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ARTERIAL OF THE
IN
THE
CLOSED HUMERUS
FRACTURE
of a Case
ISLE OF WIGHT, ENGLAND
RYDE,
aged Soon
eighty-six after
and cyanotic
fell
in her
an
home
absent
sustaining seen
radial pulse.
a closed She
of the found
neck
of the twenty
humerus.
the accident
with
she was
by her family
forearm
to be cold
to hospital,
signs of complete loss of arterial circulation a fracture of the neck and great tuberosity (Fig. injury cephalic brachial 1). an incision vein, and was made prolonged along the lower
with moderate displacement At operation five hours after the groove, axillary and preserving upper part the of the
delto-pectoral part
downwards.
of the
artery were exposed. the axillary artery was pulled laterally at the the anterior circumflex caught humerus.
of the
The main trunk of acutely kinked and point artery, of origin of which was of the a segment in was
between Distal
axillary
length
the
was
seen
to
be
the thrombosed sucked out, with narrowed freed from trunk all
structures
with papaverine well below the attempts, the lumen, unwere findings appeared
The patients
injured area, but despite prolonged including injection of saline into the brachial relieved.
FIG.
The
closed. Progress-A
Figures line
became
and
3 show
A radiograph of the fracture. just below the elbow, and the forearm, wrist and
at operation. of demarcation
gangrenous. hand
general carried
poor. condition
Twelve improved
days
injury made
mid-brachial an otherwise
was
DISCUSSION
Numerous have
508
of vascular literature.
injuries This
fractures seemed
THE JOURNAL
and
surgical
of recording
operations
because
SURGERY
appeared
worthy
OF
BONE
AND
JOINT
MAJOR
ARTERIAL
INJURY
IN CLOSED
FRACTURE
OF
THE
NECK
OF THE
HUMERUS
509
Fin. 2 FIG. 3 Operative findings. Figure 2-The initial findings at operation : the anterior circumflex artery had been trapped and pulled forward by the fracture: there was a thrombosed segment of the axillary artery and. distally, spasm of the brachial arterial trunk. Figure 3-After release of the axillary artery, ligation of the anterior circumflex artery, arteriotomy and the removal of thrombus the spasm persisted in the brachial artery.
of
the
rarity
In
of
severe
injury
of 220
humerus.
a series
Beall, nor
to the axillary artery in closed acute arterial injuries, 10 per cent de Bakey (1960) cited no case ofvascular of the axillary artery area around artery. the McQuillan artery was and axillary whole complicating
fractures of the neck of the in association with fractures, injury with a humeral neck Nolan (1968) described in a woman by arteriotomy its effects were one of
thrombosis
the the
seventy-three,
in which
to be a mass
of fibrous tissue and thrombectomy In this case apparent those of thrombosis displaced circumflex remained repeated All diagnosis injury ofthe
necessary
and radiotherapy. Treatment the ischaemia. at the moment of fracture and on arrival responsible
to the general total ischaemia. from anterior artery unrelieved instillation authorities of ischaemia
contusion, and spasm from kinking and distortion from the pull of the circumflex artery. Some of these factors were countered by anterior ligation combined with arteriotomy and removal of clot, but distal spasm despite restoration of a pulsating flow below vessel must the contused segment as and soon the and as a of papaverine and saline into the lumen. agree that exploration of the damaged has been made; and that the deep
is indicated be split
fascia
arterial
by suture, arteriotomy, endarterectomy In our case endarterectomy was and it is doubtful ifit would in any
ofthe
restored
distal
flow,
feasible because, according to Stiles (1965), this procedure is only possible when there exists a suitable plane of separation between intima and media, as found in arteriosclerosis or with longstanding thrombi. Resection-arteriectomy would have been the treatment of choice but was rejected owing to the patients age and poor general condition. Arterial spasm has recently been defined by Nolan (1968) as a response to violent
distortion,
a state
of affairs
vividly
illustrated missile
in this wounds.
case, Although
and
also
significant and
in view Nolan
incidence
of spasm
in high
velocity
McQuillan
spasm does
as to its management.
of2
NO.
per cent
3,
AUGUST
papaverine,
1969
it is not more frequently explored. of relieving it, and authorities differ advised, in order of priority, incision of the deep fascia, and excision ofthe injured segment initiating the spasm.
E. H.
J. SMYTH
that a completely futile sympathetic favoured instillation of heparin (1965) arterial rapid The
by injecting of its
but
as Eastcott
emphasised,
anticoagulants
of limited
act.
contention
thrombosis
Mustard
saline,
segment
SUMMARY
A case
humerus in
of
injury
of
the of
axillary eighty-six
artery
complicating Spasm
fracture relieved
of
the despite
neck
of repeated
the
a woman
is reported.
instillation
I am for the greatly two
of papaverine.
indebted illustrations to Mr
Gangrene
R. C. Cole, 2 and
developed
Chief 3. Instructor,
and
amputation
Department of
above
Naval
the elbow
Illustration,
was
H.M.S.
required.
Veri,on,
in Figures
REFERENCES Thrombosis of the Femoral Artery Complicating Fracture of the Femur. Journal of Bone 45-B, 344. EAsTcorr. H. H. G. (1965): The Management ofArterial Injuries. JournalofBone andJoint Surgery, 47-B, 394. MCQUILLAN, W. M., and NOLAN, B. (1968): Ischaemia Complicating Injury. Journalof Bone andfoiizt Surgery, 50-B, 482. MORRIS, G. C., BEALL, A. C., RooF, W. R.. and De BAKEY. M. E. (1960): Surgical Experience with 220 Acute Arterial Injuries in Civilian Practice. American Journal of Surgery, 99, 775. MUSTARD, W. T., and BULL, C. (1962): A Reliable Method for Relief of Traumatic Vascular Spasm. A,z,zals ofSurgery, 155, 339. NOLAN, B. (1968) : Vascular Injuries. Jour,zal of the Royal College of Surgeons of Ediizburgh, 13, 72. SEDDON, Sir H. (1964): Volkmanns Ischaemia. British Medical Journal, i, 1587. STILES, P. J. (1965): Closed Injuries of the Iliac Arteries. Journal of Bone and Joiizt Surgery, 47-B, 507.
BONNEY,
G. (1963):
and
Joint
Surgery,
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY