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

OBJECTIVES: To 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. METHODS: Two-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. RESULTS: The 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). CONCLUSIONS: PCHA 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.

Documentation of neurovascular status in supracondylar fractures and the development of an assessment proforma.

BACKGROUND: Supracondylar fractures are associated with a high incidence of neurovascular complications. Comprehensive clinical evaluation is a necessity when children with these injuries present to the emergency department. Neurovascular assessment can be difficult due to pain, anxiety and the young age of these patients; however, it is crucial findings are well documented to identify patients requiring urgent surgical intervention, in addition to allowing the neurovascular status to be monitored over time. The aim of this study was to evaluate the preoperative neurovascular documentation in children presenting with displaced supracondylar fractures and devise an emergency department assessment proforma to facilitate comprehensive evaluation. METHODS: A retrospective case-note review was performed on patients with Gartland grades 2 and 3 supracondylar fractures observed in a 2-year period from July 2008 to July 2010. RESULTS: 137 patients were included; only 12 patients (8.8%) and 19 patients (13.9%), respectively, had a complete preoperative neurological or vascular assessment documented. Regarding the individual nerves, 59 (43.1%) patients had median nerve integrity documented, 55 (40.1%) ulnar nerve and 49 (35.8%) radial nerve integrity documented. Only 18 patients (13.1%) had their anterior interosseous nerve (AIN) function documented. CONCLUSIONS: Preoperative documentation of neurovascular status in children with displaced supracondylar fractures was poor. Documentation of AIN examination was particularly poor. The introduction of a proforma (Liverpool upper limb fracture assessment) is proposed to increase documentation of neurovascular assessment and optimise emergency department evaluation of children presenting with upper limb injuries.

Quantitative assessment of the vascularity of the proximal part of the humerus.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Power Doppler assessment of the neovascularization during uncomplicated fracture healing of long bones in dogs and cats.

The aims of this prospective study were to test the feasibility of assessing neovascularization with power Doppler ultrasonography and to investigate its usefulness to follow fracture healing of long bones in dogs and cats. A total of 51 patients (44 dogs and seven cats) were followed. Fracture types differed from simple to comminuted. Therapy ranged from external coaptation to plate osteosynthesis. Patients were followed with radiography, B-mode real time and power Doppler ultrasonography every 2-4 weeks until the fracture was healed. All fractures healed uneventfully. A semi-quantitative numerical score based on signal intensity, vessel area, and number of Doppler signals was assigned and the mean value was used to compare patients and examinations. Time postoperatively was divided into periods of 10 days. No Doppler signal was present during the first 10 days. The mean of the scores was highest between 11 and 20 days postoperatively and the median of the scores peaked between 21 and 30 days. A gradual decrease was seen thereafter. The mean of the scores was zero at 71-80 days and the median at 51-0 days postoperatively for the grouped results. In all positive power Doppler examinations, signals were present in and close to the callus. In seven patients (five dogs and two cats) signals were also present in the peripheral soft tissues in one of the follow up examinations. The normal healing process of fractured bones can be visualized using power Doppler ultrasonography and follows a distinctive time-dependent pattern.

Assessment and management of three-and four-part proximal humeral fractures.

Three-and four-part comminuted fractures of the proximal humerus are difficult and technically demanding to treat. The various treatment methods reported in the literature are reviewed. It is recommended that three-part fractures be treated with open reduction and internal fixation. Four-part fractures in the younger, active patient also can be treated successfully with open reduction and internal fixation. However, in the elderly and in the patient with osteoporosis, a hemiarthroplasty is the treatment of choice. There is a need for universal agreement on a scoring system for measuring outcome in these fractures to allow a meaningful comparison between reported treatment methods.

Non-invasive assessment of systemic elastic behaviour in hypertensive patients: analysis of possible determinants.

Knowledge about the viscoelastic behaviour of the arterial wall has been proved to have physiological importance and clinical usage. Our purpose was to study the changes of the systemic arterial wall's elastic properties non-invasively, in patients with established essential and with borderline hypertension, and to evaluate its possible determinants. Three groups of normotensive, borderline and established essential hypertensive patients were evaluated. Arterial pulse wave velocity (PWV) was measured and arterial compliance (Cm) was derived in all patients. Pulse wave velocity was obtained from the pressure values of digitized carotid and radial arteries. Arterial compliance (Cm = dD/dP with P pressure and D diameter) was calculated using a formula derived from the Bramwell and Hill equation: Cm = (1,334 x D)/(2 rho x PWV2), where for D humeral diameter was used as measured by high resolution echograph, and rho is the blood density (rho = 1.06). Pulse wave velocity was significantly higher in established essential hypertensive patients with respect to normotensive patients (p < 0.05). Arterial compliance was significantly diminished in established and in borderline hypertensive patients with respect to normotensive patients (p < 0.05), which implies early alterations in hypertensive cardiovascular disease. Multiple regression analysis of the cofactors showed that age and diastolic pressure are independent determinants of Cm. Impairment of the arterial wall's intrinsic elastic properties was demonstrated in established essential hypertension, independent of age and diastolic pressure.