Hemodynamic Instability After Axillary Artery Rupture Following Inferior Glenohumeral Joint Dislocation: A Case Report

Background

The glenohumeral joint is the most commonly dislocated joint in the body and accounts for 50% of all major joint dislocations [1]. The most common dislocation types are anterior (95–97%) and posterior (2–4%). Traumatic inferior shoulder dislocations (ISD) are rare and account for 0.5% of all shoulder dislocations [2].

Patients with ISD typically present with the arm fully abducted and held above the head [3]. The most common complications of ISD are soft-tissue injury, fractures, and injury of the axillary nerve and brachial plexus [4]. In rare cases, patients damage the axillary artery, which can be limb-threatening.

Another joint dislocation with risk of vascular injury is knee dislocation. The incidence of popliteal artery injury following knee dislocation is between 1.6% and 64%. After reduction, it is recommended to evaluate vascular damage throughout the first day with ankle-branchial index>0.9 and if possible, CT angiography [5]. There are no clear guidelines or recommendations for diagnosing axillary artery injury following ISD, mainly due to its rareness.

A patient with ISD can present axillary artery injury with compromised neurovascular status in the upper extremity, but it typically normalizes after reduction, with no need for further intervention [6]. The literature is sparse on axillary artery injury after ISD that requires surgical intervention. Only 2 cases have reported pseudoaneurysm due to ISD [7,8] and 1 case had an intimal tear of the axillary artery [9]. The literature on axillary artery injury after ISD reports varying symptoms. No previous case has been reported of a patient with beginning signs of hemodynamic instability after ISD.

Axillary artery injury and its clinical presentation need quick recognition in patients with ISD to avoid delayed treatment and complications. This case report presents a male patient with hemodynamic instability after sustaining axillary artery rupture following ISD.

Case Report

HISTORY:

A 71-year-old man sustained a 1.5-meter fall from a ladder while he was cleaning the gutters. He fell on his outstretched right arm. The medical journal from the arrival of the emergency department (ED) reported normal vital parameters, Glasgow coma score (GCS) 15, and no suspicion of spinal cord, abdominal, pelvic, or head injury.

The patient had a former history of stroke, and thus had a daily intake of 10 mg Warfarin. He reported no history of alcohol or tobacco use. He reported 2 previous incidences of anterior shoulder dislocation to the same affected shoulder, which was manually reduced in the ED without complications.

ASSESSMENT AND INITIAL TREATMENT:

The patient was brought to the ED with his right arm 100 degrees abducted and complaining of severe pain and inability to move his arm. The emergency doctor reported fluctuating radial pulse with brief episodes of pulselessness and prolonged capillary refill time. The patient had normal sensibility in the right upper extremity and no sign of neuropraxia.

Radiographs of the shoulder with anterior-posterior and lateral view showed ISD and greater tuberosity avulsion fracture (Figure 1). In the ED, the physician was unable to reduce the joint with the traction-countertraction method. Few minutes before the reduction attempt, the patient was given a total of 12 mg intravenous morphine. Due to the unsuccessful reduction with intravenous morphine sedation, the patient was put under general anaesthesia 30 minutes after arrival to the ED. In full sedation, closed reduction of the glenohumeral joint was performed by the on-call orthopaedic surgeon with gentle anterior traction using the two-step reduction technique described by Nho et al [10] (Figure 2). After reduction, the on-call physician reported normal neurovascular status. The neurovascular status was evaluated based on perceived peripheral pulse in the radial and ulnar artery with normal capillary refill and normal sensibility.

Three hours after the closed reduction, there was still normal neurovascular status and vital parameters. Six hours after closed reduction, the patient showed signs of hemodynamic instability with a blood pressure of 79/41 mmHg, decreasing oxygen saturation (91%) and a heart rate of 75 beats per minute, but still had normal neurovascular status in the right upper extremity. Clinically, swelling was seen in the right axilla.

Due to beginning signs of hemodynamic instability and swelling in the right axilla, axillary artery injury was suspected. Differential diagnoses such as tension pneumothorax or hemothorax could not be excluded clinically. An acute computed tomography (CT) scan with contrast of the thorax was performed and showed a 12.5×6 cm large hematoma in the right axilla, with potential subclavian artery rupture and extravasation of contrast from the transition between the subclavian and axillary artery (Figure 3). The CT scan excluded any other internal damages to the thorax such as hemothorax and tension pneumothorax. The patient showed no sign of neurovascular compression from the bulky hematoma and the only clinical suspicion of vessel damage was beginning signs of hemodynamic instability. Warfarin was paused after the discovery of artery rupture with an International Normalized Ratio (INR) of 2.6.

