Background


Posterior Circumflex Humeral Artery (PCHA) Pathology

In 1993, Reekers was the first to suggest a causal relationship between traumatic aneurysm of the PCHA and volleyball. Fifteen years later, between November 2008 and November 2010, six volleyball players with ischemic digits of the dominant hand presented themselves in the Academic Medical Center (AMC) in Amsterdam. Following angiography of the hand and forearm, some of these players showed small microemboli in the digital arteries and were given thrombolytic therapy (Figure 1). Within weeks of returning to play, these players returned with identical complaints. Further evaluation, including angiography of the shoulder, showed an aneurysmatic dilatation of the PCHA with thrombus formation and emboli in the digital arteries of the ipsilateral limb (Figures 1 and 2). These players were treated by ligation of the PCHA to prevent further embolization and after rehabilitation returned to play at the highest level of competition within 3-4 months after surgery. All were elite male volleyball players active in the national top league and between 21 and 31 years of age.

This sudden increase in volleyball players with digital ischemia due to PCHA pathology was noted in 2010 by the physiotherapist of the Dutch national beach volleyball team and the former physician of the Dutch national indoor volleyball team. At that time, just five case reports had been published worldwide on volleyball players with finger ischemia due to arterial emboli originating from a thrombosed aneurysm in the PCHA in the dominant shoulder. Knowledge about this injury needs to be extended on an international scale considering the potential amputation of a finger as the devastating end result in a population of young, healthy and fit elite volleyball players.

Therefore, from 2010 on, we set out to elucidate the unexplored entity of PCHA pathology among volleyball players.

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Figure 1

Digital Subtraction Angiography of the right hand of a 27-year-old volleyball player with ischemic symptoms of multiple digits. The arrows point to multiple abrupt stops in digital arteries, caused by microemboli

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Figure 2

Digital Subtraction Angiography of the right arm of a 27-year-old volleyball player with ischemic symptoms of multiple digits (the same player as in Figure 1). The arrow points to the abrupt stop of contrast in the posterior circumflex humeral artery caused by thrombosis.

 

In summary then, elite volleyball players are at risk of ischemic digits due to arterial emboli originating from an aneurysmal and thrombosed PCHA in the dominant shoulder. Knowledge about this injury needs to be extended on an international scale considering the potential amputation of a finger as the devastating end result in a population of young, healthy and fit elite volleyball players.