CASE REPORT

Unusual subclavian artery injury followingclavicle fracture resulting from epileptic fit

Injury Extra (2005) 36, 110—114

www.elsevier.com/locate/inext

S.N. Anjum*, R. Sanger, P. Wake

Warrington General Hospital, Trauma and Orthopaedics, 17 Lancashire House,Warrington WA5 1QG, UK

Accepted 19 September 2004

The clavicle is an S-shaped bone that connects theshoulder girdle to the trunk and protects the majorunderlying neurovascular structures as they passfrom neck to axilla. Fracture of the clavicle iscommon, accounting for 5—12% of all fracturesand upto 44% of injuries to the shoulder girdle.Fortunately, clavicle injuries with associated signif-icant neurovascular injuries are rare.5,6,11 Penetrat-ing injuries of the clavicle are more commonlyassociated with vascular injuries following claviclefractures as compared to blunt trauma.2,7,8,10

The common mechanism of injuries is direct orindirect trauma associated with contact sports andstick sports or due to fall on outstretched arm andonto the lateral border of the shoulder.5,11

The purpose of this report is to present a case ofclosed comminuted clavicle fracture following epi-leptic fit leading to subclavian artery injury thatpresented as critical ischaemia of the upper limband was successfully treated by reversed vein graft.To our knowledge this has not been reported inEnglish language literature.

* Corresponding author. Present address: 27, Arley House, 1,Amberley Drive, Wythenshawe, Manchester, M23 2RP.Tel.: +44 779 5076619(M), +44 161 4997920(R).

E-mail address: sneshatanjum@yahoo.co.uk (S.N. Anjum).

1572-3461/$ — see front matter # 2004 Elsevier Ltd. All rights resedoi:10.1016/j.injury.2004.09.026

Case report

Seventy years old man presented in A&E with painand swelling of right shoulder and numbness in rightarm after an attack of epileptic fit. There was noradial and brachial pulse on examination and hadcritical ischaemia of the right upper limb. He wasknown to suffer from complex partial seizures withgeneralisation. X-ray of the right shoulder (Fig. 1)revealed comminuted fracture of the clavicle with alarge butterfly fragment. Angiogram (Fig. 2) showedsharp cut off of the right subclavian artery at 2 cmfrom origin. There was no contrast leak presumablydue to tamponade by the haematoma.

Patient was taken to theatre and explored. Sub-clavianarterywascontrolledandsupraclavicularsub-clavian to brachial reversed vein grafting wasperformed after plating of the clavicle fracture(Fig. 3). The graft was passed over the clavicle as itwas compressedandpatencywasdoubtfulwhenposi-tioned under the clavicle. Good pulses were estab-lished at the end of the procedure. There wassuperficialwound infection intheveingraftdonor sitein thigh that was treated by appropriate antibiotics.

The neurophysician reviewed the patient andantiepileptic drugs were changed and dose opti-mised for better control of the fit.

At 3 months follow-up the arterial graft wasworking well but the shoulder movements were

rved.

Unusual subclavian artery injury following clavicle fracture 111

Figure 1 X ray showing comminuted displaced fracture of right clavicle.

restricted. The patient was getting ischaemic painin certain position of shoulder. The clavicle fracturewas not united.

At 7 months postoperation he presented in A&Ewith painful, cold and white arm due to embolism ofbrachial artery that was successfully treated withbrachial embolectomy and good distal circulationwas established.

The symptom of positional intermittent arterialinsufficiency of upper limb continued. The repeatangiogram showed focal stenosis in subclavian graftat the site of clavicle. It was thought that thearterial graft was being kinked at certain positionof the arm due to the supraclavicular position lead-ing to ischaemia of the upper limb. After 11 months,the plate from the clavicle was removed and middleone-third of the clavicle (Fig. 4) was excised tocreate more room for the subclavian arterial graft.

The ischaemic symptoms of the upper limb dis-appeared. Subsequent duplex scan of the bypassarterial graft showed focal stenosis at the old cla-vicle excision site with good velocity of the bloodflow across the stenosis. The patient achieved goodpain-free movement of shoulder and was back to hisfavourite sports–—golf. He was discharged fromclinic after 2 years of injury.

Discussion

The comminuted clavicle fracture is usually high-energy injury sustained following sporting injuries

such as hockey, football, martial arts, gymnastics,weight lifting, wrestling and squash. The reportedincidence of clavicle injuries ranges between 0 and0.23 per 1000 athletic exposures depending on thesports.5

The other common mechanism is heavy fall on tothe shoulder that can lead to comminuted fractureof clavicle.

The epilepsy population is at increased risk ofmetabolic bone disease such as osteomalacia, osteo-penia and osteoporosis as a consequenceof the use ofhepatic enzyme inducing antiepileptic drugs includ-ing phenytoin, phenobarbital and carbamazepine.12

Uni and bilateral dislocations as well as fracture-dislocations of the shoulder, bilateral femoral neckfractures, acetabular fractures and vertebral frac-tures have been reported following convulsive epi-sodes in epileptics.1,4,9 Other common injuries arejaw fracture, teeth injury, tongue bite, bruises,lacerations and sprains, etc. Closed comminutedfracture of clavicle leading to complete transectionof subclavian artery causing critical limb ischaemiafollowing a fit is not reported. The neurologist sawthis gentleman and his antiepileptic medicationswere altered to achieve better control.

