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.