pseudoaneurysm of axillary artery secondary to proximal humeral fracture: clinical features
TRANSCRIPT
Eur J Orthop Surg Traumatol (2010) 20:51–54
DOI 10.1007/s00590-009-0493-zCASE REPORT
Pseudoaneurysm of axillary artery secondary to proximal humeral fracture: clinical features
Masaki Katoh · Yuki Iijima · Yusuke Ueda · Motohiko Oyama · Kazuo Saita · Yuichi Hoshino
Received: 17 April 2009 / Accepted: 13 May 2009 / Published online: 30 May 2009© Springer-Verlag 2009
Abstract We present here a case wherein the patientdeveloped an unsuspected pseudoaneurysm (also called afalse aneurysm) secondary to a low-energy proximalhumeral fracture. Massive hemorrhaging from the pseudo-aneurysm occurred around 4 months from the initial injury.Neurovascular deWcit and necrosis were present uponexamination and the limb was unsalvageable. The delay intreatment resulted in a severe and irreversible neurovascu-lar deWcit. A shoulder disarticulation was performed andpostoperative progress was favorable. Early diagnosis andsurgical intervention is critical to recovery in such cases.Common features and challenges associated with this sortof injury are here described based on a review of past casereports and on our own case. Although early diagnosis isdiYcult, the following are some clinical features of a pseu-doaneurysm secondary to a proximal humeral fracture (1)delayed presentation; (2) severe anteromedial displacementof the fracture; (3) somewhat atypical symptoms such as arecurrence or persistence of shoulder swelling and pain.
Keywords Shoulder disarticulation · Pseudoaneurysm · False aneurysm · Proximal humeral fracture · Clinical features
Introduction
Proximal humeral fractures are regarded as common andrelatively harmless injuries. Vascular injuries especiallypseudoaneurysms secondary to them are extremely rare [1–8]. We presented here one case in which the patient devel-oped a pseudoaneurysm secondary to proximal humeralfracture and eventually had to be treated by shoulder disar-ticulation; to our knowledge, there has been only one othercase of a pseudoaneurysm necessitating a shoulder disartic-ulation [1]. Clinical features of pseudoaneurysms second-ary to these fractures are described here for the purposes ofassisting in diagnosis and treatment.
Case report
A 75-year-old man sustained with a three-part fracture ofthe left proximal humerus fracture following a simple fall.The patient had a history of schizophrenia and his commu-nication abilities were poor. Radiographs taken at anotherhospital showed antero-medial displacement of the shaft(Fig. 1). The fracture was treated conservatively at priorhospital.
The patient fell again 35 days after the initial injury dueto a cerebellar infarction. The patient was sent to our hospi-tal nearly 2 weeks (about 2 months after the initial injury)after this second fall with swelling and bruising around theleft shoulder and arm. Evaluation revealed that negligibleparesis and weakness of distal pulse. A CT angiogramshowed a pseudoaneurysm of the axillary artery and Xowcessation of the brachial artery with collateral circulation(Fig. 2). An operation was not performed at this time, how-ever, because the patient did not wish to be treated surgi-cally and the left arm was not ischemic.
M. Katoh (&) · Y. Iijima · Y. Ueda · M. Oyama · K. SaitaDepartment of Orthopaedics, Saitama Medical Center, Jichi Medical University, School of Medicine, 1-847 Amanuma, Saitama, Saitama 330-8503, Japane-mail: [email protected]
Y. HoshinoDepartment of Orthopaedics, Jichi Medical University, School of Medicine, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0394, Japan
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The patient returned to our hospital 2 months after theWrst examination at our hospital (almost 4 months afterthe initial injury) with a 1-week history of increasingswelling of the left shoulder. The left arm was cold, par-alyzed and bruising. Necrosis of the limb and lack of
distal pulse were conWrmed (Figs. 3, 4). Computedtomography showed massively increased hematomatogether with bone erosion around the shoulder. A pro-gressive fall in the patient’s hemoglobin level wasobserved. The upper limb was nonviable and unsalvage-able. Shoulder disarticulation was performed by the Lit-tlewood-method; it was noted that the axillary artery waslacerated at the site of the bone spike. Postoperative pro-gress was favorable.
Discussion
Proximal humeral fractures are common injuries, account-ing for 5% of all fractures [3, 8]. Generally considered to bea fairly minor and uncomplicated fracture, they are oftenthe result of low-energy trauma in older patients [3]. Theanatomical structure of the area, with axillary artery closeto the proximal humerus and almost immobile at the thirdpart of it, would suggest that it would be likely for the axil-lary artery to be damaged during the such fractures [6].However, lesions of the axillary artery associated withshoulder injury are uncommon [2, 3]. And proximalhumeral fractures complicated by pseudoaneurysm areextremely rare [1, 4]. We have identiWed six prior reports(Table 1). And the features of these injuries here describedare based on a review of these cases, as well as our owncase.
Most of the cases were from the elderly population, andconsisted of anteromedial displacement caused by low-energy trauma. The degree of medial displacement wasranged from 100 to 130%. On average, the patients did notshow symptoms of a pseudoaneurysm until nearly 3 monthsafter the initial injury, and at least 2 weeks were needed tomake the diagnosis.
Most of cases were treated immediately by surgery, andpostoperative outcomes were generally favorable. In twocases-one of them our own-shoulder disarticulation had tobe performed due to necrosis of the limb, and in one casethe patient developed a systemic infection from necroticmuscle and died of sepsis.
