Posterior Circumflex Humeral Artery Research Articles

A systematic review on posterior circumflex humeral artery pathology: sports and professions at risk and associated risk factors.

Posterior circumflex humeral artery (PCHA) aneurysm formation and thrombosis as overuse injury in the dominant shoulder can result in ischemia of the forearm, hand and digits due to arterial embolisms. Increased awareness among physicians is necessary as PCHA pathology (PCHAP) might be underdiagnosed. Knowledge of sports and professions at risk and risk-factors for obtaining PCHAP is essential for the development of future preventive measures. This study aims to identify sports and professions at risk as well as risk factors for PCHAP. The databases of MEDLINE, EMBASE, BIOSIS, CINAHL and SPORTDiscus were systematically searched. Twenty-seven papers fulfilled the inclusion criteria and described 67 patients with PCHAP involved in seven sports and three professions. The sports (number of cases) were volleyball (41), baseball (13), swimming (1), tennis (3), American football (2), canoeing (1) and yoga (1) (2 unknown). The professions included a baseball coach, a circus trapeze artist and a mechanic. Apart from expert opinions, no studies have identified risk factors for PCHAP. An anatomic variation of the PCHA origin is suggested to be protective for PCHAP. PCHAP is reported in seven overhead sports and three professions. No risk factors for PCHAP were identified. An anatomic variant of the PCHA origin was found to be a potential protective factor for PCHAP. Physicians should be cautious for distal embolization as a result of PCHAP in athletes and workers, both adult and adolescent, involved in repetitive powerful overhead movements.

Quadrilateral Space Syndrome: Diagnosis and Clinical Management.

Quadrilateral space syndrome (QSS) is a rare disorder characterized by axillary nerve and posterior humeral circumflex artery (PHCA) compression within the quadrilateral space. Impingement is most frequently due to trauma, fibrous bands, or hypertrophy of one of the muscular borders. Diagnosis can be complicated by the presence of concurrent traumatic injuries, particularly in athletes. Since many other conditions can mimic QSS, it is often a diagnosis of exclusion. Conservative treatment is often first trialed, including physical exercise modification, physical therapy, and therapeutic massage. In patients unrelieved by conservative measures, surgical decompression of the quadrilateral space may be indicated.

Anatomical basis of clavicular cross-area perforator flaps

Background: Systematic studies of cutaneous (perforating) branches around the clavicle and their anastomosis have not yet been reported. We sought to comprehensively analyze the cutaneous (perforator) flaps surrounding the clavicle and their anastomosis to obtain the anatomical evidence for the application of cross-area perforator flaps. Methods: A total of 20 fresh cadaver specimens were perfused with modified lead oxide-gelatin injection for angiography. The spiral CT scan data were input in two-dimensional DICOM format into an interactive medical imaging control system, Mimics Workstation. The upper chest and neck-shoulder images were captured using a crop project, followed by three-dimensional (3D) continuous reconstruction using fast direct volume rendering (VR). Then, “3D Mask”, “Edit Mask”, and other tools were used to visualize the perforators and anatomized vessels. Results: After 3D reconstruction, the cutaneous (perforating) branches around the clavicle, anatomized vessels among perforators, and subcutaneous vessel network were clearly displayed. Three kinds of vascular anastomoses were revealed: (I) anastomosis of acromion branches of transverse cervical artery and ascending branches of posterior circumflex humeral artery; (II) anastomosis of clavicular branches of transverse cervical artery and perforating branches of thoracoacromial artery; (III) anastomosis of sternocleidomastoid myocutaneous perforators and ascending branches of 1 and 2 intercostal arteries. The average diameter of the posterior humeral circumflex artery perforator, the thoracoacromial artery perforator, the first and two intercostal arteries perforator, and the transverse cervical artery was 0.8, 0.6, 0.7, and 0.7 mm, respectively. Conclusions: (I) Mimics can be used to conveniently and comprehensively analyze the cutaneous (perforating) branches and their vascular anastomosis. (II) Cross-area flaps can be procured according to the three types of anastomosis around the clavicle, which can be easily applied in the repair and reconstruction of maxillofacial and anterior cervical soft tissue defects. (III) In anterograde flap transposition, the key anatomical site of the vascular pedicle is located in the superior part of the acromioclavicular joint, and the vascular pedicle rotation point can be set in the occipital triangle.

