Axillary Artery and Brachial Plexus Injuries due to Anterior Shoulder ...

Case Study

European Journal of Trauma

Axillary Artery and Brachial Plexus Injuries due to Anterior Shoulder Dislocation Case Report and Literature Review Bibombe Patrice Mwipatayi1, Andrew Finlayson1, Christopher John Welman2, Mark John Hamilton1, Manzoor Abbas1, Kishore Sieunarine1

Abstract Axillary artery injury after shoulder dislocation, without an associated bone fracture is very rare. Vascular injuries associated with brachial plexus lesions range in incidence from 27% to 44%. Management of axillary artery injury is mainly surgical and depends on the extent and the site of injury. The treatment of associated nerve injuries is more controversial. There is a scarcity of literature surrounding the association of injury to the brachial plexus, axillary artery and to the shoulder. The authors report a case of axillary artery associated with a delayed brachial plexus palsy and review the literature with the aim to identify the clinical pattern of this condition and to evaluate the outcome of neuropraxia after blunt axillary artery injury associated with anterior shoulder dislocation. Key Words Shoulder injury · Axillary artery · Brachial plexus Eur J Trauma 2005;31:181–5 DOI 10.1007/s00068-005-1435-z

Introduction The shoulder is the most commonly dislocated major joint following severe trauma, such as motor vehicle collisions or falls onto an outstretched arm. Males are affected far more frequently than females, especially active adolescents and young adults < 25 years of age.

Recurrent instability following nonoperative treatment ranges from 50% to 100% [1–3]. However, in elderly patients, dislocations are often associated with other injuries and can be complex. Complications due to shoulder dislocations include brachial plexus and axillary artery injuries [4]. Vascular complications are rare, with sporadic reports of their occurrence in the literature. In 1911, Guibe described for the first time 57 cases of axillary artery injury after shoulder dislocation [5]. In 1941, Calvet et al. reported a series of 64 axillary artery ruptures occurring after closed reduction of 91 chronically dislocated shoulders [6]. Gates & Knox reviewed the English literature between 1956–1995 and found only 22 cases of anterior dislocation with axillary artery injury [7]. There is a similar scarcity of literature regarding the association of injuries to the brachial plexus, axillary artery and shoulder dislocation. We report a case of an axillary artery pseudoaneurysm and brachial plexus compression after anterior shoulder dislocation, followed by a review of the literature to characterize the clinical pattern of this condition and to establish the outcomes of the neuropraxia and blunt axillary artery damage associated with anterior shoulder dislocation. Case Study A 37-year-old man initially presented to the emergency unit of his local hospital with a painful right shoulder following a shoulder dislocation which occurred while he was knee-boarding. He was able to reduce the dislo-

Department of Vascular Surgery, Royal Perth Hospital, Perth, Australia, 2 Department of Diagnostic and Interventional Radiology, Royal Perth Hospital, Perth, Australia. 1

Received: April 20, 2004; revision accepted: December 12, 2004.

European Journal of Trauma 2005 · No. 2 © Urban & Vogel

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Mwipatayi BP, et al. Axillary Artery and Brachial Plexus Injuries after Shoulder Dislocation

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Figure 1. Digital subtraction angiogram (DSA) with tip of catheter placed in right subclavian artery (쑿). A small bilobed false aneurysm (∆) arises from the second part of the right axillary artery at the origin of either the lateral thoracic or thoracoacromial arteries. The large soft-tissue hematoma in the axilla results in significant distortion of the normal vascular anatomy. The axillary artery is occluded distal to the false aneurysm. The brachial artery (씯) is reconstituted in the upper arm via collateral flow.

cation easily himself. On the day of presentation he noticed an increase in bruising and swelling in his right axilla, with an associated mild weakness and numbness of his right arm. The ipsilateral brachial artery pulse was weaker compared to the left side. He was a very fit young man with his only past medical history being a single right shoulder dislocation and arthroscopic reconstruction 5 years ago. He arrived at the tertiary hospital 14 h after the injury. On examination there was marked bruising and swelling in the right axilla. He had minimal sensation and movement in his right shoulder with 1/5 power, and no sensation or movement in the remainder of his arm and hand. No right brachial or radial pulses were present, but his hand was still well perfused with adequate capillary fill. An urgent upper limb angiogram was performed (Figure 1). This demonstrated a small bilobed false aneurysm arising from the second part of the right axillary artery at the origin of either the lateral thoracic or thoracoacromial arteries. There was a large soft-tissue hematoma causing significant distortion of the vascular anatomy. The axillary artery was occluded distal to the false aneurysm with reconstitution of the brachial artery in the upper arm by collateral flow. At surgery the damaged axillary artery was exposed through an infraclavicular incision with a deltopectoral extension. The clavicular head of pectoralis major was split in the line of its fibers to obtain access to the proxi-

