American Journal of Emergency Medicine
Volume 16 • Number 2 • March 1998
Copyright © 1998 W. B. Saunders Company
Axillary Artery Injuries After Proximal Fracture of the Humerus
RICHARD G. BYRD MD
RYLAND P. BYRD Jr MD
THOMAS M. ROY MD
From the James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN, and the Veterans Affairs Medical Center, Mountain Home, TN.
Although axillary artery injury occurs frequently with dislocations of the shoulder and fractures of the clavicle, it is rarely associated with fractures of the proximal humerus. If the axillary artery is damaged, prompt recognition and treatment are necessary to salvage the involved extremity.
Manuscript received August 21, 1996
accepted October 16, 1996.
Address reprint requests to Dr Byrd, Veterans Affairs Medical Center 111-B, VAMC BX 4000, Mountain Home, TN 37684-4000.
Fractures of the proximal end of the humerus account for 5% of all fractures in the general population. This injury is most common in the sixth and seventh decades of life when osteoporosis appears to be a major contributing factor.  There are, however, few reported cases of vascular injury associated with fracture of the proximal humerus. One study of 117 displaced fractures of the proximal humerus documented no vascular injuries.  Conversely, axillary artery injury has been frequently reported with dislocations of the shoulder and fractures of the clavicle.   We present a patient with a displaced fracture of the proximal humerus and laceration of the axillary artery resulting in a delayed bleed.
A 65-year-old white woman suffered a proximal fracture of the left humerus after slipping on ice outside her home and landing on her left side. She complained of left shoulder pain. Her history was significant only for hypertension controlled with methyclothiazide. On examination in the emergency department, her vital signs were normal. Physical examination showed left shoulder swelling and pain on palpation. Pulses were normal in all extremities. The laboratory results, including complete blood count, electrolytes, and urinalysis, were normal. Her hemoglobin and hematocrit were 14.3 g/dL and 43.3%, respectively. Radiographs of her left shoulder documented a transverse fracture through the neck of the humerus with medial displacement (Figure 1) . After the patient refused surgical intervention, her left arm was placed in a shoulder immobilizer. She was discharged for outpatient follow-up.
The patient arrived in the emergency room 8 days later. She complained of rapidly progressive weakness and of swelling in her left shoulder and arm. Her systolic blood pressure was 50 to 60 mm Hg. Her heart rate was 150 beats/min. Physical examination showed a hematoma of the left shoulder and axilla and considerable swelling of the arm. Pulses were rapid but symmetrical in the upper extremities. Her hemiglobin and hematocrit were 4.6 g/dL and 15.5%, respectively. Intravenous fluids and transfusions of packed red blood cells were started in the emergency department, and the patient was taken immediately to the operating room.
An incision was opened down to the anterior shoulder and humerus. Dissection was carried into the axilla, where abundant clotting was present. It was also evident that there was an arterial bleed. The wound was packed. An incision was then made along the distal clavicle, and a 6-cm segment of clavicle was removed with bone cutters. The subclavian artery was then dissected free, and a noncrushing vascular clamp was placed. The axilla was then re-explored. Bleeding was controlled, and the axillary artery was identified. The axillary artery was encased in scar tissue and organized clot. A jagged 3- to 4-mm laceration in the axillary artery was recognized and closed with running suture. The patient underwent open reduction and internal fixation of the humerus with placement of an anterior T-type plate. A postsurgical radiograph confirmed appropriate reduction of the fracture.
The remainder of the patient's hospitalization was complicated
Figure 1. Radiograph showing proximal fracture of the left shoulder.
by congestive heart failure and volume overload that responded to diuretic therapy. She was discharged with pulses and function of her left arm preserved.
There have been 16 reports of axillary artery injury associated with proximal fractures of the humerus (Table 1) . Ten of these injuries occurred in elderly patients who had fallen. The most common expression of axillary artery damage in these patients was thrombosis with or without a documented intimal tear.      There have been two axillary artery contusions   and one actual axillary artery tear  reported after a fall.
Six reported injuries to the axillary artery in association with proximal humeral fractures occurred in motor vehicle accidents. The damage to the axillary artery is more serious and involves a younger population when it is sustained in a motor vehicle accident. Reported injuries include three
TABLE 1 -- Published Reports of Axillary Artery Injury Caused by Proximal Humerus Fracture
Presentation Cause Findings
65F Pseudoaneurysm, delayed bleed Fall Axilla hematoma, arm swelling, radial pulse present
70M Pseudoaneurysm, delayed bleed Fall Axilla and retropectoral hematoma, radial pulse present
30M Axillary artery transection MVA Absent pulses, axilla hematoma
54F Rupture axillary artery MVA Absent radial pulse, cold, cyanotic arm, axilla hematoma
39M Rupture axillary artery MVA Absent pulses, axilla hematoma
19M Rupture axillary artery MVA Absent radial pulse, ischemia
68F Axillary artery tear Fall Absent brachial and radial pulses
37M Thrombosis and intimal tear MVA Warm arm, absent pulses
53M Thrombosis MVA Absent radial pulses, ischemia
77M Thrombosis Fall Cold cyanotic arm, diminished pulses
60F Thrombosis Fall Cold, pale arm, absent brachial and radial pulses
91F Thrombosis Fall Warm arm but absent pulses
79M Thrombosis with intimal tear Fall Cold, clammy arm, diminished pulses
86F Thrombosis, acute kink in the artery, arterial spasm Fall Cold, cyanotic arm, absent pulses
68F Thrombosis, intimal tear, contusion Fall Cold, cyanotic arm, axilla arterial hematoma
78F Axillary artery contusion, thrombosis Fall Absent radial pulse
77F Intimal tear, arterial contusion Fall Cold arm, absent pulses
A bbreviations: F, female; M, male; MVA, motor vehicle accident.
ruptures of the artery,  one case of artery transection,  and one case of thrombosis with an intimal tear and entrapment by bony fragments. 
Our case represents the second clinical report of a delayed bleed caused by a pseudoaneurysm.  Each of these cases resulted from a fall. There has been one fatality caused by an axillary artery tear in which blood extravasated into the neck and mediastinum causing tracheal compression. 
It has been proposed that injury to the axillary artery that occurs from proximal humeral fractures in patients who have fallen is caused by hyperabduction of the arm with subsequent medial subluxation of the distal humeral fragment.   Direct forces of trauma may explain the more severe nature of the injury to the axillary artery observed in motor vehicle accident victims.
The most common physical finding in a patient with axillary artery injury associated with a proximal humeral fracture is an absent or diminished radial pulse (Table 1) . Interestingly, both patients with pseudoaneurysm formation had preservation of the distal pulses. These two patients, however, had large axillary hematomas caused by arterial bleeds that lead to prompt and appropriate treatment.
If an axillary artery injury is suspected, an arteriogram should be obtained. Arteriograms aid the surgeon by identifying the site of and nature of the injuries to the axillary artery. An arteriogram was not performed in our patient because of her hemodynamic compromise and the clinical suspicion of an arterial bleed necessitating emergent surgical intervention.
Repair of a damaged axillary artery may require arthrectomy with thrombectomy, primary repair of a puncture or laceration by sutures or venous patch, or resection of a portion of the artery with end-to-end anastomosis, vein grafting, or Gortex grafting.  In patients with thrombus formation, a Forgarty catheter should be inserted distal to the site of injury to eliminate any distal embolism that may compromise the peripheral circulation. Early recognition and accurate diagnosis is essential. Circulation must be restored within 6 to 8 hours if the arm is expected to be salvaged. 
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