Posterior circumflex humeral artery pathology and digital ischemia in elite volleyball: Symptoms, risk factors & suggestions for clinical management

ObjectivesTo assess the association between posterior circumflex humeral artery (PCHA) pathology (PCHAP), symptoms and associated risk factors, in elite volleyball players, and to suggest profiles for clinical management and monitoring. DesignCross-sectional study. MethodsA questionnaire assessed symptoms of digital ischemia (DI) in the dominant hand and risk factors among 278 elite indoor and beach volleyball players of whom 6.1% (17/278) was diagnosed with PCHAP using ultrasound. Odds Ratios (OR) including 95% confidence intervals (95%CI) were calculated using binary logistic regression. ResultsAll 278 players completed the questionnaire. Three participants with PCHAP were symptomatic (18%). Ninety-three of 96 symptomatic participants had no PCHAP (OR=0.39; 95% CI 0.13–1.13). Total years playing volleyball (OR 1.14; 95% CI 1.03–1.25) and age (OR 1.17; 95% CI 1.00–1.29) were dose-response related risk factors: a volleyball career of ≥17 years and age of ≥27 years were associated with a 9-fold and 14-fold increased risk of PCHAP, respectively. ConclusionsThe volleyball career duration and age are dose-response related risk factors for PCHAP among elite indoor and beach volleyball players. DI symptoms are prevalent in a minority of athletes with PCHAP (3/17; 18%). To enable worldwide standardized care for these athletes at risk, four profiles for clinical management and monitoring have been suggested based on questionnaire and ultrasound outcomes.

Anomalous Origin and Course of the Posterior Circumflex Humeral Artery: Clinical Interest in Shoulder Arthroscopy and Open Procedures

Anomalous Origin and Course of the Posterior Circumflex Humeral Artery: Clinical Interest in Shoulder Arthroscopy and Open Procedures

Relationship between the Axillary Nerve and Accompanying Vessels and Proximal Humeral Locking Plates in Japanese: An MRI Study.

We investigated the anatomical features of the axillary nerve and its accompanying vessels with respect to the lateral wall of the greater tuberosity, focusing on the relationship between the neurovascular bundle and the proximal humeral locking plates. Magnetic resonance images of 30 Japanese patients' shoulders were examined. Oblique sagittal images across the greater tuberosity and the neurovascular bundle, which contain the axillary nerve and posterior circumflex humeral artery and vein, were obtained. The distance between the superior aspect of the greater tuberosity and the superior and inferior borders of the neurovascular bundles was measured at the anterior, middle, and posterior edges of the greater tuberosity. The neurovascular bundle was 28.5-36.7 mm, 32.6-41.3 mm, and 38.1-47.5 mm distal to the superior aspect of the greater tuberosity at the anterior, middle, and posterior edges, respectively. We evaluated the relationship between the neurovascular bundle and 3 different locking plates, which were placed at the lateral aspect of the greater tuberosity. Only 3 or four locking screws at the most proximal part could be safely inserted without axillary nerve interference.

Diagnostic properties of the SPIQuestionnaire to detect Posterior Circumflex Humeral Artery Disease in elite volleyball players: a cross-sectional study

ObjectivesSports related aneurysmal degeneration and thrombosis of the Posterior Circumflex Humeral Artery (PCHA) has been known to cause symptoms of digital ischemia (DI) in elite volleyball players. Studies have reported symptoms of DI in as much as 28% of the elite indoor volleyball players. The purpose of this study was to determine the diagnostic value of the Shoulder PCHA Pathology and digital Ischemia – Questionnaire (SPI-Q) for detection of sports related PCHA disease using ultrasound data as the standard of reference. MethodsThe SPI-Q was completed by elite indoor volleyball players from the highest and single highest Dutch volleyball division and by elite beach volleyball players participating in the 2014 Grand Slam Beach Tournament The Hague (GSBTH). Ultrasound assessment of the dominant shoulder was performed on-site using the SPI-US protocol. The SPI-Q sensitivity, specificity, positive – and negative predictive value and positive – and negative likelihood ratios, and the diagnostic odds ratio were calculated for detection of sports related PCHA disease, using ultrasound as the standard of reference. ResultsTwo hundred twenty-four elite male indoor volleyball players from the Dutch division were included in this study and 62 elite male and female beach volleyball players participating in the GSBTH: a total of 278 players. Thirty-five percent of the players reported symptoms of DI. The prevalence of PCHA disease was 6.1%. For the SPI-Q we found a sensitivity of 18% (95% CI 4–43), specificity of 64% (95% CI 58–70), positive predictive value of 3% (95% CI 0.7–8.9) and negative predictive value of 92% (95% CI 87–96), positive likelihood ratio of 0.50 (95% CI 0.18–1.40), negative likelihood ratio of 1.28 (95% CI 1.01–1.62) and a diagnostic odds ratio of 0.39 (95% CI 0.11–1.38). ConclusionThe diagnostic value of the SPI-Q to detect PCHA disease in elite volleyball players is poor, which makes it unsuitable as a diagnostic instrument for sports related PCHA disease specifically. However, it can be used to assess all-cause symptoms of DI and raise awareness within athletes and sports physicians, which is important for preventing ischemic complications.

