Acute deep venous thrombosis and late onset axillary artery injury after a displaced, proximal humerus fracture-dislocation in an octogenarian patient

Proximal humeral fractures are among the most common fractures in elderly population and they account for around 5% of all fractures seen and treated in an emergency department (ED). These lesions can be associated with severe neurological or vascular injuries. Nevertheless, axillary artery injury is often unrecognized at the patient’s initial presentation, placing the hand at risk of necrosis and amputation if there is prolonged ischemia. This vascular lesion is typically the result of the medial displacement of the proximal humeral shaft in high-energy injuries around the shoulder girdle. Further, deep venous thrombosis (DVT) is another extremely rare condition in fractures of the upper extremities, regarding which the need for thromboprophylaxis before and after surgery is still a matter of debate. A DVT of the upper limb is defined as a thrombus in any of the deep veins of the upper limb which can be classified as primary (i.e. due to vein compression) or secondary (i.e. due to coagulopathy or surgery) and can cause severe consequences, such as pulmonary embolism. This report describes the unusual case of an octogenarian patient with a displaced proximal humeral fracture-dislocation, complicated by a severe pulmonary embolism due to axillary vein thrombosis at the time of presentation, which delayed the orthopaedic surgical treatment by 8 weeks. Subsequently, the inveterate fracture was treated by a reverse total shoulder arthroplasty (RTSA), previous vascular bypass of the axillary artery, because of its intraoperative injury.