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. Author manuscript; available in PMC: 2025 Apr 10.
Published in final edited form as: JVS Vasc Insights. 2024;2:100065. doi: 10.1016/j.jvsvi.2024.100065

A systematic review of proximal humerus fractures and associated vascular injuries

Jenna Shepherd a, Athanasios Saratzis b,c, Coral Pepper d, Harvinder Singh a, Sarah Jane Messeder b,c,✉
PMCID: PMC7617580  EMSID: EMS204036  PMID: 40212535

Abstract

Objective

Proximal humerus fractures are common with a reported neurovascular injury incidence of 0.09% to 5%. This study aimed to synthesize the current evidence on the presentation and management of proximal humerus fractures with associated vascular injury to aid clinical decision-making.

Methods

A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (PROSPERO registration: CRD42023393957) to identify articles reporting proximal humerus fractures with associated vascular injury in adults. Study quality was assessed using the Joanna Briggs Institute critical appraisal tools checklist. Outcomes included presentation, fracture classification, type of vascular injury, method of orthopedic and vascular repair, and complications.

Results

A total of 40 articles representing 55 individuals with a fracture were included. Injuries most commonly occurred after a low-energy mechanism such as a fall from a standing height (n = 32, 58%). The presentation of ischemia included cool limb (n = 29, 53%), pallor (n = 21, 38%), prolonged capillary refill (n = 7, 13%), and an absent or reduced pulse (n = 47, 85%). Concomitant neurological injury was reported in 30 cases (55%) and fracture dislocations were reported in 17 cases (32.7%). Fracture classification was variable; however, when all recorded fracture patterns were described in terms of 2-, 3-, or 4-part fractures, these represented 49% (n = 27), 24% (n = 13), and 18% (n = 10), respectively. Fracture management preceded vascular repair in 30 (55%). Orthopedic management was primarily performed by open reduction internal fixation or wire fixation (n = 33, 60%) and hemiarthroplasty (n = 11, 20%). Isolated arterial injury was the most common vascular injury (n = 52, 95%). Arterial injuries were primarily repaired by an interposition graft (n = 21, 38%), primary repair (n = 11, 20%), or conservative management (n = 9, 16%). Complications such as amputation, compartment syndrome, avascular necrosis, and metalwork failure were reported in 13 cases.

Conclusions

Proximal humerus fractures with associated vascular injuries occur most commonly in the older adults after low-energy mechanisms such as a fall from a standing height. A high index of suspicion is needed as not all injuries present with classical ischemic symptoms, and these injuries carry significant associated morbidity. (JVS-Vascular Insights 2024;2:100065.)

Keywords: Humeral fracture, Vascular injury, Trauma

Proximal humerus fractures represent 5% to 6% of all adult fractures and are the third most common nonvertebral fractures in those over the age of 65 years.1,2 They are associated with significant morbidity, functional disability, and socioeconomic impact, with a mortality rate of 3.2%.3 Despite this, consensus on the management of proximal humerus fractures is lacking with insufficient evidence from major randomized controlled trials between surgical techniques and whether they should be managed operatively or nonoperatively.4–6

Associated neurovascular injury is rare in proximal humerus fractures, with varying reported incidence of between 0.09% and 5%.1,7 Unfortunately, neurovascular injury is often missed in individuals presenting with minor blunt trauma.8 This is significant given that these injuries are linked to a higher mortality, prolonged hospital stay, and increased hospital cost.7 Guidelines suggest that ischemic limb revascularization should occur within 4 hours from injury, and therefore, prompt diagnosis is essential.9 Data from Alarhayem et al10 demonstrated that shorter injury to operating room times decreased amputation rates, with a significant increase in rate after 1 hour.

To reduce morbidity, the surgical management of vascular injury requires the use of shunts where rapid definitive revascularization cannot be achieved before fracture fixation. Guidelines also suggest that definitive repair or direct interposition grafts are preferable to bypass graft for the treatment of vascular injury associated with fractures.9 Proximal humerus fracture patterns are variable, and several classification systems are used to characterize these.11,12 Surgical options for fracture management include fixation with k-wire, plate, or intramedullary nail and replacement with hemiarthroplasty or reverse shoulder arthroplasty.4

The aim of this systematic review is to synthesize the current evidence on the presentation, investigation, and management of proximal humerus fractures with associated vascular injury in order to aid clinical decision-making. We aimed to determine fracture patterns associated with vascular injury, clinical examination findings, imaging used for diagnosis, method of fracture fixation and vascular repair used, and postoperative outcomes.

Methods

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)13 and registered with the International Prospective Register of Systematic Reviews (PROSPERO; CRD42023393957).

