Clinical case: Brachial artery injury

History

58-year-old woman sustained a right posterior elbow dislocation due to a fall (Figure 1A).
She underwent closed reduction for the dislocation, and an elbow slab cast application. She was referred to the hospital three days later with complaints of severe right elbow pain, swelling and numbness in the fingers. According to the original treatment notes, there was no apparent neurovascular injury and a radial artery pulse was present after the elbow reduction.

Physical examination

On examination, the elbow was swollen, there were superficial blebs, the forearm was tense, and there was mild stretch pain. Vascular examination revealed good capillary refill with palpable radial artery pulse; neurological exam revealed less than normal sensation in the fingers.

Imaging and investigations

A radiograph of the right elbow showed a well-reduced dislocation and no evidence of fracture (Figure 1B).

To rule out any vascular injury, an arterial Doppler ultrasound scan was performed; it showed a large hematoma causing extrinsic compression over the distal end of brachial artery with little flow in the more distal arteries. The patient, under general anesthesia, underwent brachial artery exploratory surgery to remove the hematoma. Upon making the incision the surgeons were surprised to see a pulsating tubular structure with an occluded lumen, leading to the suspicion of a complete brachial artery rupture (Figure 2).

Immediately, the patient was referred to a vascular surgeon for CT angiography and management. CT angiography showed a total right brachial artery transection five cm proximal to the elbow with thrombus in both ends, but significant blood flow in the distal part presumably via collateral circulation.

Management

The patient underwent excision of the injured segment of the vessel and proximal and distal thrombectomy of the remaining brachial artery. The brachial artery was reconstructed by the interposition of a right great saphenous vein graft; forearm fasciotomy was done to prevent compartment syndrome and reperfusion injury (Figure 3C). The elbow was again immobilized in a slab cast. The patient was administered antibiotics, analgesics and anticoagulants as a post-surgical procedure.

Evolution

Sutures were removed on the 15th post-operative day; skin grafting was done for the fasciotomy wound after three weeks. Three weeks after immobilization, the patient was referred to physical therapy for elbow range of motion exercises.(Figure 3A&B).

Stem arteries of the upper limb

The stem artery of the upper limb runs as a single trunk as far as the elbow, but it is differently named according to the regions it traverses. From its origin to the proximal border of the first rib it is termed subclavian, from this point to the distal border of the tendon of the teres major it is named axillary and from here to its division opposite the neck of the radius it is called brachial (Figures 4&5).

The brachial then divides into the radial and ulnar arteries, which continue into the hand. The radial artery primarily terminates as the distal palmar arch, whereas the ulnar artery primarily terminates as the superficial palmar arch.

Elbow dislocation and complications

Because the brachial artery traverses the antecubital fossa, it is subject to rupture during an elbow dislocation. The most common mechanism of elbow dislocation is a fall on an outstretched hand that forces the elbow into hyperextension, and an open fracture. Vascular injury is usually evident from the absence of distal upper limb pulses, pale hand, cold extremity and diminished sensation. However, as evident in this case, sometimes complete brachial artery transection can occur in a closed dislocation without a fracture and with the forearm and hand remaining well perfused because of the rich collateral circulation around the elbow (Figure 6).

Early recognition of brachial artery rupture in cases with elbow dislocation is very important because such ruptures may lead to potentially devastating complications, e.g, limb loss and Volkmann's ischemic contracture. Clearly, based on this case, the presence of a radial pulse is not sufficient proof of an intact brachial artery. In addition to using a great saphenous graft as done in this case, other repair options in cases of brachial artery rupture include the use of a synthetic vein graft, and brachial artery ligation. 

The collateral circulation surrounding the elbow is depicted in Figure 6 (note arteries labeled in red). The purpose of the anastomoses surrounding joints is to enable the joint to receive blood when it is in any position.