Abstract
Vascular injury can occur with severe traumatic injury or joint dislocation. In contrast, chronic stress or overuse may cause either damage to the vascular system or symptoms referable to the vascular system. Identification of these disorders is difficult and often delayed, as symptoms are nonspecific and physical exams often unremarkable. Although uncommon, knowledge of these injuries is important, as a delay in diagnosis can be catastrophic. The following will include injury to the subclavian, axillary, posterior humeral circumflex, ulnar, iliac, femoral, and popliteal arteries
Icd-10-CM Codes
| SUBCLAVIAN ARTERY/AXILLARY ARTERY OCCLUSION | |
| G45.8 | Other transient cerebral ischemic attacks and related syndromes |
| I74.2 | Embolism and thrombosis of arteries of the upper extremities |
| QUADRILATERAL SPACE SYNDROME | |
| S44.30xa | Injury of axillary nerve, unspecified arm, initial encounter |
| HYPOTHENAR HAMMER SYNDROME | |
| I73.89 | Other specified peripheral vascular diseases |
| ILIAC ARTERY OCCLUSION | |
| I74.5 | Embolism and thrombosis of iliac artery |
| ADDUCTOR CANAL SYNDROME | |
| S76.209a | Unspecified injury of adductor muscle, fascia and tendon of unspecified thigh, initial encounter |
| POPLITEAL ARTERY ENTRAPMENT SYNDROME | |
| I77.89 | Other specified disorders of arteries and arterioles |
Subclavian Artery/Axillary Artery Occlusion
Key Concepts
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The axillary artery arises from the subclavian artery at the outer border of the first rib and courses deep to the pectoralis minor muscle.
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The subclavian artery is susceptible to compression from a cervical rib, anomalous first rib, or overdeveloped scalene muscles.
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Axillary artery occlusion develops secondary to pressure from the overlying pectoralis minor muscle in the overhead position.
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The axillary artery may also be compressed by the humerus when the shoulder is in the cocked position ( Fig. 17.1 ).
Fig 17.1
The axillary artery may also be compressed by the humerus when the shoulder is in the cocked position.
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An axillary artery aneurysm (usually at the origin of the posterior humeral circumflex artery) or distal embolization may develop.
History
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Symptoms may include claudication, fatigue, and night pain
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Sudden onset of numbness, coolness, and cold intolerance in the hand may be secondary to distal embolization.
Physical Examination
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Tenderness over pectoralis minor muscle area
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May have diminished distal pulses that are usually position dependent
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Provocative tests for thoracic outlet syndrome may be positive.
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Weakness or sensory deficits are rare.
Imaging
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Radiographs may demonstrate a cervical rib, a long transverse process, or other bone abnormalities that may cause thoracic outlet syndrome.
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Duplex ultrasonography can evaluate flow and presence of aneurysm.
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Computerized tomography arteriography and magnetic resonance arteriography can confirm diagnosis and evaluate surrounding musculoskeletal anatomy.
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A definitive diagnosis can be made with an arteriogram in the symptom-provoking position.
Treatment
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In the absence of complete thrombosis, aneurysm, or embolism, treatment can be conservative with strengthening and stretching of scalene and pectoralis minor muscles and strengthening of the posterior scapular stabilizers.
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Initial treatment for occlusion and aneurysm includes anticoagulation.
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Surgical treatment may include segmental vascular excision, bypass with a venous graft, and thoracic outlet decompression.
Quadrilateral Space Syndrome
Key Concepts
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Quadrilateral space bordered by the teres minor muscle superiorly, teres major muscle inferiorly, proximal humerus laterally, and long head of the triceps muscle medially ( Fig. 17.2 ).
Fig 17.2
Quadrilateral space syndrome. a , Artery; m , muscle; n , nerve; NSAIDs , nonsteroidal antiinflammatory drugs.
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The posterior humeral circumflex artery arises from the distal third of the axillary artery and enters the quadrilateral space with the axillary nerve.
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This space is compressed when the shoulder is in the abducted and externally rotated position.
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Possible etiologies include:
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Repetitive activity causing abnormal fibrous bands and/or muscular hypertrophy
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Traction on the posterior humeral circumflex artery by the pectoralis major muscle
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Tethering of the posterior humeral circumflex artery to the proximal humerus, placing it at risk of traction injury
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Space-occupying lesions such as glenoid labral cysts
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Glenohumeral instability
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History
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Typically occurs in a 20- to 40-year-old overhead-throwing athlete.
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Symptoms often related to compression of the axillary nerve
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May complain of poorly localized shoulder discomfort, deltoid weakness, arm fatigue in the overhead position, paresthesia to the lateral arm, and night pain
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Throwing often affected
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Coolness, pallor, or cyanosis may occur with ischemia secondary to mechanical injury to the posterior circumflex humeral artery.
Physical Examination
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Localized tenderness over the quadrilateral space
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Re-creation of the pain when the shoulder is placed in forward flexion, abduction, and external rotation for 1 to 2 minutes
Imaging
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Radiographs to rule out other pathology
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Magnetic resonance imaging can reveal teres minor muscle atrophy and fat infiltration and rule out other etiologies.
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Subclavian arteriography may show posterior humeral circumflex artery occlusion when the arm is abducted and externally rotated.
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Magnetic resonance angiography is not useful because it is positive in as many as 80% of asymptomatic shoulders that are placed in abduction and external rotation.
Differential Diagnosis
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Cervical spine disorders
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Rotator cuff pathology
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Thoracic outlet syndrome
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Suprascapular neuropathy
Treatment
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Initial treatment
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Activity modification
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Stretching into horizontal adduction and internal rotation
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Rotator cuff muscle strengthening
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Active-release soft-tissue massage technique to the quadrilateral space
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Nonsteroidal antiinflammatory drugs
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Corticosteroid injection
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Later (if not improved after 3 to 6 months)
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Surgical decompression with release of fibrous bands via a posterior approach
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Thrombolysis and surgical intervention indicated sooner if acute thrombus
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