Injuries Associated with Anterior Dislocations.
Last updated Tuesday, February 01, 2005
Vascular injuries
Vascular damage most frequently occurs in elderly patients with stiffer, more fragile vessels.Anatomical locations The injury may be to the axillary artery or vein or to the branches of
the axillary artery--the thoracoacromial, subscapular, circumflex, and
rarely the long thoracic. Sometimes these injuries can be combined, as
pointed out by Kirker who described a case of rupture of the axillary
artery and axillary vein along with a brachial plexus palsy. ( Kirker,
1952) Injury may occur at the time of either dislocation or reduction.
(Antal et al, 1973; Curr, 1970; Gugenheim and Sanders, 1984; Jardon et
al, 1973)Anatomy The axillary artery is divided into three parts that lie medial to,
behind, and lateral to the pectoralis minor muscle. Injuries most
commonly involve the second part, where the thoracoacromial trunk may
be avulsed, and the third part, where the subscapular and circumflex
branches may be avulsed or the axillary artery may be totally ruptured.Mechanism of injury Damage to the axillary artery can take the form of a complete
transection, a linear tear of the artery caused by avulsion of one of
its branches, or an intravascular thrombus, perhaps related to an
intimal tear. The artery is relatively fixed at the lateral margin of
the pectoralis minor muscle. With abduction and external rotation, the
artery is taut; when the head dislocates, it forces the axillary artery
forward, and the pectoralis minor acts as a fulcrum over which the
artery is deformed and ruptured. (Brown and Navigato, 1968; Jardon,
Hood and Lynch, 1973; Milton, 1953-1955)
Watson-Jones (Watson-Jones, 1957) reported the case of a man who had
multiple anterior dislocations that he reduced himself. Finally, when
the man was older, the axillary artery ruptured during one of the
dislocations and he died. Vascular injuries may occur either at the
time of dislocation or during attempted reduction. Sometimes it is
unclear which is the case. (Kirker, 1952; Ng et al, 1990; Stener, 1957) Injury at the time of dislocation Vascular injuries are commonly associated with inferior dislocation.
(Gardham and Scott, 1980; Lev-EI and Rubinstein, 1981; Lynn, 1921;
Meadowcroft and Kain, 1977) Gardham and Scott (Gardham and Scott, 1980)
reported an axillary artery occlusion with an erect dislocation of the
shoulder in a 40-year-old patient who had fallen headfirst down an
escalator. Although vascular injuries are most common in older
individuals, they can occur at any age. (Bertrand et al., 1981; Drury
and Scullion, 1980; Fitzgerald and Keates, 1975; Lescher and Andersen,
1979; Sarma et al, 1981; Stein, 1986) Banatta and coworkers (Baratta et
al, 1983) reported the case of a 13-year-old boy who ruptured his
axillary artery with a subcoracoid dislocation sustained while
wrestling.
Injury at the time of reduction Vascular damage at the time of reduction occurs primarily in the
elderly, particularly when a chronic old anterior dislocation is
mistaken for an acute injury and a closed reduction is attempted. The
largest series of vascular complications associated with closed
reduction of the shoulder has been reported by Calvet and coworkers,
(Calvet et al, 1942) who in 1941 collected 90 cases. This paper,
revealing the tragic end results, must have accomplished its purpose
because there have been very few reports in the literature since then
dealing with the complications that occur during reduction. In their
series, in which 64 of 91 reductions were performed many weeks after
the initial dislocation, the mortality rate was 50 per cent. The other
patients either lost the arm or the function of the arm. Besides the
long delay from dislocation to reduction, these injuries may also be
due to the use of excessive force. Delpeche observed a case in which
the force of 10 men was used to accomplish the shoulder reduction,
damaging the axillary vessel. (Guibe, 1911)Signs and symptoms Vascular damage may be obvious or subtle. Findings may include pain,
expanding hematoma, pulse deficit, peripheral cyanosis, peripheral
coolness and pallor, neurological dysfunction, and shock. A Doppler or
an arteriogram should confirm the diagnosis and locate the site of
injury.Treatment and prognosis Patients suspected of having major arterial injury are managed as a
surgical emergency with the establishment of a major intravenous line
and obtaining blood for transfusion. Jardon and coworkers (Jardon, Hood
and Lynch, 1973) has pointed out that bleeding can be temporarily
controlled by digital pressure on the axillary artery over the first
rib. This author also recommends that the axillary artery be explored
through the subclavicular operative approach, as described by Steenburg
and Tavitch. (Steenburg and Ravitch, 1963)
The treatment of choice for a damaged axillary artery is either by
direct repair or by bypass graft after resection of the injury.
Excellent results have been reported with prompt management of these
vascular injuries. (Brown and Navigato, 1968; Cranley and Krause, 1958;
Dolk and Stenberg, 1991; Gardham and Scott, 1980; Gibson, 1962; Henson,
1956; Jardon, Hood and Lynch, 1973; Lev-EI and Rubinstein, 1981;
McKenzie and Sinclair, 1958; Rob and Standeven, 1956; Stevens, 1934)
The results of simple ligation of the vessels in the elderly patient
have been disappointing, probably because of poor collateral
circulation and the presence of arteriosclerotic vascular disease in
these typically older individuals. (Johnston and Lowry, 1962; Kirker,
1952; Van der Spek, 1964) Even when ligation has been performed in
younger patients with good collateral circulation, approximately
two-thirds of these patients have lost function of the upper extremity,
for example, by developing upper extremity claudication.
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