The most devastating complications associated with dislocation of the shoulder are injuries of the vessels or nerves to the limb1,3-8,10. The signs of vascular injury must be recognized early, and the injury should be addressed promptly to minimize functional morbidity.
We report on a patient who was seen because of a mass in the axilla four weeks after glenohumeral dislocation. Radiographs showed lateral displacement of the humeral head; the humerus was levered away from the glenoid by a pseudoaneurysm of the axillary artery. We report on this patient to illustrate that late lateral dislocation of the glenohumeral joint may suggest vascular injury.
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
†Department of Orthopaedics, RK-10, University of Washington, Seattle, Washington 98195. Please address requests for reprints to Dr. Harryman.
A healthy seventy-two-year-old woman tripped at home, sustaining an injury of the left shoulder. She was seen at a local emergency room because of a painful deformity of that shoulder. The arm was in abduction at a right angle to the torso, and the humeral head was dislocated inferiorly.
A vascular examination confirmed a palpable radial pulse and normal color of the skin. The neurological evaluation was consistent with a radial-nerve palsy, as demonstrated by diminished sensibility over the dorsoradial aspect of the hand as well as an inability to extend the wrist and digits actively. Additionally, an axillary-nerve palsy was suggested by diminished sensibility over the lateral aspect of the deltoid area.
One radiograph was made before the perfomance of the reduction, and it demonstrated a dislocation of the humeral head, with a displaced and comminuted fracture of the greater tuberosity (Fig. 1). Nitrous oxide gas was administered to diminish discomfort during the reduction. According to the operative report, "fairly strong" traction was applied along the axis of the extremity with the arm in abduction, while an assistant pulled superiorly to reduce the humeral head under the acromion. Although the surgeon did not feel the humeral head reduce during this maneuver, the reduction was confirmed on anteroposterior and lateral radiographs (Figs. 2-A and 2-B). The joint surfaces appeared to be located concentrically, and the greater tuberosity seemed to be reduced anatomically.
The patient was admitted to the hospital for observation and management of pain. An abduction pillow was used to immobilize the left arm. The next day, a repeat neurological examination demonstrated normal sensation over the lateral aspect of the deltoid muscle and active extension of the wrist and digits was possible. Normal radial and ulnar pulses were palpable. She was discharged from the hospital with instructions to use propoxyphene and acetaminophen for pain.
The patient returned to the treating orthopaedic surgeon's office on three occasions during the first three weeks after the injury. On the first two visits, she reported discomfort but the neurological examination revealed normal findings each time. Radiographs made one week after the reduction demonstrated inferior subluxation of the humeral head. The patient continued to use analgesics. Three weeks after the injury, she had burning pain and muscle spasms in the shoulder and arm. The results of the neurological evaluation remained unchanged. New radiographs revealed a separation between the articular surface of the humeral head and the anterior rim of the glenoid, suggesting displacement of the joint surfaces (Fig. 3). Treatment included an abduction bolster, cyclobenzaprine for muscle relaxation, and hydrocodone, a more potent narcotic.
Four weeks after the injury, the patient was seen by one of us (D. L. W.) because of severe pain and a change in the neurological status. She was unable to move the extremity actively, and sensibility to light touch was absent distal to the elbow. Electromyographic studies documented widespread denervation (fibrillations and positive sharp waves) in the fifth cervical to first thoracic myotomes; these abnormalities were more prominent in the cephalad myotomes. The temperature and color of the hand remained normal, although the arm was edematous. A tender swelling was found in the axilla. Repeat radiographs demonstrated lateral displacement of the humeral head, with wide separation of the glenohumeral articular surfaces and complete displacement of the greater tuberosity (Fig. 4). An emergency arteriogram confirmed the presence of a false aneurysm (Fig. 5).
The patient had an immediate vascular decompression. The large pseudoaneurysm had displaced and compressed the brachial plexus and surrounding soft-tissue structures within the axilla. After the decompression, the source of the arterial injury was located at the junction of the axillary artery and the posterior humeral circumflex artery, which was partially avulsed. The vessels were successfully repaired without the need for an interpositional vascular graft.
Through a separate, superior incision, the comminuted greater tuberosity, which was attached to the rotator cuff, was dissected free from the humerus and repaired farther laterally to the bone with multiple Teflon (polytetrafluorethylene)-coated number-2 braided polyester sutures. No hematoma or tissue interposition was found within the joint.
One year after the operation, the shoulder was pain-free, stiff, and inferiorly subluxated; sensation was poor throughout the hand; and there was no functional active mobility. Two years after the operation, protective sensibility had been recovered and there was variable two-point discrimination of five to ten millimeters in the fingertips. Sensation was normal proximal to the wrist. The patient was able to elevate the shoulder actively 45 degrees, flex the elbow 70 degrees against gravity, flex and extend the wrist against light resistance, and use the digits for some assistive functions. Extension contractures of the metacarpophalangeal joints prevented a useful grip.