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Figure 2. Schematic description of the surgical procedure. Open arrow showing subclavian vein transected just for illustration purpose. RSVG was used for bypass and axillary artery was occluded. The false aneurysm as shown in the DSA (Figure 1) is not illustrated here.

mal axillary artery. Operative findings revealed a torn lateral thoracic artery with thrombosed second and third parts of the axillary artery. The hematoma was evacuated, and the injured axillary artery was bypassed with a reversed saphenous vein graft (RSVG, Figure 2). The brachial plexus was entrapped and compressed by the surrounding hematoma with no direct damage evident. In the immediate postoperative period, the right radial artery pulse was palpable with partial return of sensation and shoulder abduction, and a completion angiogram was deemed unnecessary. His neurologic progress continued to improve on follow-up in the orthopedic brachial plexus clinic. Discussion The axillary artery is anatomically divided into three parts. The first part begins at the lateral border of the first rib and extends to the superior border of the pectoralis minor. The first part is enclosed within the axillary sheath along with the axillary vein and brachial plexus. The second part of the axillary artery lies deep to the pectoralis minor muscle. The third part lies between the inferior border of pectoralis minor and the inferior (lateral) border of the teres minor muscle. There is an extensive collateral circulation associated with the subclavian and axillary arteries, particularly around the scapula. This clearly becomes of clinical significance during injury of the axillary artery, as dem-



onstrated by this case where the patient’s right hand was still well perfused despite occlusion of the distal axillary artery. Injury to an axillary artery after a shoulder dislocation without bone fractures is very rare. Vascular injuries may be associated with brachial plexus lesions, with incidences ranging from 27% to 44% [8–11]. Pubmed and Medline Ovid searches for all publications recording the association of brachial plexus and axillary artery injury due to shoulder dislocation were collected and reviewed. There were 38 patients reported in total [9–32]. Damage to the artery included intimal tears, thrombosis, and frank complete rupture. In the majority of cases, the site of damage was in the third part of the axillary artery at the origin of the subscapular or circumflex branches [7, 8, 18, 22]. It is well recognized that atherosclerotic vessels are more prone to vascular damage following shoulder dislocation, which puts the elderly population and those with preexisting vascular disease at greater risk [4, 18]. 19 patients (70%) in the reported cases were > 50 years. Mechanism of Injury There have been several theories postulated as to the cause of arterial damage. One is that the humeral head pushes the axillary artery against the inferior border of the pectoralis minor artery in a pincer-like fashion [14, 27]. Secondly, as the third part of the axillary artery is anchored by the subscapular and circumflex humeral arteries, any distracting force can lead to arterial stretching. The artery is then exposed to direct injury by the hyperabducted humeral head [28]. This links to the predominant location of injury, which was present in 15 of the 24 cases where the site of injury was reported. Pseudoaneurysm formation associated with shoulder dislocation has been related to traumatic disruption of side-branch vessels of the axillary resulting in a side-hole-type injury [25]. Finally, scar formation along the axillary sheath following previous shoulder dislocations can predispose to tearing during subsequent dislocations [20, 24]. Jardon et al. reported two cases in which the patients had recurrent anterior dislocations of the shoulder, and speculated that there was a fibrous scar formed around the artery after repetitive dislocation, fixing the neurovascular sheath to the neighboring shoulder tissue [33]. This is supported in the reported cases where 46% of patients had a history of previous ipsilateral dislocation.


