DISLOCATION OF THE SHOULDER COMPLICATED BY COMPLETE ...

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AXILLARY. ARTERY. Successful. Suture of the Artery in an eighty-seven-year-old. Man. BERTIL. STENER,. GOTHENBURG,. SWEDEN. From the Department.
DISLOCATION

OF

COMPLETE Suture

of

BERTIL

In fallen

the

October half

inferior pulse.

an

Department

1956 hour

with

aged On

by the appear 220

Xylocain

COMPLICATED

THE

Artery

AXILLARY

in an

I, Sahlgrenska

eighty-seven

was

examination

he was

Hippocratic

admitted

to

found

arm was present.

There at the

Man

University

the

Gothenburg

hospital

to have

Soon

was time

of

after

having

an

antero-

sustained

ischaemic, without Under anaesthesia,

manipulation.

in the axilla. millimetres Hg.

ARTERY

SWEDEN

sjukhuset,

The then

BY

eighty-seven-year-old

GOTHENBURG,

right shoulder. haematoma was

to 60 millimetres Hg. Energetic that there was a rupture of that the large vessels in the pressure presumably having To find out if the first alternative with a wide bore needle, but blocked

the

of Surgery

a man

performed

haematoma began to systolic blood pressure,

OF

STENER,

previously.

dislocation of his Only a slight local

immediately

SHOULDER

RUPTURE

Successful

From

THE

after

palpable reduction

the

wrist was

reduction

a large

still no palpable radial pulse. The of admission, now rapidly dropped

shock therapy was given. It was not obvious from the beginning the main artery to the arm. It was considered possible either axilla were compressed by the haematoma, the arterial blood sunk below the pressure of this, or that they were in spasm. was correct an attempt was made to puncture the haematoma only a few clots were obtained. The stellate ganglion was then

in an attempt

to release

any

spasm.

the haematoma bursting point.

continued to increase. The entire axilla It was decided to explore the lesion.

Operation-Through Large amounts

a delto-pectoral of partly coagulated

was

approach the pectorales blood were evacuated.

This

procedure

also

now

filled

blood

with

major and minor A violent arterial

failed,

and

almost

to

were divided. haemorrhage

then set in. After the subclavian artery had been compressed against the first rib the axillary artery was found completely severed immediately below the origin of the subscapular artery. There was a moderate degree of arteriosclerosis in the walls of the vessels. As the ends of the artery at the site of the rupture The subscapular branch was performed

pulse axillary were

Part

were shredded, ligated. An

about end-to-end

half

a centimetre anastomosis

of each had to be resected. of the axillary artery was

with a continuous over-and-over suture of number 5-0 arterial silk. The radial returned immediately. A vein about 5 millimetres wide (probably a branch to the vein) was ligated. The brachial plexus appeared intact macroscopically. Rents that found in the subscapularis tendon and in the joint capsule were left without suture.

of the

pectoralis

Progress-The been completely

major

post-operative paralysed

was

sewn

over

course was and anaesthetic

the

anastomosis.

uneventful. in his

Before the operation hand and fingers.

the patient Immediately

had after

awakening from the anaesthetic he had regained voluntary movements of his fingers, but there was a definite diminution of the power of active extension in the three ulnar ones. The radial pulse was strong and just as good as on the left side. For the first eight days after the operation streptomycin and penicillin were given. On the fifth day anticoagulant treatment with Sintroma (Geigy) was started and continued for about two weeks. At first the arm was fixed after

in slight abduction, the operation the

but patient

after two weeks active could raise the arm

shoulder showed Eight months

a minor compression after the operation

weakness

three

714

in the

ulnar

fingers

of the greater the patient still had

regressed

movements to a right

were encouraged. angle (Fig. 1).

tuberosity. had a strong considerably. THE

radial As

JOURNAL

pulse. this

OF

Four Radiographs The

paresis

BONE

AND

weeks of

extension was

JOINT

limited SURGERY

DISLOCATION

to

OF

certain

fingers,

dislocation

the

SHOULDER

or

had

similar

in

uninjured

was

possibly

operation,

were

it

COMPLICATED

ascribed

by

the

COMPLETE

to

a partial

reduction.

The

disappeared.

both

BY

The

hands.

