Posterior Circumflex Humeral Artery Research Articles

Quantitative Assessment of the Vascularity of the Proximal Part of the Humerus

The current consensus in the literature is that the anterolateral branch of the anterior humeral circumflex artery provides the main blood supply to the humeral head. While the artery is disrupted in association with 80% of proximal humeral fractures, resultant osteonecrosis is infrequent. This inconsistency suggests a greater role for the posterior humeral circumflex artery than has been previously described. We hypothesized that the posterior humeral circumflex artery provides a greater percentage of perfusion to the humeral head than the anterior humeral circumflex artery does. In twenty-four fresh-frozen cadaver shoulders (twelve matched pairs), we cannulated the axillary artery proximal to the thoracoacromial branch and ligated the brachial artery in the forearm. In each pair, one shoulder served as a control with intact vasculature and, in the contralateral shoulder, either the anterior humeral circumflex artery or the posterior humeral circumflex artery was ligated. Gadolinium was injected through the cannulated axillary arteries, and magnetic resonance imaging was performed. After imaging, a urethane polymer was injected, and specimens were dissected. For volumetric analysis, the gadolinium uptake on the magnetic resonance imaging was quantified in each quadrant of the humeral head with use of a custom automated program. The gadolinium uptake was compared between the control and ligated sides and between the ligated anterior humeral circumflex artery and ligated posterior humeral circumflex artery groups. The posterior humeral circumflex artery provided 64% of the blood supply to the humeral head overall, whereas the anterior humeral circumflex artery supplied 36%. The posterior humeral circumflex artery also provided significantly more of the blood supply in three of the four quadrants of the humeral head. The finding that the posterior humeral circumflex artery provides 64% of the blood supply to the humeral head provides a possible explanation for the relatively low rates of osteonecrosis seen in association with displaced fractures of the proximal part of the humerus. In addition, protecting the posterior humeral circumflex artery during the surgical approach and fracture fixation may minimize loss of the blood supply to the humeral head.

Branching patterns of the lateral thoracic, subscapular, and posterior circumflex humeral arteries and their relationship to the posterior cord of the brachial plexus

Anatomical variations in the branching pattern of the axillary artery are common and typically include the lateral thoracic, subscapular, and the posterior circumflex humeral (PCHA) arteries. Previous investigations of single specimen dissections demonstrate numerous variations to axillary artery branching, but the frequency of these occurrences is unclear. This study quantifies the frequency of variant branching of the lateral thoracic, subscapular, and posterior circumflex humeral arteries, how it they relate to the posterior cord of the brachial plexus. Axillae of 83 cadavers were dissected to allow examination of the axillary artery and its branches. Data were collected observing the branching pattern of the lateral thoracic, subscapular, and posterior circumflex humeral arteries, as well as those branches spatial relationship to the two terminal branches of the posterior cord of the brachial plexus. Some of the more common variations included the thoracodorsal artery arising from the lateral thoracic artery (LTA) (7.2%) and the subscapular artery (SSA) arising from the LTA (5.4%). The SSA also produced the LTA (4.2%) and the PCHA (12%). The PCHA also originated from the deep brachial artery (8.4%) and traversed the triangular interval to supply the deltoid muscle. These findings are relevant to both the anatomical and clinical fields as provide evidence as to the frequency of variant axillary artery branching and the potential for neurovascular elements to exist in a location other than their classical anatomical description.

Life-Threatening Posterior Circumflex Humeral Artery Injury Secondary to Fracture-Dislocation of the Proximal Humerus

Proximal humeral fractures account for 4% to 5% of all fractures, and most of these are minimally displaced and less prone to neurovascular injuries. This article presents a case of a 65-year-old man who injured the posterior circumflex humeral artery following a fracture dislocation of the proximal humerus leading to a life-threatening hemorrhagic complication during surgical fixation of the dislocated proximal humeral fracture. Preoperative vital signs were normal. Using the deltopectoral approach, the fracture site was exposed and the dislocated head was extracted. Blood pooled and overflowed the cavity at a brisk pace. Blood pressure dropped from 130/70 mm Hg to 90/45 mm Hg, and preoperative follow-up hemoglobin dropped to 4.8 g/dL. The axillary artery was explored and a ruptured posterior humeral circumflex artery was observed that was later ligated. In view of the damage to 1 of the circumflex humeral branches, primary hemiarthroplasty was performed. This article highlights the possibility of encountering life-threatening vascular injuries in highly displaced or dislocated 4-part proximal humeral fractures and the significance of obtaining the angiographic studies early in the course of management in such cases.

