When a Simple Fall Isn’t So Simple

What Did we See?

A 78-year-old woman arrived at our emergency department after what sounded like a trivial fall

— she was simply trying to sit and missed the chair. But what followed was far from trivial. She

had pain and swelling in the right shoulder and hip, complete motor and sensory loss in the right

upper limb, and absent brachial and radial pulses. On initial evaluation, she also couldn’t bear

weight on her right lower limb. She was rushed to a level 1 trauma center in Kathmandu Valley.

Radiographs showed a displaced proximal humerus fracture and an unstable intertrochanteric

fracture. But it was the CT angiogram that revealed the real danger — a complete disruption of

the axillary artery, with no distal flow. The upper limb was ischemic, neurologically silent, and

at real risk.

We made a diagnosis of closed displaced 2 part Proximal Humerus fracture right side (Neer 2

part) with axillary artery injury and Global Brachial plexus injury with ipsilateral intert-

trochanteric femur fracture right side (Boyd and Griffin type 3).

What Did we Do?

We moved fast. A multidisciplinary team — orthopedic, vascular, and anesthesiology — was

mobilized. Through a deltopectoral approach, we found a 3 cm laceration in the axillary artery,

entrapped along with the brachial plexus cords between the humeral head and shaft. Using a

reversed saphenous vein graft, the CTVS team repaired the artery. Smooth K-wires were used to

stabilize the humeral fracture quickly and minimize soft tissue trauma.

The intertrochanteric fracture was fixed with a dynamic hip screw in a staged procedure. Early

neurological recovery followed: finger flickers on day two, improving to partial wrist and elbow

movement within a week.

What Did we Learn?

This case was a powerful reminder that mechanism does not always predict magnitude. low-energy fall in an elderly patient can still lead to devastating injuries, especially in the

presence of osteoporosis.

I learned:

• Always assess neurovascular status thoroughly in proximal humerus injuries.

• Loss of distal pulses is a surgical emergency — time matters.

• Simple imaging is not enough — CTA should be done when vascular injury is

suspected.

• Biological reconstruction and minimally invasive fixation can offer stabilisation of

fracture and buys time for repair of vascular injury and minimizes anesthesia time in

elderly, high-risk patients.

And most importantly — don’t let the simplicity of the story fool you. A fall from standing

height can still be a high-stakes surgical challenge.

Figure 1: A,B: Plain radiographs of chest and pelvis showing right sided proximal humerus 2

part fracture and proximal femoral fracture (IT fracture, Boyd and Griffin type 3); C,D,E:

Computed tomography with angiogram showing filling defect in 3rd part of subclavian artery.

Figure 2: A: Intraoperative image showing laceration(arrow) of distal part of subclavian artery

and proximal part of axillary artery (3rd part of subclavian artery and 1st and 2nd part of axillary

artery); B: Laceration was repaired with reverse saphenous graft and floow was restored as seen

by the dilation of the grafted part(arrowhead); C,D,E: Intraoperative and postoperative images

showing fixation of proximal humerus with provisional k wires in both antegrade and retrograde

fashion as well as avoiding injury to the repaired part while achieving good anatomical

reduction.

Pearls: Surgical Technique for 2-part proximal humerus fracture fixation with

provisional K-wires.

• Use 2.5 mm terminally threaded K-wires after achieving an adequate fracture reduction.

• Typically, insert three K-wires: one anterior-to-posterior and two lateral-to-medial, placed in

two planes with different angulations.

• Anterior pins add torsional stability but must be placed carefully to avoid the biceps tendon or

cephalic vein.

• Based on biomechanical data, placing two K-wires from the tuberosities into the medial

proximal humeral cortex increases construct rigidity compared to lateral pins alone.

• Lateral pins should enter at a safe point to avoid the axillary nerve, ideally at twice the head

height distance from the superior margin of the humeral head.

• Insert pins through a sleeve at 30° retroversion to minimize soft tissue damage.

• Pins should diverge at the fracture site and within the humeral head for optimal stability.

• Advance K-wires to the subchondral bone without penetrating the articular surface.

• Use fluoroscopy in AP and axillary views, including 60° external rotation, to confirm accurate

and safe pin placement