Proximal humeral fracture-dislocation with axillary artery involvement treated with reverse shoulder arthroplasty

Acute deep venous thrombosis and late onset axillary artery injury after a displaced, proximal humerus fracture-dislocation in an octogenarian patient

“…In fact, effective collateral circulation at shoulder level can result in peripheral radial artery pulses despite axillary artery damage. On the contrary, Mehta et al [2] reported a case of RTSA in a patient with comminute proximal humerus fracture, with an intimate relationship between shaped fracture fragments and the axillary artery which was preserved during surgery. In our case, vascular surgeons were consulted due to vascular acute lesion, and the replacement of a portion of the artery with a PFTE graft restored good pulses and upper limb perfusion.…”

“…Proximal humeral fractures are among the most common fractures in elderly population and they account for around 5% of all fractures seen and treated in an emergency department (ED) [1]. These lesions can be associated with severe neurological or vascular injuries [1,2]. Nevertheless, axillary artery injury is often unrecognized at the patient's initial presentation, placing the hand at risk of necrosis and amputation if there is prolonged ischemia [3].…”

“…Nevertheless, axillary artery injury is often unrecognized at the patient's initial presentation, placing the hand at risk of necrosis and amputation if there is prolonged ischemia [3]. This vascular lesion is typically the result of the medial displacement of the proximal humeral shaft in high-energy injuries around the shoulder girdle [2]. Further, deep venous thrombosis (DVT) is another extremely rare condition in fractures of the upper extremities, regarding which the need for thromboprophylaxis before and after surgery is still a matter of debate.…”

Two stage treatment of a proximal humeral fracture-dislocation with vascular injury: Case report of a multidisciplinary approach

“…Usually the mechanism of injury is associated with direct trauma [5] , maneuvers of reduction in most cases or with surgical humeral head removal during the arthroplasty procedure. This complication occurs predominantly in the distal third of the axillary artery in terms of rupture, dissection of intimal layer or thrombosis [6] , [7] . In our case, the direct trauma associated with the medialization of humeral diaphysis led likely to the axillary injury, since his tethered position between anterior and posterior circumflex vessels and scapular vessels, that may make the artery more susceptible [5] .…”

“…Regarding the treatment's chronology, an initial orthopaedic treatment of the injury (reduction and internal fixation or prosthesis implantation) in patient with unstable patterns of fractures is commonly recommended, to provide a stable substrate for the following vascular repair. This is thought to prevent secondary vascular repair failure by anatomical instability or secondary dislocation [3] , [4] , [5] , [6] , [7] , [8] , [9] . However the severe vascular injury with impending limb ischemia and the slight delay for his diagnosis has brought the multidisciplinary team to decide toward prioritization of the vascular surgical intervention in order to prevent limb ischemia and sequelae, and postpone by 2 weeks the orthopaedic surgical intervention in order to avoid jeopardizing the outcome of the vascular bypass, which was deemed as absolute priority in this specific scenario.…”