Search strategy

Studies were identified by searching Ovid MEDLINE, Embase, CINAHL, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials from database inception until February 1, 2023. The search strategy (Supplementary Fig, online only) was developed in conjunction with a clinical librarian (C.P.) and used the terms shoulder fracture, humeral fracture, vascular/blood vessel injury or damage, amputation, revascularization, and limb salvage. No limitation on language or date was applied. Search results were combined into Covidence (Covidence systematic review software; Veritas Health Innovation) and all duplicates removed.

Study selection

Two independent reviewers (J.S. and S.J.M.) screened study title and abstracts against inclusion and exclusion criteria (Supplementary Table I, online only). Full papers were then accessed and screened independently (J.S. and S.J.M.) with conflicts settled by a third independent screener (A.S.). Inter-rater reliability for screener agreement was reported with calculation of Cohen’s kappa.

Quality assessment and data extraction

Risk of bias was assessed using the Joanna Briggs Institute critical appraisal tools checklist14 (Supplementary Tables II and III, online only), and conflicts of interest statements were collected. Data extraction was carried out by 1 reviewer (S.J.M.). Data extracted included year, country, and setting of the study; inclusion/exclusion criteria; patient demographics; patient history and clinical examination findings; imaging modalities used; fracture type and vascular injury; operative technique; and patient outcome. A full narrative synthesis was undertaken.

Results

A PRISMA flow diagram was used to summarize the flow of studies (Fig). Cohen’s kappa for title and abstract screening and full text screening was 0.86 and 0.73, respectively, representing almost perfect and substantial agreement.15 In total, 40 studies were included within the systematic review: 29 case reports and 11 case series. For those that were case series, only individuals meeting the inclusion criteria were included in the systematic review.

Fig.

Fig

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The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA)13 flow diagram for studies reporting the outcome of proximal humerus fractures and associated vascular injury.

Description of population

A total of 40 studies representing 55 individuals were included in the systematic review. The median age was 68 years (interquartile range: 52.5-79 years). There were similar numbers of females (n = 26, 47%) and males (n = 25, 45%). Two studies did not report on sex.16,17

Clinical presentation

Table I summarizes the clinical presentation of individuals included per study. The most common mechanism of injury was a fall at a standing height (n = 32, 58%),16–18,20,21,24,26,28–31,34,35,37–41,46–52,54,55 followed by high-energy blunt trauma (n = 21, 38%).16,17,19,22,25,27,33,35,36,41–46,51,54 Most individuals presented with a cool limb (n = 29, 53%)16,17,22,24,26–28,33–37,39–42,44,46,47,50,52–55 followed by pallor (n = 21, 38%)16,17,19,20,26–28,30,33,36,40–42,47,48,50,52,54,55 and swelling (n = 9, 16%).16,30,35,37,40,41,43,51,54 Concomitant neurological injury was reported in 30 cases (55%), with 13 having alteration in both motor and sensory function.17,20,22,25,27,31,36,45,47,51,53,54 Only one individual sustained an open fracture; all other injuries were closed in nature.46 On examination, most individuals had an absent or reduced pulse (n = 47, 85%). Capillary refill time was increased in seven cases (13%).17,26,27,33,48,52,54 Nearly a third of cases had an absent or reduced Doppler signal (n = 17, 31%).17,19–21,23,24,26,27,31,35,39,45,49,52,55 Hemodynamic instability was reported in only one case (2%).45

Table I. Clinical presentation of individuals included per study on proximal humerus fractures associated with vascular injury.

