Fracture of the shoulder girdle in multiply injured patients - an imperative for a high level of suspicion for associated neurovascular injuries
© Krasnici et al.; licensee BioMed Central Ltd. 2013
Received: 1 March 2013
Accepted: 24 June 2013
Published: 7 July 2013
The combination of a bony injury to the shoulder girdle and damage to the brachial plexus and the subclavian vessels is a rare finding. The cases of this combined injury pattern described in the literature are most notably reported in multiply-injured patients after high velocity trauma.
Three cases were admitted to our hospital after motorcycle accidents resulting in a combination of severe bony injuries to the shoulder girdle, to the subclavian artery and a lesion to the brachial plexus. Based on these three clinical cases the patterns of injury, as well as primary and secondary treatment approaches are presented.
The early detection of these injuries can be difficult in given acute, life threatening injuries addressed first in these multiply injured patients. A high level of suspicion, in conjunction with standardized ATLS based institutional protocols for secondary and tertiary survey, should increase the likelihood of a timely detection and early management of these rare but potentially devastating injuries.
Fractures of the shoulder girdle accompanied with vascular and plexus injuries are infrequent but can have a potentially devastating outcome. Injuries to the brachial plexus are either caused by distraction injuries as seen in scaphulothoracic injuries or direct injuries to the trunks, cords and nerves. Injuries to the brachial plexus occur in approximately 5% of polytrauma patients involved in motorcycle crashes . Distraction injuries with definite and unrecoverable neurological deficits are caused by root avulsions, where the rootlets are torn out of the spinal cord. In contrast postganglionic stretch injuries or ruptures show a better prognosis [2, 3]. Brachial plexus injuries are associated with a 10%–25% incidence of arterial injury . These injuries may lead to life threatening bleedings in multiply injured patients and cause hemodynamic instability. Both, the detection and treatment of an acute arterial injury as well as the treatment of plexus injuries have to be integrated in treatment algorithms for polytrauma patients. Over a period of six months, three patients were admitted to our hospital after motorcycle accidents resulting in a combination of injuries to the bony shoulder girdle, the subclavian artery and brachial plexus. Based on these three clinical cases the injury patterns, as well as treatment approaches are presented.
A thirty one-year-old man (ISS 41) was admitted to our emergency department following a motorcycle accident. On admission he was alert and oriented. Primary survey yielded tachycardia and a massive hematoma of the left shoulder. Focused examination of the left upper limb revealed paralysis of the entire arm with the radial pulse neither being palpable nor traceable by Doppler ultrasound. Chest x-ray showed a fracture of the left clavicle. The patient was emergently taken to the operating room, where the suspicion of a ruptured subclavian artery was confirmed. A vessel repair using an interpositional PTFE graft between the subclavian and the axillary artery was performed. In addition a complete brachial plexus avulsion was found. The displaced fracture of the clavicle was simultaneously fixed by plating. Femoral fractures on both sides and a tibial fracture on the left side were treated by external fixation. Definitive osteosynthesis was done 10 days after trauma. In addition, the CT scan performed after emergency surgery showed a subdural haematoma, and a pneumothorax. The patient was transferred to a neurosurgical clinic 7 weeks after trauma for the reconstruction of the plexus injury. A neurotization from the spinal accessory nerve to the musculocunaeous nerve using a suralis nerve graft and a neurotization using the phrenic nerve to the musculocutaneous nerve was performed. The last follow up was 1 year after trauma, the patient still showed a complete loss of function of the left arm. The strength of the biceps muscle was only M1 (fasciculations observed in the muscle).
Injuries of the brachial plexus and subclavian vessels can be associated with bony injuries of the shoulder girdle. They are found in approximately 5% of polytrauma patients suffering a motorcycle accident . Zelle et al. published a study presenting long term outcomes after scapulothoracic dissociations. 25 patients were included to the study over a period of 24 years. Poor functional outcome after complete plexus lesions was found . Even with modern reconstruction techniques providing far greater restoration than was possible a few years ago, sequelae such as persistent neurological deficits or functional loss of the entire arm and even unbearable neuropathic pain can cause patients to request for amputation.
Acute plexus injuries originate from a torsion-distraction-like movement to the upper extremity in which the head and neck distends away from the ipsilateral shoulder or from hyperextension-distraction injuries of the upper limb, as seen in the three high velocity motorcycle accident cases presented above. Rupture or incomplete tear of subclavian vessels can account for hemodynamic instability, along with bleeding into large body cavities. In sedated or unconscious patients, the inability to adequately examine the nervous system of the upper extremity challenges the initial evaluation. To detect and treat these life-threatening injuries during the primary trauma survey, strict adherence to ATLS based algorithms is essential. As presented in case I and II, in hemodynamic unstable patients, emergent surgical treatment to establish haemostasis may precede a trauma CT scan. In Case II and III the injured extremity was pulseless. Patients with severe extremity trauma and suspected arterial injury should undergo immediate surgery if hard signs like: pulsatile bleeding, expanding hematoma, palpable thrill and audible bruit are present [5, 6]. Literature validated the use of ankle brachial or arterial pulse indexes (ABI and API respectively), which were shown to reliably detect arterial injury to a limb and are easily performed in the Emergency room [5, 7]. In hemodynamic stable patients (Case III) a CT scan (including ateriography) can be indicated as part of the primary survey th detect the exact location of the bleeding.
In high speed complex injuries of the shoulder girdle, one must always suspect and actively rule out combined injuries to the brachial plexus and the axillary or subclavian vessels.
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