He

for

shoulder

injury

no

of

OF

the

was

able

The

raise

his

in the

skin

arm

715

ARTERY

plexus

present

good.

to

AXILLARY

brachial

paraesthesia,

sensibility

was

RUPTURE

caused

hand

temperature

almost

as

by

shortly

and much

as

the after

colour on

the

side. DISCUSSION

It is very Less

than

unusual

a hundred

were

previously

cases,

most

years

is probably

cases

more

have

been

frequent

ofwhich

were

dislocations

than from

explained

by

in the

in more

recent

the

nineteenth

old

dislocations

A contributory reason is that the now been discarded. It is reported

to be complicated

described

years. being

force

in

manipulating

quoted

by

old

an

I 825.

to the

These

191 1 Guib#{233}collected

The

reduced

much

more

four

shoulder

seventy-eight

frequency

in more

unusual

now

than

recent before.

used have combined

I

weeks

after

the

dislocation,

narcosis

vessels.

complications

rather rough manipulations that were sometimes in the literature that up to ten men have used their

patient

Guib#{233}). Relaxing

by injuries

since

In

century.

FIG.

The

literature

is also

operation.

resulting

important

in

vessel

damage

in preventing

vessel

(Delpeche

complications

during

reduction, as well as the use of operative reduction for old dislocations. Among the cases described arterial damage has been of different types There may be only intimal damage with local thrombosis, one of the branches the

from

I have

axillary

found

shoulder torn

at

its

origin

or

that

the

the

arterial

VOL.

NO.

there

As

to

the

axillary

artery

may

authentic the

itself

be

a partial

reports site

of

artery ruptures

of

the

or

total

arterial

(often where

complete

rupture lesion,

the

rupture of

it is typical

subscapular

a large

the

of

axillary that

or circumflex

branch

originates

the

main

artery a large acts

by

branch

humeral and

artery.

caused

is

arteries) as

a bridle

trunk. injuries

Less 39 B,

from

main

Vascular

or

twelve

dislocation.

on ones.

artery, only

and degrees. may be torn

than

one

4,

NOVEMBER

have

in

occurred

ten 1957

of

more

the

cases

often

published

at

reduction

have

of

been

old ascribed

dislocations with

than certainty

of

fresh to

the

716

B. STENER

dislocation itself. However, present before the reduction, the

suggestion

has

the

haemorrhage 1935). In the

been

that

the

no less or else

than forty-nine the arm lost

axillary

artery

and

In a few

humeral

dislocation or at the points against there

head

that

the until

in its

injury to the vessel was not afterwards. In some cases

displaced

position

Guib#{233}191 1 , Buchanan certainty whether the

reduction. having

The

its still

were fatal. function

the circulation

in the arm

attempts

have

been

so will the the injury. made

; but

in practice

at the

the

at which

the damaged

generally (194 1-42)

lost their to ligate

The collateral The enormous

operation,

to suture

has been Lacroix

and

few exceptions, it is possible

injuries caused by shoulder dislocations. the actual dislocation or reduction.

to this impairment, and deal of muscle to expose

instances

stopped Drescher occurred

On the other hand, the arm was ischaemic and without at the hospital. It is possible that the rupture-caused

The remaining patients, with to a great extent. Theoretically,

to preserve

has

1912, rupture

absence of a large haematoma any severe haemorrhage from

been

immediately closed by the humeral head. for arterial injuries complicating shoulder dislocations cases collected from the literature by Calvet, Leroy

unsatisfactory in vessel becomes impaired at

will also contribute cut through a good

mean discovered

(K#{246}rte 1902, to state with

artery before the reduction. pulse when the patient arrived

by the dislocation-was The prognosis poor. Of the ninety

been often

made

not necessarily if it was not

before the reduction present case it is difficult

in connection with the the time of admission axillary radial

it does even

results

arm the have

circulation haematoma

it is necessary

axillary

artery.

