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Delayed presentation of Subclavian venous thrombosis following undisplaced clavicle fracture

DOI:10.1186/1749-7922-3-25
Authors:
Tony Kochhar at University of Greenwich
Tony Kochhar
Chethan Jayadev at University of Oxford
Chethan Jayadev
Jay Smith
Jay Smith
Jay Smith
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Emmet Griffiths
Emmet Griffiths
Emmet Griffiths
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Abstract and Figures

Medial clavicle fractures are uncommon, accounting for approximately 5 percent of all clavicle fractures. Vascular injuries are uncommon but are recognised as either an immediate complication due to transection of the vessel by the displaced fracture, or as a late complication, secondary to compression from abundant callus formation. We present an unusual case of positional venous insufficiency in the upper limb as an immediate complication of a closed, minimally displaced clavicle fracture, with secondary subclavian venous thrombosis formation eleven days following the injury.
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BioMed Central
Page 1 of 4
(page number not for citation purposes)
World Journal of Emergency
Surgery
Open Access
Review
Delayed presentation of Subclavian venous thrombosis following
undisplaced clavicle fracture
Tony Kochhar*
1
, Chethan Jayadev
1
, Jay Smith
2
, Emmet Griffiths
2
and
Kamaljit Seehra
3
Address:
1
Department of Trauma & Orthopaedics, Queen's Hospital Romford, Essex, UK,
2
Department of Trauma & Orthopaedics, Hillingdon
Hospital, Middlesex, UK and
3
Department of Trauma and Orthopaedics, Norfolk and Norwich University Hospital, Colney Lane, Norwich, NR4
7UY, UK
Email: Tony Kochhar* - tonykochhar@gmail.com; Chethan Jayadev - cjayadev@gmail.com; Jay Smith - jds003@hotmail.com;
Emmet Griffiths - ejg299@doctors.org; Kamaljit Seehra - kseehra@doctors.org.uk
* Corresponding author
Abstract
Medial clavicle fractures are uncommon, accounting for approximately 5 percent of all clavicle
fractures. Vascular injuries are uncommon but are recognised as either an immediate complication
due to transection of the vessel by the displaced fracture, or as a late complication, secondary to
compression from abundant callus formation. We present an unusual case of positional venous
insufficiency in the upper limb as an immediate complication of a closed, minimally displaced clavicle
fracture, with secondary subclavian venous thrombosis formation eleven days following the injury.
Background
Injuries to the clavicle are very common and account for
up to 10% of all fractures[2]. Midshaft and lateral third
clavicle fractures are common sporting injuries; the vast
majority present without neurovascular injury and pro-
ceed to uncomplicated union [1-3]. Fractures to the
medial clavicle are uncommon, accounting for only 2–5%
of all clavicle fractures [2-5] and are often due to high
energy injuries. The medial clavicle protects the brachial
plexus, subclavian and axillary vessels and the superior
lung. Fractures can therefore be complicated by damage to
these structures.
Much of the literature and research has concentrated on
midshaft and distal clavicle fractures and acromioclavicu-
lar joint injuries. We aim to highlight the difference in
mechanism of injury and complications associated with
medial third clavicle fractures.
Review of the literature
In general, vascular injuries following clavicle fractures are
uncommon but are recognised as either an immediate
complication due to transection of the vessel by the dis-
placed fracture [6,7], or as a late complication, secondary
to compression from abundant callus formation. There
have been several reported cases of venous insufficiency
associated with clavicle fractures [8-11] and of acute com-
pression of the subclavian vessels following displaced
midshaft fractures[12]. There have also been reported
cases of neural injury associated with these common inju-
ries [13].
Isolated injuries of the medial end of the clavicle are
uncommon and are usually part of multisystem inju-
ries[14]. Throckmorton and Kuhn presented a review of
all clavicle fractures treated at their institution over a five
year period. Out of 614 clavicle fractures, only 57 were
Published: 22 July 2008
World Journal of Emergency Surgery 2008, 3:25 doi:10.1186/1749-7922-3-25
Received: 10 March 2008
Accepted: 22 July 2008
This article is available from: http://www.wjes.org/content/3/1/25
© 2008 Kochhar et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0
),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
World Journal of Emergency Surgery 2008, 3:25 http://www.wjes.org/content/3/1/25
Page 2 of 4
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identified as medial third fractures. 80% of these occurred
in middle aged men. Just over 80% of these injuries were
associated with motor vehicle accidents (53% were pas-
sengers/driver of a vehicle; 16% were pedestrians hit by a
vehicle; 11% motorcycle accidents). Ninety percent of
cases were defined as having multi-system trauma. Associ-
ated injuries included haemothorax or haemopneumoth-
orax (42%), pulmonary contusions, respiratory failure or
adult respiratory distress syndrome (55%), rib fractures
(73%) with only one patient suffering from a vascular
complication of subclavian vein perforation following a
gunshot wound. The other complications reported with
fractures of the medial clavicle were similar to those seen
in association with lateral and midshaft fractures: skin or
soft tissue complications, malunion, nonunion and
refracture.
