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Suspected axillary artery injury following anterior shoulder dislocation — MSRA MCQ

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HardShoulder InjuriesSuspected axillary artery injury following anterior shoulder dislocationMSRA

A 74-year-old woman attends your GP surgery 36 hours after a first anterior dislocation of her right shoulder following a fall. The shoulder was reduced in the emergency department; post-reduction radiographs confirmed concentric reduction without fracture. Radial pulse, capillary refill and hand sensation were documented as normal before discharge. She takes rivaroxaban for atrial fibrillation. Since this morning, she has developed increasing deep swelling in the axilla and extensive bruising over the medial upper arm. She reports new tingling affecting all fingers. The right radial pulse remains palpable but is clearly weaker than the left. Her hand is warm and capillary refill is 3 seconds. There is no recurrent shoulder deformity. What is the most appropriate management now?

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Correct answer: D — Arrange immediate transfer to the emergency department for emergency vascular and orthopaedic assessment

This presentation is concerning for axillary arterial injury with associated brachial-plexus compression after anterior shoulder dislocation. The important discriminators are the progressive axillary swelling and medial-arm bruising, new widespread hand paraesthesia, and an asymmetrically diminished radial pulse. A palpable pulse and warm hand do not safely exclude a significant axillary arterial injury because distal collateral flow may persist. Her anticoagulation may exacerbate bleeding, but it does not change the immediate priority: emergency hospital assessment with vascular capability, alongside orthopaedic review. A repeat radiograph may identify redislocation or an occult fracture but would not address a suspected evolving neurovascular complication. Community duplex ultrasound risks delaying definitive assessment and may be inappropriate if urgent CT angiography, resuscitation, vascular intervention or exploration is required. An urgent outpatient shoulder-clinic pathway is appropriate for uncomplicated post-dislocation follow-up, not progressive neurovascular symptoms. Withholding rivaroxaban may ultimately be considered by the receiving team, but observation in primary care is unsafe while active vascular injury remains possible.

Reference: Primary shoulder dislocation | Right Decisions, NHS Borders (Last reviewed 31 July 2025) — https://www.rightdecisions.scot.nhs.uk/borders-ref-help-toolkit/orthopaedic/shoulder/primary-shoulder-dislocation/ Axillary artery transection following anterior shoulder dislocation: classical presentation and current concepts (2004) — https://pubmed.ncbi.nlm.nih.gov/15488503/ Axillary Artery Injury with Intact Radial Pulse following Fracture-Dislocation of Shoulder: A Case Report (2019) — https://pubmed.ncbi.nlm.nih.gov/31890113/