Stenning et al. [6] also reported six cases of pseudo-aneurysm secondary to low-energy trauma to the shoul-der. Two of six had continuous bleeding, which wasdetected and treated 6 and 8 weeks after the initialinjury. Massive bleeding from the pseudoaneurysm,occurred in one case 8 weeks after the initial injury andin two cases 16 weeks after the initial injury. It is uncer-tain from the data whether the fractures caused the pseu-doaneurysm; details of each case were not described inthe literature. These cases are therefore not presented inTable 1.
Fig. 1 Three part fracture with medial displacement of shaft
Fig. 2 CT angiography showing pseudoaneurysm, collateral circula-tion from pseudoaneurysm and occlusion of brachial artery
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Based on our review, some common features of a pseu-doaneurysm secondary to a proximal humeral fracture weredescribed below:
1. A long delay presentation
2. Severe medial displacement of the fracture3. Atypical symptoms such as a recurring or persistent
pain and swelling
Not surprisingly, early diagnosis and treatment results inbetter outcomes [2]. However, making the diagnosis isdiYcult in case without acute ischemic symptoms [1–3].Because of the anastomotic network of collateral vesselsaround the shoulder, acute ischemia of the limb does notalmost result from axillary arterial injury, and the degreeof neurovascular damage varied in each case [1–8].Shoulder swelling, persistent or worsening pain despitefracture stabilization and delayed onset of nerve palsywere reported as signs of axillary arterial injury [3]. Allreviewed cases had recurring or persistent of local swell-ing and pain, but had no severe neurovascular deWcit atpresentation. Although it is clear that a diagnosis ofpseudoaneurysm without ischemic symptoms immedi-ately after the initial injury may prove extremely diYcultto reach, detecting the features of these injuries-espe-cially the recurrence of pain and swelling-could be verycritical to prevent a long delay in diagnosis and treat-ment.
In our case, surgical intervention did not take place until2 months after making diagnosis of the pseudoaneurysm.The situation was complicated by the patient’s schizophre-nia and refusal to consider surgical treatment at an earlierpoint, but this was certainly regrettable. The delay in treat-ment resulted in a severe and irreversible neurovasculardeWcit, which could have been fatal if bleeding had contin-ued, and the loss of the aVected limb. Earlier surgical inter-vention can be of critical importance in such cases, andshould be undertaken immediately upon the diagnosis of a
Fig. 3 Clinical photograph showing swelling, bruising and necrosis of the left arm caused by pseudoaneurysm
Fig. 4 Above at Wrst presentation 2 months after the initial injury.Below 4 months after initial injury. Computed tomography showingmassively increased hematoma
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pseudoaneurysm in this region if the outcome is to be morefavorable
Acknowledgments No funds were received in support of this study.
ConXict of interest statement No beneWts in any form have been orwill be received from a commercial party related directly or indirectlyto the subject of this manuscript.
References
1. Syed AA, Williams HR (2002) Shoulder disarticulation: a sequel ofvascular injury secondary to a proximal humeral fracture. Injury33:771–774
2. Hildingsson C, Toolanen G, Hedlund T (1996) Late vascularcomplication after fracture of the proximal humerus. Arch OrthopTrauma Surg 115:357–358
3. Modi CS, Nnene CO, GodsiV SP et al (2008) Axillary artery injurysecondary to displaced proximal humeral fractures: a report of twocases. J Orthop Surg 16(2):243–246
4. van Arkel ERA, Tordoir JHM, Arens HJ (1998) A proximal humer-al fracture, complicated by a pseudoaneurysm: a case report. ActaOrthop Scand 69(2):194–195
5. Hildingsson C, Toolanen G, Hedlund T (1996) Late vascular com-plication after fracture of the proximal humerus. Arch Orthop Trau-ma Surg 115(6):357–358
6. Stenning M, Drew S, Birch R (2005) Low-energy arterial injury atthe shoulder with progressive or delayed nerve palsy. J Bone JointSurg Br 87(8):1102–1106
7. Harris O, Roche CJ, Torreggiani WC et al (2001) Delayed presen-tation of pseudoaneurysm complicating closed humeral fracture:MR diagnosis. Skeletal Radiol 30:648–651
8. Teruo I, Yasushi I, Kenichi N et al (1997) A surgically treated caseof traumatic pseudoaneurysm of axillary associated with fracture ofthe humeral neck. Jpn J Vasc Surg 6:757–762
Table 1 Case reports of peudoaneurysm complicating closed humeral fracture
hrs hours, wks weeks, mos monthsa Degree of displacement/shaft diameter £ 100(%)b Time to diagnose: time from appearance of symptoms to detection of pseudoaneurysmc Time to op: time from pseudoaneurysm diagnosis to operationd Weather neurovascular deWcit present or not at the time of diagnosis
CaseAge/sex
Trauma Fracture type/displacementtype/% displacementa
Time to diagnoseb/Time to opc
Neurological deWcit(+/¡)d
Distal pulse (+/¡) treatment/result
1/60/F Fall downstairs 2-Part antero-medial/110% 6 mos/? ¡/+/Embolization and hemiarthroplasty/good
2/80/F Fall 2-Part antero-medial/100% 2 wks/ > 48 hrs §/+/Shoulder disarticulation/good
3/76/M ? 4-Part antero-medial/130% ?/1 mos ¡/+/Closure of pseudoaneurysm and hemiarthroplasty/good
4/72/F Fall 2-Part antero-medial/100% 2 wks/a few days §/+/Closure of pseudoaneurysm/died of sepsis
5/63/M Fall Unknown >3 days/? §/+/End to end repair/good
6/75/F Fall 2-Part/antero-medial/120% 11 days/2 days ¡/+/Vein patch and external Wxater/paresis of the limb (weakness of biceps)
Our case 75/M Fall 3-Part antero-medial/100% 2 wks/2 mos §/§/Shoulder disarticulation/good
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