AxillaryArteryRupturefollowinganAnteriorDislocationoftheShoulder.

ACaseReport
Kaissar*,YAMMINE*
*OrthopedicDepartment,EmiratesHospital
Address for Correspondence:
Kaissar,
OrthopedicDepartment,EmiratesHospital
JumeirahBeachRoad
73663,Dubai,UAE
Phone: +971 506659300
E-mail: kayseryam@yahoo.com

Abstract:
The association of an anterior dislocation ofthe shoulder andan injury
of the axillary artery is extremely rare but could be potentially serious.
This case reportwilldiscusstheclinicalaspectsofthiscomplication,its
incidence and circumstances along with a note on reduction
techniques.
J.Orthopaedics20129(1)e8
Keywords:
shoulderdislocation,axillaryartery,injury
Introduction

Theestimated incidence of shoulder dislocation isapproximately1.7%

[1,2]. Chalidis et al. showed in a recent study thatfalling was the most
frequent mechanism of injury and that the overall recurrence rate was
50% in all ages, 89% in patients younger than 20 years [3]. Vascular
injuries are exceptional with approximately one reported case every
year.
CaseReport

An81yearoldwomanwasadmittedtotheemergencydepartmentfora
Left shoulder trauma 2 hours after a fall while she was doing her daily
walking sport activity. Her initial clinical exam raised a suspicion of an
anterior dislocation with no previous history of such incident. She had
preserved motor functionbut signaledthat her lefthandwasnumb.Her
radial pulse was present and strong. The radiographs showed an
anterior dislocation of the scapulahumeral jointwitha mildlydisplaced
fracture of the trochiter and a calcified axillary artery. After
administrating intravenous analgesics a reduction of the dislocated
shoulder wasattempted usingthe Hippocratesmaneuveritwasalong
and difficult reduction and before sending the patient for xrays the
shoulder wasredislocated with acomplete abolitionoftheradialpulse
at thattime.The attendingorthopedic surgeon wasthencontacted and
asecondattempt, under general anesthesia,wassuccessfultheradial
pulse was fully restored and the limb color was back to normal. The
radiographs confirmed the reduction. The patient was discharged at
home.
Twentyfour hours laterthe patient was readmitted for an acute painin
her left upper limb with all the signs of a subacute ischemia. An
important hematoma in the axillary and supraclavicular region was
notedextending tothe anteromedial aspect of thearm.Therewereno
signs of compartmental syndrome.The angiography showed anabrupt
occlusion of the distal axillary artery with distal collateral supply to the
brachialarteryatitsmidlevel[Fig.1].Twohoursaftertheadmissionthe
vascular surgical team was performing an exploration through an
infraclavicular approach a thrombosis was found in the retropectoral
partofthe axillary arteryassociatedwith apartialadventitialtransection.
Reconstruction wasperformed with a reversed saphenous vein and an
endtoend anastomosis. The compartments of the upper extremity
werenormalafterrevascularization.
ThepatienthadanormalneurovascularstatuswithDopplerevidenceof
a patent graft six months after her surgery. The trochiter fracture was
healed and no recurrent instability was noted. A written informed
consent was obtained from the patient prior to the publication of this
Casereport.
Discussion

Injuries of the axillary artery after adislocationof theshoulderare very

uncommon in the recent literature but such complication was not
infrequent when reviewing the literature of the first half of the last
century. In 1911, Guibe [4] collected 78 observations of vascular
complications related to shoulder dislocations. Calvetetal.[5]reported
that 73 over 90 documented cases of artery injuries were observed
after the reductionmaneuveranddiscussedthemedicolegalaspectof
this complication. The high rate of complications was probably due to
the forceful methods, yet widely used at that time, on old dislocations
(64 over 91 cases according to Calvet et al.) and without anesthesia
withligation as the sole treatmentat thattime.Afterthecommonuseof
powerful analgesics and/or general anesthesia this rate dropped
dramatically Rowe [6] couldnt find any arterial injury over a series of
500dislocations.
The hemorrhage due to an injury to the axillary artery might be fatal.
WatsonJones [7]describedthecaseofanelderlymanwitharecurrent
dislocation of the shoulder reduced bythe patient himself until theday
whenhisatheroscleroticarteryrupturedcausinghisdeath.
Dislocation type seems to be a predisposing factor for some authors
where the anterior dislocation comes secondto theinferior dislocation
intermsofcomplicationfrequency[6,7].Intrathoracicandsubclavicular
dislocations also seem to be prone to arterial injuries according to
Fontaineetal.[8].
Blunt trauma usually causes injury to the third segment of the axillary
artery positioned under the lower edge of pectoralis minor, which is
relatively anchored by the branches of the circumflex humeral and
subscapulararteries[9].
Inup toa third of patientsthere isahistoryofpreviousdislocation[10],
suggesting that the initial injury may cause the artery to be fixed by
inflammatory tissue in the torn shoulder joint capsule this renders it
moresusceptibletoinjurywithsubsequentdislocations[11].
Over 90% of reported cases of vascular injury following shoulder
dislocation occur in patients over the age of 50 [12, 13]. Allie et al
described three possible mechanisms for the axillary artery injury a)
sudden kinking of the artery over the edge of pectoralis minor, b)
entrapment of thearterybyfibroticadhesionsbetweenthejointcapsule
and the artery, c) direct or transmitted pressure on a nonelastic
atherosclerotic artery predisposing it to damage by a dislocated
humeral head [13]. Our patient had a calcified axillary artery on xrays
such radiological sign, when present, indicates an important loss of
elasticity due to arteriosclerosis and need to be considered as a red
flagforarterialinjuries.
We cannot emphasize more on the importance of the neurovascular
clinical assessment following a shoulder dislocation Allie et al.
estimated the incidence of an axillary mass and the absence of distal
pulse on admission to be 71% and 93% respectively [13], but thereit
was rarely mentioned whether these signs were recorded before or
afterreduction,forafirstepisodedislocation.
The literature is abundant in the number of described techniques to
reduce an anterior dislocation of theshouldermany of them are soft
and non traumatic. Details of reduction techniques were generally
underreported forshoulder dislocationsassociatedto vascular injuries.
We believe, as many others that Hippocrates maneuver is a brutal
method for reducing a dislocated shoulder and this could be more
relevantin elderly people with inelasticvessels. We dont know,forour
patient, iftheaxillaryinjurywasduetothedislocationmechanism,tothe
repetitive and difficult attempts with the Hippocrates maneuver or to
their association. We believe that this forceful technique could be a
possible mechanism or a risk factor to axillary injuries. Gibson
postulated that the hyperabducted humeral head exposes the axillary
artery which then bends it againstthe fulcrum of theedge ofpectoralis
minor leading to vascular injury [14].We recommend abandoning this
techniqueoranyothertechniqueusingabductionforreduction.
Conclusion
Vascular complications as a result of shoulder dislocation or after
reduction are very rare.The case wepresent isa reminder to clinically
assess theneurovascular statusof theupper limb before andafter the
reduction maneuver and to seek further investigation incaseofdoubt.
Reduction maneuvers need to be gentle, particularly in elderly people
whose arteries are often atherosclerotic. The use of adequate
analgesia is important in helping to insure that reduction is possible
withoutrepeatedforcefulattempts.
References
1. Kroner K, Lind T, Jensen J. The epidemiology of shoulder
dislocations.ArchOrthopTraumaSurg.1989108(5):28890.
2. Hovelius L. Incidence of shoulder dislocation in Sweden. Clin
OrthopRelatRes.Jun1982(166):12731.
3. ChalidisB,Sachinis N, Dimitriou C, PapadopoulosP,Samoladas
E, Pournaras J. Has the management of shoulder dislocation
changedovertime?IntOrthop.Jun200731(3):3859.
4. GuibeM:Deslsionsdesvaisseauxdelaissellequicompliquent
lesluxationsdelpaule.Rev.Chir.,1911,44:580(Abstarct).
5. Calvet J, Leroy B, Lacroix C: Luxations de lpaule et lsions
vasculaires.JournaldeChirurgie194158:33742.
6. Rowe CR : Prognosis in Dislocations of the Shoulder. JBJS
1956,38A:957.
7. WatsonJones, Sir R : Fractures and Joint Injuries., Baltimore,
Williams and Wilkins Company, Fourth Edition, 1955 Vol. II :
p.479.
8. Fontaine R, Kieny R, Pietri J, et Marotti F: les complications
artrielles au cours des luxations de lpaule et de leur suites.
Ann.Chir.196620:104857.
9. Milton GW.The circumflex nerve and dislocation ofthe shoulder.
BrJPhysMed195415:136.
10. Kelley SP, Hinsche AF, Hossain JFM. Axillary artery
transection following anterior shoulder dislocation: classical
presentation and current concepts. Injury, Int. J. Care Injured
200435,11281132
11. Jardon OM, Mood LT, Lynch RD. Complete occlusion of the
axillary arteryasa complication ofshoulderdislocation.JBJSAm
197355:189.
12. Gates JD, Knox JB. Axillary artery injuries secondary to
anteriordislocationoftheshoulder.JTrauma199539(3):5813.
13. Allie B, Kilroy DA, Riding G, Summers C. Rupture of axillary
artery and neuropraxis as complications of reccurent traumatic
shoulder dislocation: case report. Eur J Emerg Med
200512:1213.
14. Gibson JMC: Rupture of the axillary artery. J Bone Joint Surg
Br44B:116,1962.