To determine the course of the axillary nerve, it is useful to identify the course of the posterior humeral circumflex artery that runs along the nerve using a handheld ultrasound blood flowmeter and ultrasound diagnostic equipment

To determine the course of the axillary nerve, it is useful to identify the course of the posterior humeral circumflex artery that runs along the nerve using a handheld ultrasound blood flowmeter and ultrasound diagnostic equipment

Case report of high origin of radial, ulnar, and profunda brachii arteries, its clinical implications and review of the literature

Arterial variations in the arm are of potential clinical implications as it is a frequent site of injury and also involved in many surgical and invasive procedures. During a dissection of the right upper extremity, an abnormal high origin of the radial and ulnar arteries was found. The brachial artery had a very short segment without any branches, divided into the radial and ulnar arteries at the upper third of the arm. The course and branching pattern of these radial and ulnar arteries in the arm are discussed. It was also observed that the profunda brachii artery was represented by two separate branches arising from the posterior circumflex humeral artery. Accurate knowledge of these variation patterns is of considerable clinical importance in the conduct of reparative surgeries around the shoulder and fracture management of the humerus. These additional data of arterial anomalies to contemporary anatomical literature are of interest to clinicians, in particular vascular and plastic surgeons and radiologists.

0645: Ultrasound of the Posterior Circumflex Humeral Artery

Quadrilateral space syndrome (QSS) is described as compression neuropathy of the axillary neurovascular bundle in the quadrilateral space of the shoulder. This neurovascular bundle includes the posterior circumflex humeral artery (PCHA).

Posterior circumflex humeral artery perforator flap (PCHAP-flap) in axillary scar release

Scar contracture after burn injury is frequent in the axillary region. If conservative treatment of scars limiting the range of motion of the shoulder joint fails, surgical correction is needed. The authors performed an early reconstruction in a case with unstable scar formation and limited range of motion after burn injury to the axillary region, using the posterior circumflex humeral artery perforator flap. In their opinion, the flap (beside its conventional use as a free flap) may be useful as an island flap in the reconstruction of the axillary region, e. g. for axillary scar release.

Pseudoaneurysm of the posterior circumflex humeral artery diagnosed by sonography

We report a rare case of a pseudoaneurysm of the posterior circumflex humeral artery, probably related to a steroid injection in the shoulder 3 months earlier. The clinical presentation was atypical and the location not previously described in the literature. The patient was referred with a painless, nonpulsatile mass in the posterior shoulder region and was suspected of a malignant soft-tissue tumor. Sonography, including power Doppler imaging, demonstrated a pseudoaneurysm, with the intralesional blood-filled cavity developed from the posterior circumflex humeral artery. The diagnosis was confirmed by pathologic examination of the surgical specimen.

The Subscapular Artery in the Axillary Region: Tracking its Anatomical Distribution for Clinical Application

The subscapular arterial vessel, the largest branch of the axillary artery, is a key player in the blood supply of the pectoral girdle and associated upper limb musculature. Its multiple branches ensure the functional integrity of the region. Identification of its pattern and distribution is clinically essential to avoid insult during invasive surgical procedures. Forty‐six subscapular trunks from twenty‐three donor bodies were examined from the first year gross anatomy course for SUNY Downstate College of Medicine. In this study we recorded subscapular anatomical patterns, noting variation of arterial branching. 82.6% of our sample exhibited the template pattern reported in anatomy textbooks. The vessel originates from the posterior aspect of the third part of the axillary artery, following the inferior margin of the subscapularis muscle for a few centimeters before dividing into two terminal branches, the circumflex scapular and thoracodorsal arteries. Variations in the overall arterial pattern of the axillary artery appear to be taken up by the subscapular vessel, for example, the posterior circumflex humeral artery comes off the subscapular or the thoracodorsal vessels in three individuals. Another common variation we encountered was the origination of the lateral thoracic artery from the thoracodorsal instead of the second part of the axillary artery. Knowledge of the frequency and distribution of the subscapular vessel will aid in successful transplantation procedures used in reconstructive surgeries.

Axillary artery and branch variations in an 83 year‐old male Caucasian

Results: A male cadaver was found to have a left subscapular artery that branched early off of the axillary artery (at the inferior border of the second rib). The cadaveric subscapular artery was 30% larger in diameter than the continuation of the axillary artery. Additional variants appearing on the left side included (1) the origin of the thoracoacromial artery from the proximal subscapular artery, (2) the origin of the posterior circumflex humeral artery from the subscapular artery and (3) the origin of the lateral thoracic artery from the subscapular artery immediately proximal to the bifurcation into the circumflex scapular and thoracodorsal arteries. Additional variations were seen on the left arm of the cadaver including a high origin of the radial artery in which the radial artery arose from a superficial branch of the brachial artery at mid‐humerus. The superficial branch of the brachial artery was noteworthy by its tortuous route. In comparison, in the right arm, no variants appeared in the axillary, subscapular, or brachial arteries.

A Case of Neck Scar Contracture Reconstructed Using a Pedicled Supraclavicular Flap

Sir: The supraclavicular fasciocutaneous island flap was introduced by Lamberty in 1979,1 and in 1998, Baudet and Martin reported the clinical application of it as a free flap for hand surgery.2 The supraclavicular flap is thin and highly reliable. In this report, we present a neck scar contracture case reconstructed with good results using the pedicled supraclavicular flap. A 72-year-old man sustained severe flame burns on the neck and chest. Emergency split-thickness skin grafts were applied, but neck scar contractures developed postoperatively. His left shoulder was not burned, so neck reconstruction using a unilateral pedicled supraclavicular flap measuring 16 × 10 cm was designed on the patient’s shoulder. The recipient site determined the size of the flap (Fig. 1).Fig. 1.: A 72-year-old man who sustained severe flame burns on the neck and chest underwent reconstruction using the supraclavicular flap. The flap measured 16 × 10 cm, and the harvested flap included skin, subcutaneous tissue, and the fascia of the deltoid muscle.The recipient-site scars were debrided to the depth of the deep fascia to release the contractures completely. The harvested flap included skin, subcutaneous tissue, and the fascia of the deltoid muscle. In the medial part of the flap, the supraclavicular artery, which arises from the transverse cervical artery, could be identified. The flap could be rotated up to cover the defect after removal of the scar. It survived completely, and the functional and aesthetic results were good (Fig. 2). The donor site was closed with a split-thickness skin graft.Fig. 2.: Six-month postoperative view. The flap survived completely, and the functional and aesthetic results were good.The main vessel of the supraclavicular flap is the supraclavicular artery. The supraclavicular artery is a perforator that arises from the transverse cervical artery in 93 percent of cases and the suprascapular artery in 7 percent.3 It divides into one or two arteries before reaching the deep fascia of the deltoid muscle in the third medial clavicle. These one or two arteries then branch out toward the acromioclavicular joint; when reaching that point, they further divide into small branches that reach the superior part of the deltoid muscle. At this level, they become interfused with the cutaneous branches of the posterior circumflex humeral artery. The supraclavicular artery is also interfused with the vascular network of the musculocutaneous perforator of the trapezius muscle in the dorsal region and with the vascular network of the cutaneous branches of the thoracoacromial artery in the anterior chest.1 In our experience, the average supraclavicular artery is 1.0 to 1.5 mm in diameter, and we have been able to include 3 to 4 cm of vascular pedicle when we harvest island flaps. In some cases, however, this was too short for use in the ipsilateral neck area, so we refined the transverse cervical artery to allow us to harvest longer vascular pedicles. Using our refinement technique, we are able to harvest 5 to 6 cm of pedicle. From our experience, it is possible to harvest flaps of up to 11 cm in width and 21 cm in length. This allows the anterior edge to reach the inferior border of the clavicle, the posterior edge to reach the upper area of the trapezius muscle, and the distal edge to reach the upper arm. Our contention is that the supraclavicular island flap is thin, reliable, and easy to harvest. Vu Quang Vinh, M.D. Department of Plastic and Reconstructive Surgery Nippon Medical School Hospital Tokyo, Japan Department of Plastic and Reconstructive Surgery Vietnam National Institute of Burns Hanoi, Vietnam Rei Ogawa, M.D., Ph.D. Department of Plastic and Reconstructive Surgery Nippon Medical School Hospital Tokyo, Japan Tran Van Anh, M.D. Department of Plastic and Reconstructive Surgery Vietnam National Institute of Burns Hanoi, Vietnam Hiko Hyakusoku, M.D., Ph.D. Department of Plastic and Reconstructive Surgery Nippon Medical School Hospital Tokyo, Japan

A study to determine the usefulness of measuring the position of the posterior humeral circumflex artery which runs along with the axillary nerve using a handhold ultrasound blood flowmeter in order to estimate the course of the axillary nerve

A study to determine the usefulness of measuring the position of the posterior humeral circumflex artery which runs along with the axillary nerve using a handhold ultrasound blood flowmeter in order to estimate the course of the axillary nerve

The anatomy of the quadrilateral space with reference to quadrilateral space syndrome

Quadrilateral space syndrome is a rare condition in which the contents of the quadrilateral space, the axillary nerve and the posterior circumflex humeral artery, are compressed, leading to vague symptoms of shoulder pain, tenderness over the quadrilateral space on palpation, and teres minor and deltoid denervation. Fibrous bands within the quadrilateral space are often cited in the literature as a cause of compression in quadrilateral space syndrome; however, Cahill and Palmer did not see these bands in cadaveric dissection. These are postulated to cause compression of the quadrilateral space contents in abduction and external rotation of the shoulder. To clarify the anatomic features that may predispose the development of quadrilateral space syndrome, 16 cadaveric shoulders were studied. Dissection revealed that fibrous bands are a common finding in the quadrilateral space, being present in 14 of 16 shoulders. The most common site for a fibrous band was between the teres major and the long head of the triceps. Where the bands were present, both internal and external rotation of the shoulder caused a reduction in the cross-sectional area of the quadrilateral space.

Diagnosis and management of vascular injuries in the shoulder girdle of the overhead athlete

Vascular injuries represent a rare cause of shoulder pain and functional limitation among overhead athletes. Complaints of heaviness, fatigue, paresthesias, and effort-related pain should prompt the sports medicine clinician to consider vascular pathology as a possible cause of such symptoms. Position-dependent compression of the subclavian and axillary vessels within the thoracic outlet may result in functional limitation and a decline in overhead athletic performance, particularly when symptoms occur in the dominant upper limb. Treatment options include physical therapy and (in the case of thrombus) thrombolysis, but surgical decompression of the neurovascular bundle is generally advocated. This article reviews the diagnosis and management of effort thrombosis (also known as Paget-Schroetter syndrome), arterial thoracic outlet syndrome, and entrapment of the posterior circumflex humeral artery within the quadrilateral space. Familiarity with these conditions may help to minimize the risk of delayed diagnosis and associated morbidity.

Diagnosis and Management of Vascular Injuries in the Shoulder Girdle of the Overhead Athlete

Vascular injuries represent a rare cause of shoulder pain and functional limitation among overhead athletes. Complaints of heaviness, fatigue, paresthesias, and effort-related pain should prompt the sports medicine clinician to consider vascular pathology as a possible cause of such symptoms. Position-dependent compression of the subclavian and axillary vessels within the thoracic outlet may result in functional limitation and a decline in overhead athletic performance, particularly when symptoms occur in the dominant upper limb. Treatment options include physical therapy and (in the case of thrombus) thrombolysis, but surgical decompression of the neurovascular bundle is generally advocated. This article reviews the diagnosis and management of effort thrombosis (also known as Paget-Schroetter syndrome), arterial thoracic outlet syndrome, and entrapment of the posterior circumflex humeral artery within the quadrilateral space. Familiarity with these conditions may help to minimize the risk of delayed diagnosis and associated morbidity.

A study of variable origins of arteries in arm

A series of anomalous arterial supply of the arm and shoulder is presented. In these cases, the deep brachial artery arose from a common trunk with posterior circumflex humeral artery. In one case, the superior ulnar collateral artery and deep brachial artery originated from the posterior circumflex humeral artery. The common trunk or posterior circumflex humeral artery arose from the brachial artery at the level of the lower border of the teres major (at the origin of the brachial artery). A possible ontogenetic explanation is provided for this situation. Awareness of the variations of arteries of the arm or shoulder is important for angiographers and the surgeon who operates in this region.

The Anatomy and Function of the Low Posterolateral Portal in Addressing Posterior Labral Pathology

A standard posterior portal allows excellent visualization of the glenohumeral joint but is inadequate for anchor placement because of its parallelism to the glenoid surface. The purpose of this study was to describe the low posterolateral portal for glenohumeral arthroscopy, describe the anatomy of the portal and surrounding structures, and discuss the portal's usefulness in addressing posterior and inferior shoulder pathology. Five cadaveric shoulders were dissected after placement of a spear through the low posterolateral portal. The location was identified via a spinal needle, 2 to 4 cm lateral and 4 to 5 cm inferior to the posterolateral corner of the acromion. Measurements from the spear to the anatomic structures were recorded with a caliper. Seventeen patients with posterior labral pathology were included in this study. The low posterolateral portal was established while visualizing through the anterosuperolateral or posterior portal. The spear and anchor were inserted through the low posterolateral portal. Five shoulders were dissected, and the neurovascular structures relative to the low posterolateral portal were identified. The portal was 13.8 +/- 1.6 mm from the axillary nerve and 13.4 +/- 1.2 mm from the posterior humeral circumflex artery. In the retrospective review the low posterolateral portal was created without difficulty or complication in all 17 patients. The portal was extremely helpful for anchor insertion in the posteroinferior glenoid. It was useful in suture passage through the posterior and inferior labrum and in suture management. The low posterolateral portal provides the optimal angle for insertion of instruments and anchors, resulting in a more anatomic repair. The standard 3 portals are not optimal for approaching posterior and inferior labral tears, and use of the low posterolateral portal improves access and treatment.

Axillary nerve repair by triceps motor branch transfer through an axillary access: anatomical basis and clinical results

Grafting or nerve transfers to the axillary nerve have been performed using a deltopectoral approach and/or a posterior arm approach. In this report, the surgical anatomy of the axillary nerve was studied with the goal of repairing the nerve through an axillary access. The axillary nerve was bilaterally dissected in 10 embalmed cadavers to study its variations. Three patients with axillary nerve injuries then underwent surgical repair through an axillary access; the axillary nerve was repaired by transfer of the triceps long head motor branch. At the lateral margin of the subscapularis muscle, the axillary nerve was found in the center of a triangle bounded medially by the subscapular artery, laterally by the latissimus dorsi tendon, and cephalad by the posterior circumflex humeral artery. At the entrance of the quadrangular space, the axillary nerve divisions were loosely connected to each other, and could be clearly separated and correctly identified. Surgery for the axillary nerve repair through the axillary access was straightforward. Eighteen months after surgery, all three patients had recovered deltoid strength to a score of M4 on the Medical Research Council scale and had improved abduction strength by 50%. No deficit was evident in elbow extension. The axillary nerve and its branches can be safely dissected and repaired by triceps motor nerve transfer through an axillary access.

Bilateral arterial and nervous variations in the human upper limb: A case report

During routine dissection, we found bilateral arterial and nervous anomalies in a female cadaver. On the left side the axillary artery divided into a medial brachial artery and lateral profunda brachii artery, and the musculocutaneous nerve arose from the upper trunk of the brachial plexus, before the formation of the lateral cord. On the right side a common trunk that divided into the circumflex scapular artery, thoracodorsal artery and posterior circumflex humeral artery was observed, while the musculocutaneous nerve fused with the median nerve.

Quadrilateral Space Syndrome Caused by a Humeral Osteochondroma: A Case Report and Review of Literature

Quadrilateral space syndrome (QSS) is a rare condition in which the posterior humeral circumflex artery and the axillary nerve are entrapped within the quadrilateral space. The main causes of the entrapment are abnormal fibrous bands and hypertrophy of the muscular boundaries. Many other space-occupying causes such as a glenoidal labral cyst or fracture hematoma have been reported in the literature. However, we could not find a report on classical QSS caused by an osteochondroma. The aim of this case report is to attract attention to an unusual etiology of shoulder pain, and to emphasize the importance of physical examination and x-ray imaging before performing more complex attempts for differential diagnosing.