Brachial plexus lesions following shoulder dislocation are typically postganglionic, infraclavicular, and occur in continuity. The mechanisms of brachial plexus injury are diverse. The mechanisms could be stretching at the time of injury, compression by hematoma and/or direct trauma by the humeral head. Also entrapment of the nerve during reduction of the dislocation may be responsible. The prognosis for recovery is excellent, since the lesion is usually a neuropraxia or an axonotmesis. Complete lesions have poor outcome. Neurologic deficit recovery usually occurs within 4–6 months, although one patient required exploration for repair. Electromyography may be useful in follow-up [4, 34]. Clinical Presentation and Diagnosis Arterial. In the literature reviewed, all but one (4%) of the patients presented with an ipsilateral axillary mass and 16 patients had an absent distal pulse. The extensive collateral circulation around the shoulder helps explain why hand ischemia is rare in uncomplicated shoulder dislocation, despite the 95% absence of distal pulses. In these cases, or when there is a large hematoma, angiography is strongly recommended, if time allows [7, 35]. Duplex scanning is technically difficult due to the inevitable soft-tissue swelling which makes visualization of the vasculature very difficult. Patients with absent pulses that return to normal after reduction of shoulder dislocation should be observed, because the arterial injury may be due to transient external compression of the artery by the head of humerus [12, 13]. Neurologic. In the acute phase, electrodiagnostic studies cannot discriminate between complete or partial lesions. Magnetic resonance imaging (MRI) may demonstrate hematoma causing compression or discontinuity of the nerve branches [8, 17, 36]. In our patient, the neurologic features appeared approximately 6 h after the trauma suggesting compression by hematoma rather than anatomic disruption. This was confirmed by surgical exploration. Treatment The management of these injuries has been largely surgical and depends on the extent and the site of injury. The treatment of associated nerve injuries is controversial and requires a multidisciplinary approach. The surgical approach depends on the operative findings specifically regarding the degree of nerve disruption. It is essential to identify the nerve ends to be joined and to fix them to the muscle fascial planes during the initial

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exploration. A complete repair may be undertaken after 2–3 months, ideally with intraoperative nerve action potential recordings [20, 37, 38]. Arterial repair is the preferred option for the vascular injury. A Fogarty catheter should be used to remove any intraluminal thrombus in the distal arterial tree. The favored reconstruction is an interposition graft with RSVG which occurred in 62% of the literature reviewed. Prosthetic graft material was used in one patient. In the case of complete transection, the choice of reconstruction is either by direct end-to-end anastomosis or the use of vein or prosthetic interposition grafts [15]. Whenever adequate vein is available, the surgeon should use this as a first choice, since it crosses the very mobile shoulder joint. Prosthetic material does not perform as well in this site. The avulsion of a collateral branch is usually treated by ligation [26]. A completion angiogram should be performed as quality control, if the pulse at the graft and beyond it is either decreased or not palpable. Axillary artery ligation as a treatment has been abandoned [39]. Endovascular techniques such as control of bleeding by occlusion balloon prior to surgical repair, coil embolization of nonessential vessels and, more recently, the use of endovascular stent grafts have become increasingly important tools in the management of acute and chronic vascular trauma. In 2002, Zanchetta et al. reported their experience of the endoluminal repair of axillary artery and vein rupture after reduction of shoulder dislocation in one patient [21]. They found that in the acute setting, endovascular control of inflow allowed better conditions for open surgical repair and may be the temporizing choice in a patient with other more life-threatening injuries. Moreover, nonsurgical, ultrasound-guided management of chronic traumatic pseudoaneurysm of the axillary artery by compression obliteration has recently been proposed (although this may not be appropriate in acute situation) [40, 41]. Advantages of stent-graft therapy over surgical treatment for arterial trauma in this location includes the ease of percutaneous device insertion, reduced blood loss, absence of potential neurologic damage, and decreased hospitalization time [21, 42–48]. Nevertheless, while endovascular treatment may produce optimal radiologic and clinical vascular results, it does not address the possible need for hematoma evacuation and therefore the risk of delayed nerve damage and infection. Moreover, the endovascular procedure may expose patients to the risk of acute thrombosis, occlusion and late intra-stent resteno-

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sis. Inadequate data are available concerning the long-term follow-up of large series of patients who have undergone endovascular stent-graft repair. Contraindications to endovascular repair include unstable patients with or without evidence of external bleeding, evidence of neurologic deficit, and an occluded artery (thrombotic occlusion) or axillary artery injury at different location. The surgical approach is definitely advocated, if there is a bony injury requiring intervention. Conclusion Simple anterior dislocation of the shoulder is seldom complicated by an arterial injury. However, the associated nerve damage in these cases is severely incapacitating. A lesion of the axillary artery should therefore be suspected in all patients with expanding hematoma and/or neurologic deficit. Angiographic studies are recommended whenever vascular injury is suspected or where the reduction of the dislocation has not improved the clinical features. A delay in surgical exploration and treatment of the arterial lesion may lead to a poor outcome. Owing to the proximity of the axillary artery and brachial plexus, the associated exploration of the plexus is strongly recommended, inasmuch as compression, or discontinuity of the nerve, are decisive prognostic factors. Functional recovery from neurovascular damage depends both on early revascularization and on restoration of the nerve function, even if the criteria for establishing the full neurologic recovery in a limb remain unclear. Acknowledgment We wish to acknowledge Professor Steve Beningfield, Head of the Department of Radiology, Groote Schuur Hospital, Cape Town, South Africa, for his keen guidance and expert assistance in writing this article.