Blood supply and vascularity of the glenoid labrum: Its clinical implications.

Tears of the glenoid labrum are common after dislocation of the glenohumeral joint. The outcome for healing or surgical reconstruction of the glenoid labrum relies on the extent of its vascularization. This study aims to evaluate the glenoid labrum blood supply and to determine its regional vascularity. A total of 140 shoulders (30 male and 40 female cadavers) were examined: mean age 81.5 years, range 53-101 years. All blood vessels around the glenohumeral joint were dissected and recorded. Ten specimens with the glenoid labrum and fibrous capsule attached were randomly selected and detached at the glenoid neck and subjected to decalcification. Sections (10-20 μm) were cut through the whole thickness of each specimen from the centre of the glenoid fossa perpendicular to the glenoid labrum at 12 radii corresponding to a clock face superimposed on the glenoid. Sections were stained using haematoxylin and eosin and then examined. The blood supply to the glenoid labrum is by direct branches from the second part of the axillary artery, subscapular, circumflex scapular and anterior circumflex humeral and posterior circumflex humeral arteries, as well as branches of muscular arteries supplying the surrounding muscles. This study shows that the glenoid labrum has a rich blood supply suggesting that, regardless of the types of the glenoid labrum lesions or their management, an excellent outcome for glenoid labrum healing and joint stability is possible. The observations also suggest that the blood supply to the glenoid labrum is sufficient, enabling its reattachment.

A rare case of common trunk of posterior circumflex humeral and subscapular arteries along with early division of axillary nerve

Lichen planus pigmentosus-inversus (LPP-inversus) which is an uncommon variant of lichen planus, is characterized by well bordered hyperpigmented macules and patches involving intertriginous areas. Since it was first defined, very few cases have been reported worldwide. Herein we report eight new patients with characteristic features of LPP-inversus. The hyperpigmented lesions of our patients were mostly located on axilla and the inguinal region. Two patients also had lesions that were clinically consistent with classic lichen planus. Three patients had lesions with unilateral distribution. In all of the cases a skin biopsy was performed to confirm the clinical diagnosis of LPP-inversus. LPP-inversus is a disease with unique clinical and histopathological features that we should bear in mind in the differential diagnosis of hyperpigmented flexural lesions. The etiopathogenesis and the treatment strategy of this rare entity need to be clarified.

Establishing a new appropriate intramuscular injection site in the deltoid muscle

ABSTRACTIt is becoming increasingly important for clinicians to identify a safer intramuscular (IM) injection site in the deltoid muscle because of possible complications following the vaccine administration of IM injections. We herein examined 4 original IM sites located on the perpendicular line through the mid-acromion to establish a safer IM injection site. Thirty healthy volunteers participated in this study and the distances from our 4 IM sites to some anatomical landmarks on their left arms were measured. Ultrasonography (US) was also performed to measure the thickness of the deltoid muscle and identify the posterior circumflex humeral artery (PCHA) along the course of the axillary nerve. Subcutaneous thickness was measured using 2 methods: measuring the skin thickness with caliper after pinching the skin, and with US. The results obtained revealed that the intersection between the anteroposterior axillary line (the line between the upper end of the anterior axillary line and the upper end of the posterior axillary line) and the perpendicular line from the mid-acromion was the most appropriate site for IM injections because it was distant from the axillary nerve, PCHA, and subdeltoid/subacromial brusa. At this site, depth of needle insertions was 5 mm greater than the subcutaneous thickness at a 90° angle, which was sufficient to penetrate subcutaneous tissue in both sexes. Subcutaneous thickness can be assessed with almost the same accuracy by US or measuring with calipers after pinching the skin. The results of the present study support the improved vaccine practice for safer IM injections.

Accessory subscapularis muscle – A forgotten variation?

The quadrangular space is a space in the axilla bounded by the inferior margin of the teres minor muscle, the superior margin of the teres major muscle, the lateral margin of the long head of the triceps brachii muscle and the surgical neck of the humerus, medially. The axillary nerve (C5-C6) and the posterior circumflex humeral artery and veins pass through this space in order to supply their territories. The subscapularis muscle is situated into the scapular fossa and inserts itself into the lesser tubercle of the humerus, thus helping stabilize the shoulder joint. A supernumerary muscle known as accessory subscapularis muscle originates from the anterior surface of the muscle and usually inserts itself into the shoulder joint. It is a rare variation with few reports of its existence and incidence. We present a case of the accessory subscapularis muscle in a male cadaver fixated with a 10% formalin solution. The muscle passed anteriorly to the axillary nerve, thus, predisposing an individual to quadrangular space compression syndrome. We perform a review of the literature and address its clinical, anthropological and anatomical significance.

Blood supply of the subacromial bursa and rotator cuff tendons on the bursal side.

Vascularity of the subacromial bursa and rotator cuff tendons is key factors in the pathogenesis of subacromial bursitis and impingement syndrome, rotator cuff tendinitis, and rotator cuff tears. The purpose of this study was to investigate and describe blood supply to the cranial and caudal parts of the subacromial bursa and the vascularity of the rotator cuff tendons on the bursal side. Fourteen fresh cadaveric shoulders from six females and eight males with a mean age of 71.7 (±10.8) years were studied. Before dissection, an arterial injection of 10% aqueous dispersion of latex was administered. Post-injection, the shoulders were fixed in an alcohol-formalin-glycerol solution. The cranial and caudal bursa of all specimens was mainly supplied by the thoracoacromial, suprascapular, and anterior and posterior circumflex humeral arteries. The cranial part of the bursa was supplied anteriorly by the thoracoacromial artery, and posteriorly and medially by the posterior circumflex humeral artery as far as the medial third. The caudal part received arterial blood anteriorly from the anterior circumflex humeral artery, and posteriorly and medially by the posterior circumflex humeral artery as far as the medial third of the caudal bursa. In addition, the suprascapular artery branched at the upper surface of the coracohumeral ligament, and the subcoracoid artery branched at the under surface of the same ligament. The subacromial bursa appears well vascularized. The results of the present investigation showed that blood supply to the subacromial bursa at the caudal part and rotator cuff tendons on the bursal side was linked to the same arteries. The subcoracoid artery supplied interval rotator structures close to the caudal bursa. It is the wish of the authors that this meticulous anatomical work will help surgeons in their day-to-day clinical work, e.g. to minimize the risk of complications such as perioperative bleeding.

Rare Variation of the Profunda Brachii Artery and its Clinical Significance

Variations in the origin of axillary artery branches are one of the most common variations. However, derivation of profunda brachii artery from circumflex humeral artery is a rare occurrence. Since it is a frequent site of injury and it is involved in many surgical and invasive procedures, the arterial variations in the arm is important for a clinician. During routine dissection, for students of medical school, a variation of profunda brachii artery was observed in right upper extremity of 62 year old male cadaver. In the present study, profunda brachii artery arose from posterior circumflex humeral artery and radial nerve in radial sulcus did not accompany profunda brachii artery. Awareness of details of variations of the axillary artery may function as a beneficial guide for vascular surgeons. It may contribute to preventing complications during the surgery of the axilla region.

Anatomy of the terminal branch of the posterior circumflex humeral artery: relevance to the deltopectoral approach to the shoulder.

Despite the expansion of arthroscopic surgery of the shoulder, the open deltopectoral approach is increasingly used for the fixation of fractures and arthroplasty of the shoulder. The anatomy of the terminal branches of the posterior circumflex humeral artery (PCHA) has not been described before. We undertook an investigation to correct this omission. The vascular anatomy encountered during 100 consecutive elective deltopectoral approaches was recorded, and the common variants of the terminal branches of the PCHA are described. In total, 92 patients (92%) had a terminal branch that crossed the space between the deltoid and the proximal humerus and which was therefore vulnerable to tearing or avulsion during the insertion of the blade of a retractor during the deltopectoral approach to the shoulder. In 75 patients (75%) there was a single vessel, in 16 (16%) a double vessel and in one a triple vessel. The relationship of these vessels to the landmark of the tendon of the insertion of pectoralis major into the proximal humerus is described. Damage to these previously undocumented branches can cause persistent bleeding leading to prolonged surgery and post-operative haematoma and infection, as well as poor visualisation during the procedure. Cite this article: Bone Joint J 2016;98-B:1395-8.

Test-retest reliability and agreement of the SPI-Questionnaire to detect symptoms of digital ischemia in elite volleyball players

ABSTRACTThe Shoulder posterior circumflex humeral artery Pathology and digital Ischemia – questionnaire (SPI-Q) has been developed to enable periodic surveillance of elite volleyball players, who are at risk for digital ischemia. Prior to implementation, assessing reliability is mandatory. Therefore, the test-retest reliability and agreement of the SPI-Q were evaluated among the population at risk.A questionnaire survey was performed with a 2-week interval among 65 elite male volleyball players assessing symptoms of cold, pale and blue digits in the dominant hand during or after practice or competition using a 4-point Likert scale (never, sometimes, often and always). Kappa (κ) and percentage of agreement (POA) were calculated for individual symptoms, and to distinguish symptomatic and asymptomatic players. For the individual symptoms, κ ranged from “poor” (0.25) to “good” (0.63), and POA ranged from “moderate” (78%) to “good” (97%). To classify symptomatic players, the SPI-Q showed “good” reliability (κ = 0.83; 95%CI 0.69–0.97) and “good” agreement (POA = 92%). The current study has proven the SPI-Q to be reliable for detecting elite male indoor volleyball players with symptoms of digital ischemia.

Ultrasound assessment of the posterior circumflex humeral artery in elite volleyball players: Aneurysm prevalence, anatomy, branching pattern and vessel characteristics

ObjectivesTo determine the prevalence of posterior circumflex humeral artery (PCHA) aneurysms and vessel characteristics of the PCHA and deep brachial artery (DBA) in elite volleyball players.MethodsTwo-hundred and eighty players underwent standardized ultrasound assessment of the dominant arm by a vascular technologist. Assessment included determination of PCHA aneurysms (defined as segmental vessel dilatation ≥150 %), PCHA and DBA anatomy, branching pattern, vessel course and diameter.ResultsThe PCHA and DBA were identified in 100 % and 93 % (260/280) of cases, respectively. The prevalence of PCHA aneurysms was 4.6 % (13/280). All aneurysms were detected in proximal PCHA originating from the axillary artery (AA). The PCHA originated from the AA in 81 % of cases (228/280), and showed a curved course dorsally towards the humeral head in 93 % (211/228). The DBA originated from the AA in 73 % of cases (190/260), and showed a straight course parallel to the AA in 93 % (177/190).ConclusionsPCHA aneurysm prevalence in elite volleyball players is high and associated with a specific branching type: a PCHA that originates from the axillary artery. Radiologists should have a high index of suspicion for this vascular overuse injury. For the first time vessel characteristics and reference values are described to facilitate ultrasound assessment.Key Points• Prevalence of PCHA aneurysms is 4.6 % among elite volleyball players.• All aneurysms are in proximal PCHA that originates directly from AA.• Vessel characteristics and reference values are described to facilitate US assessment.• Mean PCHA and DBA diameters can be used as reference values.• Radiologists need a high index of suspicion for this vascular overuse injury.

B-Mode Sonographic Assessment of the Posterior Circumflex Humeral Artery: The SPI-US Protocol-A Technical Procedure in 4 Steps.

