Brachial artery pseudoaneurysms are rare complications that can occur following penetrating injuries or vascular procedures as a result of direct damage to the artery1-4. These injuries can become large and may compress surrounding neurovascular structures5. Much less frequently, brachial artery pseudoaneurysms have been reported after blunt trauma resulting in diaphyseal or proximal humeral factures. In this report, we detail the case of a brachial artery pseudoaneurysm and subsequent radial nerve damage that occurred in a patient awaiting operative treatment for a surgical neck fracture of the humerus and review the relevant literature.
The patient was informed that data concerning the case would be submitted for publication, and she provided consent.
An 84-year-old woman presented after sustaining a left proximal humerus fracture after a fall from standing while getting out of bed. She initially did not want to see a medical provider and was not evaluated for 4 weeks after her injury. During this time, she had become concerned about her progressively worsening shoulder function, which was affecting her ability to live independently. At presentation, she complained of mild discomfort and restricted motion but denied numbness or weakness in her hand and had no arm or shoulder surgical history.
Examination of the left shoulder at initial presentation demonstrated intact skin with no gross deformity and a normal neurovascular examination to the left upper extremity. Left anterior-posterior (AP), axillary, and outlet radiographic views demonstrated a comminuted, 4-part proximal humerus fracture with surgical neck displacement and a minimally displaced fracture of the glenoid (Fig. 1). The decision was made for surgical treatment to improve her function and allow her to remain living independently. A reverse total arthroplasty was determined to be her best option given the severity of the fraction pattern, patient age and bone quality, and her delayed presentation. Unfortunately, this patient had problems acquiring transportation and a complex social situation that prevented her from getting necessary preoperative care and clearance by her primary care physician. This caused a long delay in definitive treatment during, which she was unable to be properly seen and evaluated.
Five weeks after this encounter, she presented to the emergency department with an enlarging mass on her left shoulder for several days. At this time, she began complaining of increasing numbness and loss of extensor motor function in her left hand. Vascular surgery was consulted and examination showed 2+ distal pulses and a pulsatile mass in the proximal shoulder. A computed tomography (CT) angiogram revealed a 12 × 13 cm hematoma and a 4 × 4 × 4 cm pseudoaneurysm of the brachial artery at the axillary artery transition point (Fig. 2).
The patient underwent urgent percutaneous graft stent placement for repair of the pseudoaneurysm with an associated incisional evacuation of 1.5 L of hematoma. During the evacuation, several sharp bone fragments were noted at the site and were debrided back to stable bone. The radial nerve was identified and protected, at which time it was seen to be grossly intact without any structural deformity. She was cleared to undergo definitive reverse total shoulder arthroplasty 1 week later, which was completed uneventfully. During the procedure, the greater tuberosity was found to still have viable cuff; however, the lesser tuberosity and subscapularis were not identifiable. The glenoid was approached and the fracture was observed to be stable in an adequate position to place the baseplate without the need for a graft. The remainder of the procedure was completed without complications and postoperative radiographs were obtained on follow-up (Fig. 3). An electromyography conducted 3 months after surgery demonstrated radial and mild axillary nerve conduction deficits with normal function of the ulnar and median nerves.
At 1 year after the injury, the patient still demonstrated a radial nerve palsy with minimal motor function of the wrist and digit extensor tendons as well as a sensory deficit in the radial nerve cutaneous distribution. She had flexion extension of 120°, deltoid strength of 4/5, and normal sensation in the axillary nerve distribution. The patient is currently considering forearm tendon transfers because further improvement of motor function is unlikely at this stage.
There are currently 3 reported cases of pseudoaneurysms following conservative management of proximal humerus fractures.
The first reported case was seen in 1975 by Dolibois and Matrka6. A 66-year-old man presented following a fall and was found to have sustained a spiral fracture of the left humeral shaft. Distal pulses along with sensory and motor function were all intact. The arm was placed in a sling and the patient was discharged. Three months later, he presented obtunded with a with massive edema of the left upper extremity and a weak radial pulse. Arteriography demonstrated a rapidly filling cavitary defect at the distal portion of the brachial artery. The left arm was amputated and the specimen demonstrated a pseudoaneurysm in the distal 1/3 of the brachial artery, and the ulnar and median nerves were noted to be pale and necrotic.
In 1997, Crawford et al.7 reported on a 77-year-old woman who sustained a proximal humerus fracture of her right arm following a fall. No vascular injury was observed at the time of presentation and the fracture was managed conservatively. Two years later, the patient presented to the emergency department (ED) with 1 day of pain and swelling of the right proximal arm and was found to have a pseudoaneurysm of the brachial artery on subsequent imaging. In this case, the patient did not develop subsequent neurovascular compromise and underwent repair of the brachial artery without complications.
The most recent case published in 2014 by Kemp et al.8 involved an 82-year-old man who suffered a comminuted fracture of the right humerus. As with the other cases, the limb had no neurovascular compromise and the patient received conservative treatment, and follow-up X-rays showed that the fracture had healed well. He presented 8 months later complaining of progressive swelling and hand weakness over the past 6 months. Examination showed wasting of the thenar and lumbrical muscles and decreased sensation in a median nerve distribution. CT angiography showed a large brachial artery pseudoaneurysm and the patient underwent subsequent repair of the defect. Postoperative recovery was uncomplicated and the patient regained near normal motor and sensory function at 4 weeks.
To date, our case is the first report of a radial nerve injury from a pseudoaneurysm secondary to humeral fracture with all other cases demonstrating isolated damage to the median and ulnar nerves. This is likely due to the location of the fracture at the level of the surgical neck whereas other cases involved fractures at more distal sites (1 proximal humerus and 2 mid diaphysis). As a result, this created a more proximal brachial artery pseudoaneurysm at its origin where the radial nerve lies in proximity prior to coursing posterior through the triangular interval.
From the very few reported cases, the presentation is a delayed onset with distal motor and sensory impairment arising on the order of months to years following conservative management of humerus fractures. In more distal fractures, the neurological deficits are seen in median and ulnar nerve distributions; however in this case, we demonstrate the potential for radial nerve involvement for surgical neck fractures.
It is important to note that this pseudoaneurysm presented only 2 months from the initial injury, which is the shortest reported time frame for this complication. Because of the long delay in both presentation and definitive treatment, it developed in our patient despite having planned for operative management. Pseudoaneurysms therefore can occur not only in conservatively managed fractures, but in surgical candidates as well, particularly when unforeseen delays in treatment are encountered.
The insidious onset poses a risk for delayed or missed diagnoses without careful follow-up, and as such, it is critical to recognize that there is risk for neurovascular injury despite the absence of signs or symptoms on initial presentation. In these cases, a team approach with quick involvement of vascular surgery colleagues is necessary to avoid potentially catastrophic damage to the limb.
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