References 1.

Hovelius L, Augustini BG, Fredin H, et al. Primary anterior dislocation of the shoulder in young patients. A ten-year prospective study. J Bone Joint Surg Am 1996;78:1677–84. 2. Hovelius L. The natural history of primary anterior dislocation of the shoulder in the young. J Orthop Sci 1999;4:307–17. 3. Mahaffey BL, Smith PA. Shoulder instability in young athletes. Am Fam Physician 1999;59:2773–82, 2787. 4. Stayner LR, Cummings J, Andersen J, et al. Shoulder dislocations in patients older than 40 years of age. Orthop Clin North Am 2000; 31:231–9. 5. Guide M. Des lésions des vaisseaux de l’aisselle qui compliquent les luxations de l’épaule. Rev Chir 1911;44:916. 6. Calvet L, Leroy M, Lacroix L. Luxations de l’épaule et lésions vasculaires. J Chir (Paris) 1941;58:337–46. 7. Gates JD, Knox JB. Axillary artery injuries secondary to anterior dislocation of the shoulder. J Trauma 1995;39:581–3.



8. Adovasio R, Visintin E, Sgarbi G. Arterial injury of the axilla: an unusual case after blunt trauma of the shoulder. J Trauma 1996; 41:754–6. 9. Yagubyan M, Panneton JM. Axillary artery injury from humeral neck fracture: a rare but disabling traumatic event. Vasc Endovasc Surg 2004;38:175–84. 10. Shaw AD, Milne AA, Christie J, et al. Vascular trauma of the upper limb and associated nerve injuries. Injury 1995;26:515–8. 11. Sparks SR, DeLaRosa J, Bergan JJ, et al. Arterial injury in uncomplicated upper extremity dislocations. Ann Vasc Surg 2000;14:110–3. 12. Paley D, Love TR, Malcolm BW. Bilateral anterior fracture dislocation of the shoulder. With brachial plexus and axillary artery injury. Orthop Rev 1986;15:443–6. 13. Volpin G, Langer R, Stein H. Complete infraclavicular brachial plexus palsy with occlusion of axillary vessels following anterior dislocation of the shoulder joint. J Orthop Trauma 1990; 4:121–3. 14. Brown FW, Navigato WJ. Rupture of the axillary artery and brachial plexus palsy associated with anterior dislocation of the shoulder. Report of a case with successful vascular repair. Clin Orthop 1968;60:195–9. 15. Sarma A, Saranchak H, Levinson ED, et al. Thrombosis of the axillary artery and brachial plexus injury secondary to shoulder dislocation. Conn Med 1981;45:513–4. 16. Gugenheim S, Sanders RJ. Axillary artery rupture caused by shoulder dislocation. Surgery 1984;95:55–8. 17. Sturm JT, Perry JF Jr. Brachial plexus injuries from blunt trauma – a harbinger of vascular and thoracic injury. Ann Emerg Med 1987; 16:404–6. 18. Mullett H, Babu J, McMahon B, et al. Vascular complication of anterior dislocation of shoulder with associated brachial plexus injury – a case report. Ir J Med Sci 1998;167:196. 19. Nash E, Soudry M, Abrahamson J, et al. Neuropraxis secondary to hemorrhage in a traumatic dislocation of the shoulder. J Trauma 1984;24:546–7. 20. Helm AT, Watson JS. Compression of the brachial plexus in a patient with false aneurysm of the axillary artery as a result of anterior shoulder dislocation. J Shoulder Elbow Surg 2002;11: 278–9. 21. Zanchetta M, Rigatelli G, Dimopoulos K, et al. Endoluminal repair of axillary artery and vein rupture after reduction of shoulder dislocation. A case report. Minerva Cardioangiol 2002;50:69–73. 22. Onyeka W. Anterior shoulder dislocation: an unusual complication. Emerg Med J 2002;19:367–8. 23. Mustonen PK, Kouri KJ, Oksala IE. Axillary artery rupture complicating anterior dislocation of the shoulder. Case report. Acta Chir Scand 1990;156:643–5. 24. Nicholson DA. Arterial injury following shoulder trauma: a report of two cases. Br J Radiol 1991;64:961–3. 25. Nugud OO, Hedges AR. Axillary artery pseudoaneurysm. Int J Clin Pract 2001;55:494. 26. Julia J, Lozano P, Gomez F, et al. Traumatic pseudoaneurysm of the axillary artery following anterior dislocation of the shoulder. Case report. J Cardiovasc Surg (Torino) 1998;39:167–9. 27. Laverick MD, D’Sa AA, Kirk SJ, et al. Management of blunt injuries of the axillary artery and the neck of the humerus: case report. J Trauma 1990;30:360–1. 28. Milton JW. The circumflex nerve and dislocation of the shoulder. Br J Phys Med 1954;17:136. 29. Ng KC, Singh S, Low YP. Axillary artery damage from shoulder trauma – a report of 2 cases. Singapore Med J 1990;31:592–5. 30. Emadian SM, Lee WW. Axillary artery pseudoaneurysm and axillary nerve palsy: delayed sequelae of anterior shoulder dislocation. Am J Emerg Med 1996;14:108–9.