Clavicle fracture has been traditionally treatedconservatively with variable results. The range ofmovement and shoulder strength recover well.Recent studies have critically looked at the resultsand malunion, residual pain and some brachialplexus irritation as well as cosmetic complaints incase of severely displaced fracture that showed final

112 S.N. Anjum et al.

Figure 2 Angiogram showing blockade of the right subclavian artery at the fracture site.

shortening of 20 mm or more to be the most impor-tant factor of unsatisfactory result. It has lead to therecommendation of open reduction and internalfixation in severely displaced fracture.5 Any asso-ciated neurovascular deficit usually requires stabi-lisation of the fracture.

Blunt subcalvian artery injury is relativelyuncommon and the presenting signs can be subtle.High suspicion and early use of arteriography andprompt surgical correction by a variety of vasculartechniques can save the limb and give good results7.Early diagnosis was made in this patient as therewere obvious signs of ischaemia and it was con-firmed by prompt arteriography.

Most of the reported blunt subclavian arteryinjuries are associated with high-energy traumasuch as road traffic accident, direct trauma or heavy

falls2,7 but the present patient had epileptic fit andhigh suspicion is necessary for prompt diagnosis.

A tension free, end-to-end primary anastomosis isthe preferred method of repair in blunt subclavianartery injury. If a primary repair is not feasible thena saphenous vein graft is the second option. In thepresent case, reversed saphenous vein graft waspositioned over the clavicle after plate fixation.This supraclavicular position of the graft was causingpositional transient ischaemia in the limb and leadto thromboembolism of brachial artery thatrequired embolectomy. Subsequently it was treatedby excision of the middle-third of the clavicle tocreate more space for the artery.

Frequently in blunt trauma with associated cla-vicle fracture, the medial portion of the clavicle isexcised for better exposure of the subclavian artery

Unusual subclavian artery injury following clavicle fracture 113

Figure 3 X ray showing plate fixation of clavicle fracture.

Figure 4 X ray showing excision of middle one-third clavicle.

114 S.N. Anjum et al.

during repair and it also solves the problem ofsubsequent compression of the graft. This patientbecame asymptomatic after excision of middle-third of the clavicle. Gehman et al. reported nofunctional problem after partial excision of theclavicle in cervicothoracic approach for removalof desmoid tumour of thoracic outlet.3

In summary, the key point of early diagnosis is ahigh index of suspicion, recognising that the signs ofsubclavian arterial trauma may be subtle because ofthe excellent collateral circulation to the upperlimb. Epileptic fit can lead to comminuted fractureof clavicle leading to vascular injury and if treatedpromptly, good function can be achieved. In vascu-lar injury associated with clavicle fracture it isadvisable to remove the part of the clavicle forbetter exposure and to avoid subsequent pressureover the graft and its complications.

References

1. Aboukasm AG, Smith BJ. Nocturnal vertebral compressionfracture. Arch Fam Med Chicago 1997;6(2):185—7.

2. Costa MC, Robbs JV. Non-penetrating subclavian arterytrauma. J Vasc Surg 1988;8:71—5.

3. Gehman KE, Currie I, Ahmad D, Parrent A. Desmoid tumour ofthe thoracic outlet: an unusual cause of thoracic outletsyndrome. Can J Surg Ottawa 1998;41(5):404—7.

4. Haronian E, Silver JW, Mesa J. Simultaneous bilateralfemoral neck fracture and greater tuberosity shoulderfracture resulting from seizure. Orthopedics 2002;25(7):757—8.

5. Hill JM, McGuire MH, Crosby. Closed treatment of displacedmiddle-third fractures of the clavicle gives poor results. JBone Joint Surg 1997;79(4):537—9.

6. Hutchinson MR, Ahuja GS. Diagnosing and treating clavicleinjuries. Phys Sports Med Minneapolis 1996;24(3):26—31.

7. Katras T, Baltazar U, Rush DS, Davis D, Bell TD, Browder IW, etal. Subclavian arterial injury associated with blunt trauma.Vasc Surg 2001;35(1):43—50.

8. Kendall KM, Burton JH, Cushing B. Fatal subclavian arterytransaction from isolated clavicle fracture. J Trauma2000;48:316—8.

9. Kristiansen BN, Cristensen S. Fractures of the proximal end ofthe humerus caused by convulsive seizures. Injury 1984;16:108—9.

10. Natali J, Maraval M, Kieffer E. Fractures of the clavicle andinjuries of the subclavian artery. J Cardiovasc Surg 1975;16:541—54.

11. Rockwood Jr CA, Williams GR, Young DC. Injuries to theacromioclavicular joint. In: Rockwood Jr CA, Green DP,Bucholz RW., editors. Fractures in adults. 3rd ed. Philadel-phia: JB Lippincott Co.; 1991. p. 1181—239.

12. Tatum WO, Liporace J, Benbadis SR, Kaplan PW. Updates onthe treatment of epilepsy in women. Arch Intern Med Chicago2004;164(2):137—45.