CASE REPORTAxillary artery transection following anterior shoulder dislocation: classical presentation and current concepts
Introduction
Injury to the axillary artery is a relatively rare occurrence, representing 15–20% of the arterial injuries to the upper limb.1 Ninety-four percent of such injuries are due to penetrating trauma with only 6% due to blunt trauma. Fracture-dislocation of the glenohumeral joint accounts for the majority of blunt injuries,12 and less than 1% have dislocation without associated fracture.15
In excess of 200 cases of vascular injury secondary to anterior shoulder dislocation have been reported in the literature. The first review of this injury was performed 90 years ago with Guibe8 identifying 57 cases of axillary artery injury secondary to shoulder dislocation. It was suggested that the mechanism of injury was due to horse and cart drivers suffering dislocation of the shoulder whilst trying to control an over enthusiastic horse. Calvet3 described a series of 64 axillary artery ruptures after closed reduction of 91 chronically dislocated shoulders. By 1956 a further 10 cases were identified by Cranley and Krause,4 and 22 more cases by Gates and Knox5 in 1995.
This paper describes a classic case of axillary artery transection following a recurrent shoulder dislocation, the associated neurological injury and a review of the literature. It is aimed at raising the index of suspicion for identifying this limb threatening injury with its pathognomic triad of findings on clinical examination, and to consolidate current thinking on the subsequent management and outcome.
Section snippets
Case report
A 75-year-old right handed gentleman presented to the Accident and Emergency Department after falling onto his outstretched right arm, complaining of pain in his right shoulder. The patient was known to have suffered an uncomplicated anterior dislocation of the ipsilateral shoulder one year previously.
On clinical examination he was noted to have a dislocated right shoulder. The radial and brachial pulses were absent. Accurate neurological examination was difficult to perform and assess due to
Discussion
Elderly patients such as the gentleman described in this review have a high susceptibility to axillary arterial injury following trauma such as shoulder dislocation, due to the loss of arterial elasticity secondary to atherosclerosis. Over 90% of reported cases of vascular injury following shoulder dislocation occur in patients over the age of 50. Blunt trauma usually causes injury to the third segment of the axillary artery, as is described here, defined by its position under the lower edge of
Conclusion
This case report presents the very rare but now classical presentation of an axillary artery rupture in its third segment following dislocation of the shoulder joint, in a susceptible individual. It also describes the pathognomic triad of an anterior shoulder dislocation with a diminished radial pulse and an expanding axillary haematoma. This necessitates urgent arteriography and surgical exploration to manage not only the vascular injury, but also the brachial plexus lesion with which it is so
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