Introducción:las fracturas traumáticas del húmero son comunes en el departamento de emergencias,representandoentreel4%yel5%detodaslasfracturas,yel45%delas fracturas quirúrgicas del cuello del húmero, de las cuales el 85% son no desplazadas.Casoclínico:este informe de caso presenta a una mujer de 57 años con una fractura completa delcuelloquirúrgicodelhúmero,quesemanifiestacondolor,movilidadfuncionallimitaday pérdidaderangodemovimiento.Durantelaartroplastiadehombro,lapacienteexperimenta una complicación intraoperatoria con un desgarro marginal de 1 cm de la arteria axilar, lo que provoca un sangrado profuso. Esto requiere la intervención de cirugía vascular, que decidecolocaruninjertoautólogodelavenasafenamayor.Discusión:laartroplastiadehombroes unprocedimientocomplejoquedemandaunaevaluacióncuidadosayunaintervenciónrápi- da,yaquelaslesionesenestaáreapuedenafectarlafuncionalidaddelbrazoylacalidadde vidadelpaciente.Lascomplicacionesvascularespuedenocurrirenhastaun3%deloscasos, y la reparación vascular se realiza generalmente mediante cirugía abierta, prefiriendo injertos autólogosporsumenorriesgodeinfecciónytrombosis.Conclusiones:laslesionesvascula- res de los vasos axilares son raras, y su tratamiento requiere un equipo multidisciplinario con habilidadesquirúrgicasadecuadasyunconocimientoexhaustivodelaanatomíadelhombro. Elinjertoautólogodelavenasafenamayorseconsideraunaalternativaterapéuticaconfiable para el manejo de estas lesiones.

A traumatic humeral fracture is a clinical entity that pre- sents with relative frequency in emergency services. It is estimated that its incidence is between 4% to 5% of all fractures, 45% of surgical neck of the humerus and addi- tionally 85% of these are non-displaced.(1)Complications that may occur during surgical correction of a humeral fracture include vascular and neurological lesions, with vascular lesions being the most common.(2,3)Vascular trauma can have various consequences, including, com- promise of the patient’s life and loss of limbs.(4,5)Theclose proximity of the axillary vasculature to the head of the humerus increases the risk of vascular lesion during a fractureorananteriorluxationoftheshoulder(6%-15%).

(2)The injury of axillary or subclavian vasculature has an associated mortality of 5% and 30% respectively and a significantly high morbidity.(6,7,8)

While the injuries that most frequently occur and, at the same time, are more conspicuous are those affecting neurological structures such as the brachial plexus, they aremorecloselyrelatedtomortalityandmorbidityrates.

(2)In accordance with the aforementioned, it is imperative to consider the anatomical relationship these morpholo- gical structures bear due to the likelihood of causing inju- ries within the thoracic cavity. This, in turn, increases the possibilityofthepatientexperiencingapneumothorax orhaemothorax,whichhaveanincidenceofupto29% in such injuries. Additionally, injuries to the aerodigestive tract, sympathetic chain, and other structures of the ner- vous system may occur at a rate of 3%.(8)

Figure3.Axillaryarteryrepairedwithanautologous graft of the greater saphenous vein.

Shoulder arthroplasty is one of the most demanding current joint replacement procedures from a technical standpoint.(9)The management of such injuries,regardless of their etiology, requires comprehensive evaluation and timely intervention by a multidisciplinary team with the correct training to address these injuriesdue to their complexity. Given the numerous osteo muscular, vascular, and nervous structures in this anatomical region, any injury here can compromise both thefunctionalityofthelimbandthepatient’slife.(2,10)To promptly identify such injuries, a detailed physical examination is crucial, supported by diagnostic imaging that can guide appropriate therapeutic management.(10)

Despitethesuccessrepresentedbytheperformance of shoulder arthroplasties, complications such as intraoperative vascular injuries may occur, with a rate of occurrence of up to 3%. Therefore, it is important to be familiarwiththetelltalesignsofvasculartrauma,such as active bleeding, expansive hematoma, loss of distal pulses,andevidenceofdecreasedirrigation.Thesesigns

exhibit high specificity for vascular trauma and can orient the team towards an accurate diagnosis and treatment. However, it is essential to note that the absence of these signsdoesnotruleoutthepossibilityofsuchinjuries, due to the fact that in non-severe cases these signs may not be evident, and collateral circulation systems may continue to perfuse these tissues, as seen in the collateral vascular network irrigating this anatomical region.(2,11,9)

Considering that vascular repair in this type of injuries favors open surgery as the first line of treatment over vascular surgery management, it is important to recognize thetypeoftraumabeingaddressed.Primarysuture repair or primary anastomosis are preferred for focal and pinpoint lesions. In contrast, complete dissections of the vascular pathway will be candidates for repair with grafts, whether autologous or prosthetic.(4,5)

When the dissection is secondary to trauma or intraoperativeinjury,asinthepresentedcase,there is a greater loss of the vascular segment. Therefore, a decision must be made between the use of autologousand prosthetic grafts, with a preference for autologous grafts. Prosthetic grafts have shown a higher rate of infectionandthromboticprocesses,increasingtherisk of postoperative complications and re-interventions. In contrast, autologous grafts have demonstrated better performance, a lower incidence of infection and rejection, thereby reducing complications such as compartmental syndrome and even limb loss.(4,11,9)

The autologous graft of the greater saphenous vein is an excellentresourceforthistypeofvascularrepairduetoits length and location, which is easily accessible and widely available.(11)In terms of its structural characteristics, it is stronger and more resistant than any other vein that can be used as a graft. Its wall thickness and diameter are similar to those of medium-caliber arteries, such as the axillary artery.(7,1,10)Additionally, it exhibits histological features that make it the ideal vein for vascular repairs of thiskind,includingthepresenceofendothelialcellson its luminal surface and elastic properties comparable to those found in arteries.(13)

While autologous grafts have proven to be more efficient thanprostheticgraftsinvasculartrauma,asinthis case where the patient achieved full recovery of upper limb functionality, there is still insufficient evidence to assert that the use of autologous grafts is the preferred technique in all cases.

Vascular injuries to the axillary vessels in shoulder arthroplasties are infrequent. Their management requiresamultidisciplinaryteamwiththerelevantsurgicalskills toprovideasuccessfulsolutiontotheinjury,along with a comprehensive understanding of shoulderanatomyandmeticuloussurgicaltechniquetoreduce theoccurrenceofsuchinjuries.Itshouldbenotedthat the manifestations, management, and reconstruction of these injuries vary, making it challenging to standardize a singular management method. Therefore, it is importantto consider the autologous graft of the greater saphenous vein as a reliable therapeutic alternative within the emergingmeasuresformanagingsuchvascularinjuries.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for- profit sectors.

The authors declare that they have not conflicts of inte-rest.

SNM: Resources, Methodology, Conceptualization, Revi- sion and Edition.

LSPS:AdministrationoftheProject,Conceptualization Resource and Revision.

SCM:Software,Drafting,Editionandtranslation,Revi- sion and Edition.

SCR: Resources, Methodology and Supervision. VRCN: Resources, Supervision and Revision.

GranmaUniversityofMedicalSciences

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