Study details Patient demographics Vascular presentation Orthopedic presentation
First author Year Age Sex Injury Cool Pale Increased CRT Pulse Doppler Neurology affected Open fracture
Bucci18 2017 85 F Fall—standing height N N N Normal NA Motor N
Cawich19 2015 68 F High-energy blunt trauma—fall down stairs Y Y – Reduce Absent – N
Cotman20 2017 79 M Fall—standing height – Y – Absent Absent Both N
Di Giacomo21 2021 70 F Fall—standing height N N N Absent Absent NA N
Githens22 2018 57 M High-energy blunt Y – – Absent – Both N
Goyal23 2014 59 F Blunt trauma – – Present Absent Monophasic – N
Hayes24 1983 42 F Fall—standing height Y – – Absent Absent Sensory N
Hegde25 2021 48 M High-energy blunt trauma – – – Normal Present Both N
Hofman26 2011 92 F Fall—standing height Y Y Y Reduce Monophasic – N
48 M Fall—standing height – – – Absent Absent Sensory N
Irimia27 2019 58 M High-energy blunt trauma Y Y Y Absent Absent Both N
Isawa28 2015 82 M Fall—standing height Y Y – Absent – Sensory N
Kanda29 2020 66 F Fall—standing height – – – Reduce – Motor N
Karita30 2018 88 F Fall—standing height – Y – Normal – Motor N
Kese31 2011 51 M Fall—standing height – – – Absent Absent Both N
Kurnaz32 2018 80 F Atraumatic – – – Absent – – N
Lam33 2005 85 M High-energy blunt Y Y Y Absent – Sensory N
Laverick34 1990 65 F Fall—standing height Y Y – Absent – – N
Lim35 1987 91 F Fall—standing height N – – Absent – – N
79 M Fall—standing height Y – – Reduce – – N
77 M High-energy blunt trauma—fall downstairs Y Y – Reduce 40 mm Hg (brachial = 150 mm Hg) – N
Lin36 2007 29 M High-energy blunt trauma—fall from 30 ft Y Y N Absent – Both N
Manak37 1996 77 M Fall—standing height Y – – Absent – – N
McLaughlin38 1998 77 F Fall—standing height – N N Absent – – N
Modi39 2008 41 F Fall—standing height Y N N Absent Monophasic Sensory N
Mouzopoulos40 2008 78 F Fall—standing height Y Y – Absent – Motor N
Mouzopoulos41 2008 45 M Fall—standing height N N N Absent – – N
65 F High-energy blunt trauma—fall downstairs Y Y – Absent – Motor N
Naouli42 2016 24 M High-energy blunt trauma Y Y – Absent – – N
Palanisamy43 2017 20 M High-energy blunt trauma – – – Reduce – Sensory N
Paley44 1986 60 M High-energy blunt trauma Y – – – – – N
Palm45 2013 38 W High-energy blunt trauma N N N Absent Monophasic Both N
Peters46 2017 56 M High-energy blunt trauma Y – – Absent – Sensory N
96 F Fall—Standing height – – – Absent – – Y
81 M High-energy blunt trauma – – – Normal – Sensory N
85 F Fall—standing height – – – Reduce – – N
94 F High-energy blunt trauma – – – Reduce – – N
Puri47 1985 77 W Fall—standing height Y Y – Absent – Both N
Razaeian48 2018 76 M Fall—standing height – Y Y Absent – – N
Seagger49 2009 88 F Fall—standing height N – N Absent Absent Motor N
Smyth50 1969 86 F Fall—standing height Y Y – Absent – – N
Stromqvist51 1987 79 M Fall—standing height – – – Normal – – N
60 F High-energy blunt trauma – – – Absent – Both N
54 M High-energy blunt trauma – – – Normal – – N
Sukeik52 2009 74 F Fall—standing height Y Y Y Absent Absent – N
Theodorides16 1976 30 – High-energy blunt trauma – – – Absent – – N
68 – Fall—standing height Y Y – Absent – – N
Thorsness53 2014 60 F Fall—standing height Y – – Absent – Both N
Yagubyan17 2004 68 – Fall—standing height Y – – Absent Absent Both N
69 – High-energy blunt trauma Y – – Absent Present Motor N
78 F Fall—standing height Y Y Y Absent Monophasic Both N
Zhang54 2012 22 M Fall—standing height Y Y Y Absent – Both N
45 M High-energy blunt trauma Y – – – – Sensory N
47 M High-energy blunt trauma N – – Reduce – – N
Zuckerman55 1983 64 M Fall—standing height Y Y – Absent Absent Motor N
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CRT, Capillary refill time; F, female; M, male; N, no; NA, not applicable; Y, yes.

Imaging

All fractures were diagnosed by plain film except one case, which was diagnosed on computed tomography (CT) imaging.54 Vascular injury was diagnosed by CT angiogram in 20 cases (36%),20,22–26,28,30,32,42,43,46,48,49,54 digital subtraction angiography in 17 cases (31%),16,17,21,31,33–35,37,38,40,41,45,47,51 and arterial duplex in two cases (4%).52,54 Sixteen cases (29%) did not report any preoperative vascular imaging.17–19,26,27,29,35,36,39,41,44,50,51,53,55 Five (11%) of these cases went on to receive intraoperative imaging in the form of digital subtraction angiography.26,35,39,40,55

Fracture pattern

Table II summarizes the different fracture patterns reported. The fracture classification system used to describe the fracture pattern varied, including Neer (n = 26, 47%),18,20–22,25,27–30,32,33,37–40,43,46,48–51,53,55 Arbeitsge-meinschaft für Osteosynthesefragen (n = 3, 5%),26,30 and basic anatomical description of site of fracture (n = 21, 38%). Fracture type was not recorded in 9% (n 5) of cases.23,24,40,41,51 For the purposes of simplification, however, when all recorded fracture patterns were described in terms of 2-, 3-, or 4-part fractures, these represented 49% (n = 27), 24% (n = 13), and 18% (n = 10), respectively. The majority of fractures were described as displaced, whereas three (5%) were minimally displaced24,45,52 and six (11%) did not report degree of displacement.20,23,36,41,53 The humeral head was dislocated in 17 (31%)17,20,21,26,38,39,46,22,27,44,36,53,32 and subluxed in one case (2%).34

Table II. Management of individuals included per study on proximal humerus fractures associated with vascular injury.