INTERVENTION:

The patient was immediately transferred to the Department of Vascular Surgery at the nearest Level I hospital. At arrival, the vascular surgeon reported no ulnar pulse. The patient had developed suggillations and swelling in the right axilla.

Rupture of the axillary artery with development of pseudo-aneurysm was concluded with arteriogram intraoperatively. Surgical repair was performed endovascularly, and a covered-VBX Viabahn Gore® stent was placed at the site of rupture with termination of the pseudoaneurysm and patent arterial axis (Figure 4). The hematoma was not evacuated.

Warfarin was resumed on the first postoperative day. Blood samples showed a decrease in hemoglobin from 7.6 mmol/L at the initial emergency contact to 5.9 mmol/L at the time of surgery. The patient was transfused with a single unit of red blood cells during transportation between hospitals.

FOLLOW-UP:

He was discharged on the third postoperative day and immobilized with his upper extremity for 3 weeks following physiotherapist exercises. Immediately after the operation, the patient had normal neurovascular status. After 3 months, there are no signs of stent malfunctioning and the patient continues rehabilitation of the shoulder.

Discussion

We present a case of an ISD complicated with acute need of surgical intervention due to vascular injury. To the best of our knowledge, the existing literature reports no previous cases of ISD with signs of hemodynamic instability due to axillary artery injury.

Axillary artery injury is reported in 10% of ISD, is mainly caused by compression, and intervention is typically not needed. Surgical intervention due to axillary artery injury after ISD is rarer and only 5 cases are reported in the literature [6]. The incident of axillary artery injury following anterior shoulder dislocation is only 1–2% [11].

The higher risk of axillary artery injury following ISD highlights the importance of proper and quick recognition to avoid unnecessary delay before possible intervention. However, the diagnosis of axillary artery injury is complex due to the potentially vague debut and presentation of symptoms. Axillary injury due to shoulder dislocation are easily overlooked. There have been case reports of perceived pulse of the radial and ulnar arteries despite rupture of the axillary artery [8,12]. Likewise, our patient had hours of perceived pulse in the ulnar and radial arteries after reduction. Rupture of the axillary artery can be contained by hematoma up to 6 months after the trauma [13], but acute ischemia in the upper extremity can present a few minutes after reduction of ISD [7]. Furthermore, Plaga et al reported a case of a patient who was initially discharged with improvement, but after 48 hours returned to the ED due to axillary injury after ISD. In our case, the debut of axillary artery injury presented when the patient showed signs of hemodynamic instability together with clinical suspicion of an enlarging hematoma in the right axilla 6 hours after reduction. Eyler et al has reported that signs of an enlarging haematoma and diminished radial pulse following anterior shoulder dislocation are characteristic of axillary artery injury [14].

It has been reported that in cases of anterior shoulder dislocation, the third and distal part of the axillary artery contribute to most axillary injuries (90%) [15]. This part of the artery is limited in mobility caused by the attachment of the circumflex humeral artery and the subscapsular artery [15]. The tendon of the minor pectoralis muscle and the closeness of the axillary artery to the head of the humerus may also contribute to injury. Plaga et al presented 3 hypothesized mechanisms of injury: the minor pectoralis muscle, atherosclerosis making the artery non-elastic, and fibrotic adhesions caused by recurrent dislocation and arthritis [8]. The latter is supported by Allie et al [16], who reported a case of anterior shoulder dislocation with complete rupture of the axillary artery associated with recurrent shoulder dislocations.

Compared to these previous cases, our patient had a higher risk of artery injury due to ISD. Our patient had been prescribed Rosuvastatin at the highest recommended dose, suggesting a high probability of general atherosclerosis. The patient also had 2 previous anterior shoulder dislocations, which made him prone to glenohumeral adhesions. Furthermore, 75% of axillary artery injuries occur in patients aged 60 years or older [16]. The patient in the present case was 71 years old.

The use of diagnostic modalities such as CT scan with contrast or arteriogram should be performed with a low threshold of suspicion. The literature on axillary artery injury caused by inferior or anterior shoulder dislocation suggests that 1 or more of the following symptoms after reduction should lead to considerations of utilizing further diagnostic modalities: enlarging hematoma in the right axilla, diminished radial and ulnar pulse [14], sudden increase in pain from the shoulder/axilla [8], and or hemodynamic instability, as in our patient. The threshold of suspicion should be even lower if the patient has a medical history of recurrent shoulder dislocations, arthro-sclerosis [8] or age above 60 years old [16].

Conclusions

Our case highlights the importance of observing and evaluating patients after reduction of ISD due to the risk of axillary artery injury and hemodynamic instability in elderly patients. Symptoms of axillary injury may appear after months or develop within a few minutes after reduction. We suggest that diagnostic modalities of CT scan with contrast or arterio-gram should be performed with a low threshold of suspicion after reduction of ISD.