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Suspected axillary arterial injury after anterior shoulder dislocation — MSRA MCQ

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HardShoulder InjuriesSuspected axillary arterial injury after anterior shoulder dislocationMSRA

A 71-year-old woman attends your GP surgery 6 hours after discharge from the emergency department. She sustained an anterior right shoulder dislocation after falling downstairs. Radiographs before and after reduction confirmed relocation without fracture. Since leaving hospital, she has developed worsening upper-arm pain and paraesthesia in the thumb and index finger. Examination shows a tender, non-pulsatile swelling in the right axilla. Her right hand is warm with capillary refill of 2 seconds, but the radial pulse is clearly weaker than on the left. There is no active external bleeding and she is haemodynamically stable. What is the most appropriate management?

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Correct answer: D — Arrange immediate emergency transfer for CT angiography and urgent combined orthopaedic and vascular assessment

Explanation lettering: B = shown as A · C = shown as B · E = shown as C · A = shown as D · D = shown as E

This patient has suspected vascular injury following shoulder dislocation and reduction. The reduced radial pulse, new paraesthesia and non-pulsatile axillary haematoma are indirect (soft) signs of vascular trauma. A warm hand and normal capillary refill do not exclude clinically important arterial injury; collateral circulation can preserve distal perfusion despite axillary arterial damage. She is haemodynamically stable and has no direct sign mandating immediate operative exploration, such as uncontrolled haemorrhage or an expanding pulsatile haematoma. The appropriate next investigation is therefore CT angiography as soon as possible, alongside urgent orthopaedic and vascular involvement. This defines the arterial lesion and relationship to the previously dislocated joint, allowing coordinated repair where required. B is attractive because duplex can assess arterial flow, but it is not the recommended definitive imaging strategy for soft signs of vascular trauma after a fracture or dislocation and could delay treatment. C inadequately addresses the neurovascular red flags; repeat radiographs assess alignment but not arterial injury. D would be appropriate for direct signs of major vascular injury or an unstable limb when imaging would delay revascularisation. E is inappropriate because post-reduction radiographs confirm a congruent joint; the new problem is vascular rather than persistent dislocation.

Reference: Vascular trauma associated with fractures/dislocations (2025) — https://www.rightdecisions.scot.nhs.uk/south-east-scotland-major-trauma-guidelines/generalvascularurology/vascular-trauma-associated-with-fracturesdislocations/ Dislocated shoulder (17 May 2023) — https://www.nhs.uk/conditions/dislocated-shoulder/?src=conditionswidget