Study details Injury Management Quality
First author Year Country Design Vascular injury Fracture pattern Fracture Vascular JBI score
Bucci18 2017 Spain Case report Arterial Nondislocated, displaced Neer 2 ORIF Interposition vein graft → prosthetic bypass 10/10
Cawich20 2015 Trinidad and Tobago Case report Arterial Nondislocated surgical neck of humerus K-wire Interposition vein graft → interposition prosthetic graft 9/10
Cotman20 2017 United States Case report Arterial Dislocated, Neer 2 ORIF Vein bypass 9/10
Di Giacomo21 2021 Italy Case report Arterial Dislocated, displaced, Neer 4 Reverse shoulder arthroplasty Vein bypass 10/10
Githens22 2018 United States Case report Arterial and venous Dislocated, displaced, Neer 4 ORIF → shoulder hemiarthroplasty Primary repair (+thrombectomy) 9/10
Goyal23 2014 India Case report Arterial – ORIF Interposition vein graft 9/10
Hayes24 1983 United States Case report Arterial Nondislocated, minimally displaced K-wire Primary repair 8/10
Hegde25 2021 India Case report Arterial Nondislocated, displaced Neer 4 ORIF Primary repair (+thrombectomy) 9/10
Hofman26 2011 Germany Case series Arterial Dislocated, displaced type II-A3 ORIF Endovascular (+thrombectomy) 6/9
Arterial Dislocated, displaced type II-B3 Hemiarthroplasty Endovascular stent –
Irimia27 2019 Spain Case report Arterial Dislocated, displaced Neer 4 ORIF Interposition vein graft (+thrombectomy) 9/10
Isawa28 2015 Japan Case report Arterial Displaced Neer 3 ORIF Endovascular stent 10/10
Kanda29 2020 Japan Case report Arterial Nondislocated, displaced Neer 4 Shoulder arthroplasty Endovascular stent 10/10
Karita30 2018 Japan Case report Arterial Nondislocated, displaced Neer 4 Removal of humerus head Prosthetic bypass 9/10
Kese31 2011 Turkey Case report Arterial Nondislocated, displaced, surgical neck of humerus K-wire Ligation 9/10
Kurnaz32 2018 Turkey Case report Arterial Dislocated, displaced Neer 4 Resection arthroplasty Interposition prosthetic graft 8/10
Lam33 2005 United Kingdom Case report Arterial Nondislocated, displaced Neer 2 ORIF Conservative 8/10
Laverick34 1990 United Kingdom Case report Arterial Subluxed, displaced surgical neck of humerus Hemiarthroplasty Interposition prosthetic graft 9/10
Lim35 1987 United States Case series Arterial Nondislocated, displaced surgical neck of humerus Neer proximal humerus replacement Primary repair 6/9
Arterial Nondislocated, displaced surgical neck of humerus ORIF Interposition vein graft –
Arterial Nondislocated, displaced surgical neck of humerus Rods Primary repair –
Lin36 2007 China Case report Arterial Dislocated greater tuberosity Reduction Conservative 10/10
Manak37 1996 Czech Republic Case report Arterial Nondislocated, displaced Neer 3 Conservative Interposition prosthetic graft 10/10
McLaughlin38 1998 United States Case report Arterial Dislocated, displaced Neer 3 Humerus head prosthesis Primary repair (+thrombectomy) 9/10
Modi39 2008 United Kingdom Case series Arterial Dislocated, displaced Neer 3 K-wire Patch repair 6/9
Mouzopoulos40 2008 Greece Case report Arterial – Reduction and bone sutures Interposition vein graft 10/10
Mouzopoulos41 2008 Greece Case series Arterial Displaced K-wire Ligation 6/9
Arterial Nondislocated, displaced Neer 2 Stabilized—bone sutures Interposition vein graft –
Naouli42 2016 Morocco Case report Arterial Nondislocated, displaced surgical neck of humerus – Interposition vein graft 9/10
Palanisamy43 2017 India Case report Arterial Nondislocated, displaced Neer 4 K-wires → ORIF Conservative 8/10
Paley44 1986 Canada Case report Arterial Dislocated, displaced greater tuberosity Reduction Conservative 8/10
Palm45 2013 United States Case report Arterial Nondislocated, minimally displaced comminuted head of humerus and surgical neck ORIF Conservative 9/10
Peters46 2017 United States Case series Arterial Nondislocated, displaced Neer 3 Open reduction Interposition prosthetic graft 6/9
Arterial Dislocated, displaced Neer 3 Hemiarthroplasty Interposition prosthetic graft (+shunt) –
Arterial Dislocated, displaced greater tuberosity Hemiarthroplasty Conservative –
Arterial Dislocated, displaced surgical neck of humerus Hemiarthroplasty Endovascular stent –
Arterial Dislocated, displaced Neer 3 ORIF Interposition prosthetic graft –
Puri47 1985 United Kingdom Case report Arterial Nondislocated, displaced surgical neck of humerus ORIF Primary repair 10/10
Razaeian48 2018 Germany Case report Arterial Nondislocated, displaced Neer 4 Head replacement Interposition vein graft (+thrombectomy) 9/10
Seagger49 2009 United Kingdom Case report Arterial Nondislocated, displaced Neer 2 ORIF Vein patch (+thrombectomy) 9/10
Smyth50 1969 United Kingdom Case report Arterial Nondislocated, displaced Neer 3 Not reported Primary repair (+clot aspiration) 9/10
Stromqvist51 1987 Sweden Case series Arterial Displaced Rush pins Primary repair 6/9
Arterial Nondislocated, displaced humerus head split and neck ORIF Primary repair –
Arterial Nondislocated, displaced Neer 3 ORIF Patch repair –
Sukeik52 2009 United Kingdom Case report Arterial Nondislocated, minimally displaced surgical neck of humerus Conservative Conservative 10/10
Theodorides16 1976 Nether-lands Case series Arterial Nondislocated, displaced surgical neck of humerus Nail Interposition vein graft 6/9
Arterial Nondislocated, displaced, surgical neck of humerus Conservative Interposition vein graft –
Thorsness53 2014 United States Case series Venous Dislocated, Neer 3 ORIF Conservative 7/9
Yagubyan17 2004 United States Case series Arterial and venous Displaced head of humerus ORIF Primary repair 7/9
Arterial Dislocated, displaced head of humerus and surgical neck of humerus Hemiarthroplasty Interposition vein graft
Arterial Nondislocated, displaced surgical neck of humerus K-wire Interposition vein graft –
Zhang54 2012 China Case series Arterial Nondislocated, displaced surgical neck of humerus ORIF Interposition vein graft 6/9
Arterial Nondislocated, displaced surgical neck of humerus ORIF Conservative –
Arterial Nondislocated, displaced surgical neck of humerus Reduced and fixed Conservative –
Zuckerman55 1983 United States Case series Arterial Displaced Neer 2 Rods Thrombectomy and interposition vein graft 6/9
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JBI, Joanna Brigg’s Institute; ORIF, open reduction internal fixation.