31. Maweja S, Sakalihasan N, Van Damme H, et al. Axillary artery injury secondary to anterior shoulder dislocation: report of two cases. Acta Chir Belg 2002;102:187–91. 32. Razif MA, Rajasingam V. Anterior shoulder dislocation with axillary artery and nerve injury. Med J Malaysia 2002;57:496–8. 33. Jardon OM, Hood LT, Lynch RD. Complete avulsion of the axillary artery as a complication of shoulder dislocation. J Bone Joint Surg Am 1973;55:189–92. 34. Gariepy RAD, Laurin C. Brachial plexus paralysis following shoulder dislocation. Can J Surg 1962;5:418–21. 35. Fontaine R, Kieny R, Pietri J, et al. [Arterial complications in shoulder dislocations and their sequelae. Apropos of 6 personal cases.] Ann Chir 1966;20:1048–56. 36. MacNamara AF, Ismail A, eds. Combined brachial plexus and vascular injury in the absence of bony injury. J Accid Emerg Med 2000;17:378–9. 37. Nichols JS, Lillehei KO. Nerve injury associated with acute vascular trauma. Surg Clin North Am 1988;68:837. 38. Sampson LN, Britton JC, Eldrup-Jorgensen J, et al. The neurovascular outcome of scapulothoracic dissociation. J Vasc Surg 1993;17:1083–88, discussion 1088–9. 39. Winkelaar GB, Taylor DC. Vascular trauma associated with fractures and dislocations. Semin Vasc Surg 1998;11:261–73. 40. Elford J, Burrell C, Roobottom C. Ultrasound guided percutaneous thrombin injection for the treatment of iatrogenic pseudoaneurysms. Heart 1999;82:526–7. 41. Szendro G, Golcman L, Klimov A, et al. Arterial false aneurysms and their modern management. Isr Med Assoc J 2001;3:5–8. 42. McArthur CS, Marin ML. Endovascular therapy for the treatment of arterial trauma. Mt Sinai J Med 2004;71:4–11. 43. Xenos ES, Freeman M, Stevens S, et al. Covered stents for injuries of subclavian and axillary arteries. J Vasc Surg 2003;38:451–4. 44. Du Toit DF, Strauss DC, Blaszczyk M, et al. Endovascular treatment of penetrating thoracic outlet arterial injuries. Eur J Vasc Endovasc Surg 2000;19:489–95. 45. Parodi JC, Schonholz C, Ferreira LM, et al. Endovascular stent-graft treatment of traumatic arterial lesions. Ann Vasc Surg 1999; 13:121–9. 46. Demetriades D, Chahwan S, Gomez H, et al. Penetrating injuries to the subclavian and axillary vessels. J Am Coll Surg 1999; 188:290–5. 47. Babatasi G, Massetti M, Le Page O, et al. Endovascular treatment of a traumatic subclavian artery aneurysm. J Trauma 1998; 44:545–7. 48. Kember PG, Wood RF, Gaines PA. Endovascular management of a non-penetrating traumatic axillary artery occlusion. Eur J Vasc Endovasc Surg 1997;14:227–8.

Address for Correspondence Bibombe Patrice Mwipatayi, FCS (SA), MMed (Surg) Cape Town Department of Vascular Surgery Royal Perth Hospital Wellington Street Perth, WA 6000 Australia Phone (+61/8) 92242-191, Fax -625 e-mail: [email protected]

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