Article, Cardiology, Surgery

Blunt traumatic axillary artery truncation, in the absence of associated fracture

a b s t r a c t

Background: Axillary artery injuries can be associated with both proximal humeral fractures (Naouli et al., 2016; Ng et al., 2016) [1,2] as well as Shoulder dislocations (Leclerc et al., 2017; Karnes et al., 2016) [3,4]. We report a rare case of an isolated axillary artery truncation following blunt trauma without any associated fracture or dis- location.

Case report: A 58-year-old male presented to the emergency department for evaluation after falling on his outstretched right arm. The patient was found to have an absent right radial pulse with decreased sensation to the right arm. Point of Care Ultrasound showed findings suspicious for traumatic axillary artery injury, and X- rays did not demonstrate any fracture.

Computed tomography with angiography confirmed axillary artery truncation with active extravasation. The pa- tient underwent successful Vascular repair with an axillary artery bypass.

Although extremity injuries are common in emergency departments, emergency physicians need to recognize the risk for Vascular injuries, even without associated fracture or dislocation.

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Extremity injuries are a common presentation in the emergency de- partment (ED). Although not as common as musculoskeletal injuries, vascular injuries need to remain in the differential diagnosis when assessing traumatic injuries. The hard signs of Vascular injury have been created to help assess these patients. These include pulsatile bleeding, expanding hematoma, absent distal pulses, cold or pale limb and a palpable or audible thrill. If present, a patient will need immediate operative intervention. In certain cases a vascular injury is less obvious and only soft signs are found. These include peripheral nerve deficits, history of moderate hemorrhage at scene, reduced but palpable pulse or injury in proximity to a major artery [5]. These patients often require further investigation, imaging and observation.

The axillary artery is the major Blood supply to the arm and brachial plexus [6]. The artery forms as the subclavian artery passes underneath the first rib. The two most common causes of blunt traumatic axillary ar- tery injuries are proximal humeral fractures and shoulder dislocations [2,4]. In this case review we will discuss the presentation, workup and

* Corresponding author at: Department of Emergency Medicine, Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY 10305, United States.

E-mail address: [email protected] (J. Greenstein).

management of a patient with a traumatic axillary artery truncation without any Associated fractures or dislocations.


A 58-year-old male presented with right Arm pain after a fall on hardened snow and ice. The patient fell with an outstretched arm from a standing position. He reported pain, numbness and limited mo- tion in his right upper extremity. On examination, the right upper ex- tremity was cold to touch, with absent radial or brachial pulses. He had no strength or sensation in the entire extremity. There was tender- ness to palpation and swelling over the upper arm and anterior chest. There was no break in the skin noted. Radiographs of the right upper ex- tremity showed no fracture or dislocation. Point of care ultrasound re- vealed good arterial flow proximally, but no flow was visualized distally. The patient was emergently transferred to a tertiary care facility.

Upon arrival to the tertiary care center the patient was found to have an expanding hematoma over his chest and upper arm and was given blood products and Tranexamic acid. A computed tomography with an- giogram of his chest and right arm demonstrated a patent right subcla- vian artery with abrupt truncation of the right axillary artery, contrast extravasation into the right axilla and a 6.4 x 5.7 cm axillary hematoma. (Figs. 1 and 2) The patient was taken emergently to the operating room where vascular team successfully performed an axillary artery bypass.

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Fig. 1. Axial image from CT angiography demonstrating narrowing of axillary artery (white arrow) with active adjacent extravasation (white arrowhead) of contrast into the axilla.

Follow up a few months after the procedure showed that the patient has regained movement and sensation in his arm and continues to improve with Physical therapy.


Vascular injury from blunt trauma only accounts for 5-10% of all vas- cular upper extremity injuries. Of these injuries the axillary artery is the least likely be involved [7]. An anterior glenohumeral dislocation, a Proximal humerus fracture and a fracture-dislocation are the most com- mon reasons for the axillary artery injury in blunt trauma [8]. The axil- lary artery will get injured in 0.09% of proximal humeral fractures and in 0.97% of shoulder dislocation [9]. An axillary artery truncation from blunt trauma, without a concurrent fracture or dislocation, is extremely rare but possible as seen in our case [3].

Vascular injuries are a time sensitive diagnosis that needs immediate intervention and can have significant morbidities and mortalities. The axillary artery runs along the brachial plexus and is vital in providing blood supply to the nerves in the upper extremity [10]. Brachial plexus injury must be assessed with any axillary artery injury due to its

Fig. 2. 3D reconstruction of the left axillary artery showing abrupt disruption (white arrow) of the axillary artery with surrounding contrast extravasation (white arrowhead).

potential for neurologic deficit. Additionally, you can see avascular ne- crosis of the humeral head with an axillary artery injury.

If a patient presents with pulsatile bleeding, an expanding hemato- ma, an absent distal pulses, a cold or pale limb and a palpable or audible thrill following a Traumatic event a clinical diagnosis of a vascular injury can be made. A positive hard sign should prompt immediate surgical in- tervention without any imaging [11]. Imaging studies are still common- ly done and the gold standard to assess vascular injury is an angiography study although Doppler Ultrasound studies are become more commonly used [12]. There is a high risk of massive hemorrhage in these patients so blood products and quick surgical intervention by the vascular team are necessary.

It is important for physicians to understand that although, extremely rare, vascular injuries are possible even without associated fractures or dislocations [1]. Knowing the hard signs of vascular injuries and getting these patients to the operating room immediately can be the difference between the patient maintaining the use of their arm or becoming dis- abled. In conclusion, the emergency medicine physician plays a critical role in assessing, managing and determining the course of treatment for patients with vascular injuries.


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