Surgical approach

A deltopectoral approach was most commonly used (n = 28, 51%). Three were managed through an anterolateral approach (5%),23,42,51 two through subclavicular approach,20,21 and one through a brachial approach.17 A total of 21 (38%) cases did not report the surgical approach. Most cases underwent fracture fixation followed by vascular repair (n = 30, 55%), 16 (29%) underwent vascular repair followed by fracture fixation,16,17,21,22,26,28–32,35,39–41,51,53 isolated fracture fixation was carried out in four cases (7%),33,46,54 isolated vascular repair in two cases (4%),37,50 fracture reduction in only one case (2%),36 conservative management in one case (2%),36 and one case (2%) started with vascular repair, then fracture fixation, and finally further vascular repair.46

Fracture fixation

A summary of fracture management per individual included can be found in Table II. All but three cases (5%) underwent the operative management of the fracture.16,37,52 Open reduction internal fixation or wire fixation was the most common operative fracture management (n = 33, 60%), followed by hemi-arthroplasty (n = 11, 20%).17,22,26,29,34,35,38,46,48 Specific operative fracture management was not specified in 4% of cases (n = 2).42,50 Adjunct procedures included one biceps tenotomy22 and one coracoid osteotomy.49

Vascular repair

Table II summarizes the type of vascular repair per individual included. Two cases (4%) reported both arterial and venous injuries17,22 and one (2%) an isolated venous injury.53 Venous injuries were either ligated22,53 or received primary repair.17 All other vascular injuries were arterial in origin. Arterial injuries were primarily treated with an interposition graft (n = 21, 38%) with preference for venous over prosthetic conduit.16–19,23,27,32,34,35,37,40–42,46,48,54,55 Two interposition vein grafts were converted intraoperatively to interposition prosthetic grafts due to caliber mismatch18 or poor flow.19 Primary repair was carried out in 11 cases (20%).17,22,24,25,35,38,47,50,51 Nine cases were managed conservatively,33,36,43–46,52,54 five received endovascular management,26,28,29,46 three underwent patch repair,39,49,51 two underwent a vein bypass,20,21 two were ligated,31,40 and one received a prosthetic bypass.30 Adjunct procedures included thrombectomy (n = 8, 15%)22,25–27,38,48,49,55 and clot aspiration (n = 1).50 The use of a shunt was documented in only one case.46

Length of stay

The total length of hospital stay postoperatively was reported in seven studies.20,21,29,36–38,42 The median length of stay reported was 7 days post-operatively, ranging from 2 to 24 days.

