognosis of patients who have an axillary nerve neuropraxia pre-operatively and sustain an avulsion injury to the anterior circumflex artery intraoperatively. The high association of neurovascular injuries should reinforce the need for a detailed neurovascular exam pre-operatively and post-operatively in the setting of a proximal humerus fracture, especially when there is a dislocation present. Non-invasive vascular studies and early vascular consultation are recommended for any patient presenting with concerns of a vascular injury. This case demonstrates the importance of having a well equipped orthopedic and vascular team available for prevention, recognition, and management when there is concern of a significant arterial injury.
- 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.
- 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. 1367-1371.
- Gorthi, V., et al., Life-threatening posterior circumflex humeral artery injury secondary to fracture-dislocation of the proximal humerus. Orthopedics. 2010; 33(3).
- 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.
- 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.
- Thorsness, R., et al., Proximal humerus fractures with associated axillary artery injury. J Orthop Trauma. 2014; 28(11): p. 659-663.
- Padegimas, E., et al, Evaluation and management of axillary artery injury: The orthopedic and vascular surgeon’s perspective. J Bone Joint Surg. 2017; 5 (6): p. e1-8.
- Lo, I., et al, Surgery about the Coracoid: Neurovascular Structures at Risk. Journal of Arthroscopic and Related Surgery. 2004; 20(6): p. 591-595.
- 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.