Elite overhead athletes are at risk of vascular injury due to repetitive abduction and external rotation of the dominant arm. The posterior circumflex humeral artery (PCHA) is prone to degeneration, aneurysm formation, and thrombosis in elite volleyball players and baseball pitchers. The prevalence of PCHA-related thromboembolic complications is unknown in this population. However, the prevalence of symptoms associated with digital ischemia is 31% in elite volleyball players. A standardized noninvasive imaging tool will aid in early detection of PCHA injury, prevention of thromboembolic complications, and measurement reproducibility. A standardized vascular sonographic protocol for assessment of the proximal PCHA (SPI-US protocol [Shoulder PCHA Pathology and Digital Ischemia-Ultrasound protocol]) is presented.

A rare variation in the branching pattern of axillary artery

An unusual variation of the axillary artery was reported in the right side of a 63-year-old female cadaver during routine dissection classes. It was observed that the first part of the axillary artery gave origin to the superior thoracic artery as usual and the second part gave thoracoacromial artery, which showed the normal course and branching pattern. In addition to this branch, the second part also gave a large common trunk from which lateral thoracic artery and subscapular artery arose. The subscapular artery was divided into circumflex scapular and thoracodorsal arteries. The circumflex scapular artery after passing through the upper triangular space of axilla emerged out near the lateral border of scapula on the posterior aspect. The thoracodorsal artery was seen as continuation of the subscapular artery after giving the branch circumflex scapular artery, lies posterior to the lateral thoracic artery. It gave muscular branches to teres major and serratus anterior. The third part of the axillary artery gave anterior and posterior circumflex humeral artery only. The detailed knowledge about anatomy of normal as well as variant axillary artery is very helpful to clinicians in operative and invasive procedures around pectoral and axillary regions, especially in the field of vascular surgeries. This is also useful to radiologists in different Doppler and contrast imaging study of the vessels.

Reproducibility of the SPI-US protocol for ultrasound diameter measurements of the Posterior Circumflex Humeral Artery and Deep Brachial Artery: an inter-rater reliability study.

ObjectivesElite overhead athletes are at risk of posterior circumflex humeral artery (PCHA) degeneration, aneurysm formation and thrombosis. Identification of the proximal PCHA and the nearby originating deep brachial artery (DBA) can be a challenge, even among experienced sonographers. The aim of this study was to assess the accuracy and precision of a newly designed standardized ultrasound (US) protocol (SPI-US) for assessment of the PCHA and DBA.MethodsTwo experienced sonographers determined diameters of the PCHA and DBA using the SPI-US protocol. Inter-observer agreement was evaluated using intra-class correlation coefficient (ICC), standard error of measurement (SEM), minimal detectable change (MDC), Bland-Altman (BA) analysis, and variance component (VARCOMP) analysis.ResultsThirty-three healthy volunteers participated. The ICC for diameter measurement of the PCHA and DBA were 0.70 (95 %CI 0.50-0.83) and 0.60 (95 %CI 0.30-0.80), respectively. The SEM for the PCHA and DBA was 0.32 mm and 0.29 mm and MDC was 0.90 mm and 0.80 mm, respectively. The BA and VARCOMP analyses showed no systematic and only marginal sonographer bias.ConclusionsThe SPI-US protocol is accurate and precise for PCHA and DBA diameter assessment in cases where they originate from the axillary artery. PCHA and DBA diameter measurements are sonographer-independent using the SPI-US-protocol.Key points• PCHA & DBA diameter assessment is accurate and reliable using the SPI-US protocol• PCHA & DBA diameter measurements are sonographer-independent using the SPI-US protocol• The SPI-US protocol minimal detectable change is 0.90 mm for PCHA diameter measurement• This minimal detectable change enables detection of PCHA aneurysms• First step towards international periodic surveillance of athletes at risk of PCHA-injury

A Variation In The Origin And Course Of The Posterior Circumflex Humeral Artery And The Deep Brachial Artery: Clinical Importance Of The Variation

Summary A case of an unusual variation of the blood supply of an upper limb is presented. During a routine anatomical dissection, it was found that the posterior circumflex humeral artery had an unusual course and branching. It arose as a branch of the brachial artery, not the axillary one, and it did not accompany the axillary nerve. It ran under the lower border of the teres major muscle instead of passing through the lateral axillary foramen, then followed its usual course around the surgical neck of the humerus, supplying the deltoid muscle. It was also found that instead of arising from the brachial artery, the deep brachial artery arose from the posterior circumflex humeral artery. Variations are reported and their clinical relevance is discussed.