Complications

Table III describes the postoperative outcome of individuals included per study. As mentioned, two interposition vein grafts were changed intraoperatively to an interposition prosthetic graft.18,19 A total of 13 postoperative complications were reported.

Table III. Postoperative outcome of individuals included per study on proximal humerus fractures associated with vascular injury.

Study details Clinical Imaging
First author Year Pulse Sensation Motor ROM Vascular Fracture
Bucci18 2017 Present – Postganglionic brachial plexopathy – N N
Cawich19 2015 Present – – Full N N
Cotman20 2017 – Reduced: ulnar border – No motion elbow/wrist/ hand N X ray
Di Giacomo21 2021 Present – – Quick Dash score 22; ROM 110° active elevation and 100° active abduction – X ray
Githens22 2018 Present – Complete brachial plexopathy – – –
Goyal23 2014 Present – – – N N
Hayes24 1983 Present Normal Normal Normal N N
Hegde25 2021 – Normal Normal Good N N
Hofman26 2011 – – Deficit hand muscles—improved Intact N –
Irimia27 2019 – – – 50° flexion, 40° abduction Doppler X ray
Isawa28 2015 – – – – N N
Kanda29 2020 Present Normal Normal Normal N N
Karita30 2018 Present – Arm paralysis – N N
Kese31 2011 – – Radial nerve dysfunction –normal after 3 months Normal N N
Kurnaz32 2018 Present Normal Normal Normal N N
Lam33 2005 – – – – –
Laverick34 1990 Normal Normal Normal DSA N
Lim35 1987 Present – – – N N
Present – – Functional N X ray
– – – Flexion 60°, abduction 60°, external rotation 20° N N
Lin36 2007 Numb: ulnar 2 fingers 4/5 deltoid power, minimal intrinsic muscle weakness hand Active abduction 110° with 120° of forward elevation N X ray
Manak37 1996 – – – Active flexion shoulder 70°, extension 40°, abduction 40° Doppler N
McLaughlin38 1998 Present – Neer shoulder score at 1 year = 83 – N N
Modi39 2008 – – – – N Y
Mouzopoulos40 2008 – – – – N
Mouzopoulos41 2008 – – – Functional Doppler N
– – – Functional Doppler Y
Naouli42 2016 Present Normal Normal Normal N N
Palanisamy43 2017 – – – Normal N X ray
Paley44 1986 – – Deltoid 4/5 Normal N –
Palm45 2013 – Reduced: lateral and medial forearm – Normal N N
Peters46 2017 – – Improved Improved – –
Present Normal Normal Passive flexion 120°, active flexion and abduction 30° – Y
– – – Forward flexion 85°, external flexion 15°, and internal rotation to L5 – –
Present – – Abduction 45° – X ray
Puri47 1985 Present – – – – –
Razaeian48 2018 Present – Plexopathy Shoulder function 10° and Constant Shoulder Score 17/100 N X ray
Seagger49 2009 – – 4/5 elbow flexion, extension 2/5 – N X ray
Smyth50 1969 – – – – N –
Stromqvist51 1987 Present – Palsy of radial branch – – –
– – 50% reduction grip strength Reduction in arm mobility N –
Sukeik52 2009 Present – – Good – –
Theodorides16 1976 – – – – DSA –
– – – Restricted abduction DSA –
Thorsness53 2014 – – Complex brachial plexopathy – Doppler N
Yagubyan17 2004 Present Regained C5/6 – – – –
Present – Functional use for light grasping – – –
Present – Weakness wrist and finger extension, and handgrip – DSA –
Zhang54 2012 – Y Weakness of wrist and finger extension – CTA –
– Numb: 2 ulnar fingers – – – –
Zuckerman55 1983 Present – Posterior cord lesion – Doppler X ray
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CTA, Computed tomography angiogram; DSA, digital subtraction angiography; N, no; ROM, range of motion; Y, yes.