In children, physeal fracture of the medial end of the clav-
icle has been documented with a range of associated com-
plications occurring acutely by the initial injury or
chronically following a missed diagnosis [15]. Hoarseness
[16], thoracic outlet syndrome[17], pneumothorax[18],
tracheo-oesophageal fistula[19], and venous thrombosis
have also been reported[7]. Blunt subclavian injury has
been documented following fracture of the clavicle usu-
ally associated with high energy trauma[20], however one
case has been documented of it occurring following an
epileptic fit. In this particular instance the patient pre-
sented as critical ischaemia of the upper limb [21].
AP X-Ray AP X-Ray showing an undisplaced fractureFigure 1
AP X-Ray AP X-Ray showing an undisplaced frac-
ture.
AP X-Ray showing an undisplaced fracture of the medial end of the clavicleFigure 2
AP X-Ray showing an undisplaced fracture of the
medial end of the clavicle.
Duplex scan – arm in flexion demonstrating vascular com-promiseFigure 3
Duplex scan – arm in flexion demonstrating vascular
compromise.
Initial duplex scan – arm straightFigure 4
Initial duplex scan – arm straight.
World Journal of Emergency Surgery 2008, 3:25 http://www.wjes.org/content/3/1/25
Page 3 of 4
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Discussion
Medial clavicle fractures are uncommon injuries and have
therefore been largely overlooked. The available literature
points out that medial third clavicle fracture, like scapular
body fractures, are commonly associated with a high-
energy blunt trauma mechanism of injury and should
therefore prompt the treating physician to look for other
associated poly-trauma. There is a high association with
mortality from multi-system trauma. In such situations,
cardio-respiratory injuries and compromise appear to be
the most frequent and most serious associated injuries.
Other injuries to neck/thoracic viscera have been
reported.
While there have been several reports of vascular injury
(laceration, compression; acute or late) following frac-
tures of the clavicle, the vast majority have been due to
displaced fractures of the midshaft or lateral end. How-
ever, most midshaft and lateral clavicle fractures are not
associated with injuries to other structures. Such fractures
heal completely without complication with non-operative
management. This review reiterated the inherently differ-
ent nature of medial third clavicle compared to the more
common midshaft or lateral third fractures. Medial third
clavicle fractures are more likely to be associated with
poly-trauma and serious complications, which can easily
be overlooked, particularly after the immediate post-
injury phase. This paper also emphasises the need for
repeated vigilance following initial clinical assessment.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
TK conceived the idea and wrote the paper. CJ, JS and EG
were instrumental in analysing the notes, collecting the
data and inserting images. KS was responsible for editing
and approving the final manuscript.
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... There are, however, a few cases reported of VTE sustained after non-operative treatment of low-energy clavicle fractures [1,[6][7][8]. Of these cases, the subclavian, axillary, and brachial veins were most commonly involved [1,[6][7][8]. ...
... There are, however, a few cases reported of VTE sustained after non-operative treatment of low-energy clavicle fractures [1,[6][7][8]. Of these cases, the subclavian, axillary, and brachial veins were most commonly involved [1,[6][7][8]. This study aimed to provide another rare example of VTE after a low-energy, non-operative clavicle fracture. ...
... Thromboses can either be an acute complication following clavicle fracture due to transection of the veins by the displaced fragments or a subacute complication caused by compression of the veins by hypertrophic callus development [9]. The current literature consists of subacute VTE presentations, ranging from one week to two months post-injury, with one week being the most common [1][2][3][4][6][7][8][9]. All reported thromboses occurred in middle third clavicle fractures, which is consistent with this case presentation. ...
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... Though infrequent, neurovascular injuries are a recognized complication. They may be present as an acute or late complication, both in nonoperative and in operative scenarios [14][15][16]. Acute complication may be present after the transection of the vessel by the displaced fracture or as a late complication, secondary to compression from abundant callus formation [14][15][16][17]. ...
... They may be present as an acute or late complication, both in nonoperative and in operative scenarios [14][15][16]. Acute complication may be present after the transection of the vessel by the displaced fracture or as a late complication, secondary to compression from abundant callus formation [14][15][16][17]. ...
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... Clavicle fracture is one common clinical fracture, and the comminuted fragment may pierce subclavian vessels and nerves, which makes small odds for life salvage. Vascular complications of clavicle fracture are rare and are generally recognized as an early complication due to transection of the vein by a displaced fracture of the mid-shaft or lateral end [16][17][18] or by a late complication [3,19], secondary to the compression caused by abundant callus formation. Brachial plexus injury following clavicle fracture is generally a delayed phenomenon occurring days, weeks and even months after the original lesion [20][21][22][23]. ...
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