to K#{246}rte

(1902) repaired a hole in the side of the artery, but he was later obliged to ligate the because of secondary haemorrhage. The final result was considerable invalidity of the Lexer (1907) reported a case in which after resecting the ruptured ends, he bridged the with a saphenous vein graft. After the operation the patient suffered delirium tremens, died on the fifth day from circulatory insufficiency. At the necropsy the graft and the lines were free from thrombosis, but the lumen of the artery was half obliterated by

artery arm. defect and suture a clot

attached

(1912)

to the wall

described had and

a case

a clamp

caused a transverse laceration an end-to-end anastomosis

the patient anastomosis, The patient had

where

been

applied

of the

end-to-end

anastomosis

of the

local thrombosis caused In the other case-that a complete

supervened. described axillary

by a displaced of a man aged

severance

of the

to the proximal

shoulder

of the axillary was performed.

did not regain any distinct radial but was obliged to disarticulate died after a few hours. Drescher

been tried, but gangrene Recently Henson (1956)

caused

had

of fracture-dislocation

artery. The “

the

Buchanan

fractured

humeral

The damaged segment hand soon recovered

head

was resected, its heat,” but

pulse. Schirmer (1932) made an end-to-side the shoulder on account of later haemorrhage. (1935) reported a case in which arterial suture

two

cases

in

which

he

artery.

In

one

case

there

fracture of the seventy-two-a

axillary

stump.

in which

artery,

surgical typical

had

performed

was

an

a successful

intimal

injury

with

neck in a man aged sixty-five. subcoracoid dislocation had

aneurysmally

dilated

in consequence

of

arteriosclerosis.

The possibility of performing a successful arterial suture in an injury to the axillary artery caused by shoulder dislocation has, according to the literature, generally been regarded with scepticism. This injury often occurs in elderly persons with arteriosclerotic vessels, and, from the nature of the injuring force, the ends of the artery are generally torn to a great extent, and must be resected more or less. The possibility of the patient’s regaining limited-and

good

function of the arm in old persons even less

after than

ligation of the in young ones,

stumps because

of the artery the collateral

is, however, vessels are

arteriosclerotic. After having obtained a successful result in the case reported here I agree with Henson that advanced age is an indication rather in favour of, than against, suture of the artery in cases

of this

type. THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY

DISLOCATION

OF SHOULDER

COMPLICATED

BY

COMPLETE

RUPTURE

OF

in a man

aged

AXILLARY

717

ARTERY

SUMMARY

The not

A case

of complete

injury known

occurred whether

of the

in connection the rupture

A successful suture attempts to suture are

rupture

axillary

artery

eighty-seven

with an antero-inferior dislocation was caused by the dislocation itself

of the artery was the artery in cases

performed. of this type

A review are noted.

is described.

of the shoulder. It is or by the reduction.

of the literature The indications

is given, and earlier for this operation

discussed. REFERENCES J. J. (1912):

BUCHANAN,

Fracture-Dislocation CALVET,

Circular

Resection

of Anatomical

LEROY,

and

and

Neck

(1941-42):

LACROIX

Suture

of

of the Humerus.

Luxations

the

Axillary

Surgery,

Artery

for

Gynecology

de l’#{233}paule et lesions

and

Transverse

Laceration

Obstetrics,

vasculaires.

Journal

15,

by

648.

de Chirurgie,

58, 337. 184,

GuiBE,

M. G.

Luxationen

bei

und

deren

Repositionen.

Archiv

f#{252}r klinische

F.

lesions

des

vaisseaux

de

l’aisselle

qui

compliquent

les

Injuries.

Journal

luxations

de

l’#{233}paule. Revue

de

916.

(1956):

Vascular

Complications

of

Shoulder

of

Bone

and

Joint

Surgery,

528.

KORTE,

W.

(1902) : Em Fall von Arterien-Verletzung

Unterbindung

Heilung.

E.

LEXER,

klinische

(1907): Chirurgie,

SCHIRMER,

VOL.

Des

44, 580;

HENSON,

Gef#{228}ssschadigungen

361.

(1911):

Chirurgie, 38-B,

(Jber

K. (1935):

DRESCHER,

Chirurgie,

39 B,

H.

NO.

(1932):

4,

Archly

f#{252}r klinische

Die ideale Operation 83, 458. Ruptur der Arteria

NOVEMBER

1957

bei Verrenkung Chirurgie,

des arteriellen axillaris

des Oberarmes.

Arteriennaht.

Nachblutung.

66, 919.

und

des arteriell-ven#{246}sen Aneurysma.

bei Schulterluxation.

Zentralblatt

f#{252}r Chirurgie,

Archiv 23,

f#{252}r 1,433.