Metalwork failure (n = 1)39 and loss of fracture reduction (n = 1)35 were observed 1 month postoperatively, leading to revision of fracture fixation in both cases. Avascular necrosis was evident radiologically in one case at 6-month follow-up imaging, following an initial open reduction internal fixation with plate fixation.20 After coracoid osteotomy during the surgical approach, coracoid displacement was observed on plain radiographs at 1-year follow-up in one case.49 One case of compartment syndrome was reported.53 This occurred several hours after the initial procedure following missed arterial injury that required a thrombectomy and vein bypass, where fasciotomy was not undertaken at initial surgery.

Only one case reported limb loss as a complication where a mid-brachial amputation was undertaken at 12 days following the initial procedure. This was a 3-part proximal humerus fracture with arterial injury that underwent clot aspiration followed by primary repair.50 Similarly, persistent deltoid and intrinsic muscle weakness at 3 months postoperatively, requiring brachial plexus exploration, was observed in one case.44 Systemic complications were also reported in these injuries, including disseminated intravascular coagulopathy (n = 1)18 and mortality (n = 4) secondary to myocardial infarction, acute renal failure, and sepsis.26,35,40,46 Reported mortality occurred within 2 weeks postoperatively in all cases before patient discharge. Inpatient mortality was reported; however, overall 30-day and 1-year mortality was not reported in any studies.

Risk of bias

The risk of bias was assessed according to the Joanna Briggs Institute Critical Appraisal Tools checklist. The risk of bias in all studies was low (Table II, Supplementary Tables IV and V, online only).

Discussion

This systematic review synthesizes the current evidence with regard to presentation, management, and complications observed in this rare but clinically important injury.

Clinical presentation and mechanism of injury

We emphasize the need for a high index of suspicion for the accurate and prompt diagnosis of associated vascular injury in patients presenting with proximal humerus fractures. This is especially significant given the time-critical nature, with joint orthopedic, plastic, and vascular surgery guidelines advocating management within 4 hours.9 Furthermore, increased risk of limb loss is associated with delays, leading to prolonged ischemic time.10,56 More than half of proximal humerus fractures associated with vascular injury occurred after a fall from a standing height, therefore highlighting the importance of considering such an injury even in the absence of a high-energy mechanism. Although the importance of the management of major trauma is reflected in guidelines for the management of vascular trauma and fracture-related arterial injury,9,57 it is also vital to emphasize the incidence of these significant injuries in low-energy trauma. This is particularly meaningful in the context of proximal humerus fractures, with increasing incidence of fragility fractures of the humerus due to an aging population.58

A cool, pale limb was present in the majority of cases, with 13% also recorded as having an increase in capillary refill time. Interestingly, 13% of all cases did not have any of these clinical features, suggesting that reliance on these clinical features alone may miss an associated vascular injury in more than 1 in 10 cases. In addition, concurrent neurological injury was present in the majority of cases, suggesting that we should not be falsely reassured by a normal capillary refill time when these other features, particularly neurological injury, are present. This is implied in the current BOAST guidelines, which advises “associated nerve injury should be presumed until disproven.”9 Our findings, however, emphasize the importance of this also as an indicator of associated vascular injury and should act as a further prompt to consider the presence of vascular injury. Indeed, concomitant brachial plexus injury has been identified as a risk factor for associated axillary artery injury in one retrospective study.7 Similarly, an absent or altered pulse was not always present in individuals with an associated vascular injury, and therefore a normal pulse does not necessarily exclude this.

Imaging

In this review, preoperative imaging to delineate vascular injury was variable with mixed imaging modalities used. Several cases proceeded to surgical management without prior vascular imaging, of which several subsequently required intraoperative imaging. In the current joint guidelines, CT angiography is the only imaging modality discussed and is advised to be undertaken immediately after a CT trauma scanogram.9 This, however, also implies the assumption of major trauma as the mechanism of injury. Our review emphasizes the consideration of appropriate imaging in lower mechanism injuries. In the context of general peripheral vascular trauma, CT angiography is reported to be the mainstay of imaging used for the diagnosis of vascular injury.57

Management

Vascular injuries associated with proximal humerus fractures were predominantly arterial in nature and most commonly treated with interposition graft, with preference for venous over prosthetic, followed by primary repair. This is in keeping with current guidelines, which state that these are preferable to the use of bypass grafts.9 Vein grafts were traditionally thought to have higher patency and reduced infection rates;59 however, more recent literature on the use of interposition grafts in the context of trauma suggests that there may be no difference, albeit these data are retrospective in nature.60 Of note, the vein interposition graft required conversion to prosthetic in some cases in this review, and the possible need for conversion should be considered. The use of shunts, however, was only reported in a single case. This is surprising given that most cases underwent fracture fixation followed by vascular repair, and guidelines recommend the use of arterial shunts when rapid definitive restoration of flow cannot be achieved in order to reduce ischemic time and subsequent limb loss.9,56 However, similar findings are reported in another study assessing the use of temporary shunts in civilian trauma.61 Nevertheless, it is key to highlight the availability and importance of the use of arterial shunt during fracture fixation to restore flow before definitive repair.

Proximal humerus fractures are common injuries associated with increasing age and frailty,58 as well as in high-energy trauma in younger patients. Male sex, open fracture, concomitant brachial plexus injury, and atherosclerosis have been identified as risk factors for arterial injury in proximal humerus fractures,7 the presence of which is an indication for the surgical management of these otherwise commonly conservatively-managed fractures. The heterogeneity seen in the surgical management of proximal humerus fractures reflects that of patient comorbidities, functional status, and observed fracture pattern. In this review, associated vascular injury occurred in a variety of fracture patterns, most commonly in two-part fractures, and was managed most commonly with open reduction internal fixation. The literature suggests that decision-making between open reduction internal fixation and arthroplasty, either hemiarthroplasty or reverse shoulder arthroplasty, should be largely dictated by fracture patterns, degree of displacement, and patient factors, with older and highly comorbid patients more frequently undergoing hemiarthroplasty.62,63

Strengths and limitations

The evidence regarding lower limb arterial injuries associated with fracture has been summarized to date and resulted in clinical guidance available to aid decision-making.56 Upper limb arterial injuries, however, are known to differ from lower limb injuries in terms of management and complications.59 Despite this, upper limb fractures with associated vascular injuries are less established in the literature, particularly in predominantly low-energy injuries, such as proximal humerus fractures, compared with high-energy major trauma. Our review attempts to address and discuss this in the context of the current multispecialty guidelines. The overall aim is to aid clinicians across specialties involved in the surgical management of these injuries in the decision-making process, as well as those assessing these injuries at initial presentation. This systematic review, conducted according to PRISMA guidelines,13 presents the current evidence that was found to have low risk of bias. We do acknowledge, however, several potential limitations within this. For example, the included studies are case reports and series, representing a lower level of evidence than other retrospective or prospective study designs. As such, despite the low risk of bias suggesting that these studies were well conducted, the evidence collated from this must be interpreted accordingly, and caution used when extrapolating. Therefore, although we describe the reported complications, no consecutive observational studies were identified to be able to truly comment on rates of outcomes and complications with confidence. Rates of amputation, however, have previously been reported to be lower in upper limb compared with lower limb arterial injuries, in keeping with the low rate we observed.59 Furthermore, although reduced ischemic time has been shown to be vital in terms of limb salvage within lower limb arterial injuries,56 this was not sufficiently reported to comment on in this study. For this reason, this review intends to describe and evaluate reported assessment and management, discussed alongside current guidelines, to facilitate early identification and aid surgical decision-making in these injuries.

Conclusions

Vascular injuries are seen in a wide range of proximal humerus fracture patterns, but most commonly in displaced two-part proximal humerus fractures. Vascular injury should be particularly considered in the presence of nerve injury with vascular repair predominantly performed by interposition graft or primary repair and fracture management most commonly by open reduction internal fixation. The use of arterial shunts may be vital to restore flow while fracture fixation occurs before definitive vascular repair. Proximal humerus fractures with associated vascular injury occur most commonly in the older adults after low-energy trauma such as a fall from a standing height. A high index of suspicion is needed as not all injuries present with classical ischemic symptoms and these injuries carry a significant burden of morbidity.

Supplementary Material

Supplementary

Funding

J.S. is supported by a National Institute for Health and Care Research Academic Clinical Fellowship award (Award No. ACF-2022-11-003). S.J.M. is supported by a British Heart Foundation Clinical Research Training Fellowship award (Award No. FS/CRTF/23/24452). A.S. receives funds from the National Institute for Health and Care Research (salary support), the Academy of Medical Sciences, and the British Heart Foundation (research support); and also receives honoraria, lecture fees, research support, and consultation fees from Shockwave Ltd, Abbott Ltd, Cook Medical, Bentley Ltd, Medyria GmBH, General Electric Healthcare, Cordis, and Boston Scientific Ltd.

Footnotes

Author Contributions

Conception and design: JS, AS, CP, HS, SM

Analysis and interpretation: JS, AS, SM

Data collection: JS, CP, SM

Writing the article: JS, SM

Critical revision of the article: JS, AS, CP, HS, SM

Final approval of the article: JS, AS, CP, HS, SM

Statistical analysis: Not applicable

Obtained funding: Not applicable

Overall responsibility: SM

Disclosures

None.

The editors and reviewers of this article have no relevant financial relationships to disclose per the Journal policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest.

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