Orthopedics

Case Reports 

Upper-Extremity Deep Venous Thrombosis Following Humeral Shaft Fracture

Gregory A. Sawyer, MD; Roman Hayda, MD

Abstract

Upper-extremity deep venous thrombosis (DVT), although not as common as its lower-extremity counterpart, is a clinical entity with potentially devastating complications. Approximately 1% to 4% of all DVT cases involve the upper extremity, with 9% to 14% of these cases complicated by pulmonary embolism. Prompt diagnosis with duplex ultrasonography and subsequent anticoagulation are the gold standards for identification and treatment. The majority of these cases are secondary to medical comorbidities such as malignancy, hypercoagulable states, and indwelling catheters. Although rare, several case reports of orthopedic-related upper-extremity DVT are present in the literature. This article reports a case of upper-extremity DVT in a humeral shaft fracture treated nonoperatively.

A 58-year-old man presented with right elbow pain after a fall from scaffolding. Radiographs demonstrated a distal humeral shaft fracture at the tip of a previously placed intramedullary nail. Initial treatment consisted of closed reduction in a coaptation splint. The patient re-presented 4 days later with increasing forearm pain and swelling. An ultrasound revealed an extensive thrombus of the right brachial vein. A coaptation splint was replaced and the patient was admitted to the hospital for therapeutic anti-coagulation. After hematology consultation and a short hospitalization, the patient was discharged home on a 3-month course of Warfarin. The goal of treatment of upper-extremity venous thrombosis is to improve the patient’s acute symptoms and prevent both pulmonary embolism and post-thrombotic syndrome. Post-thrombotic syndrome is a chronic, potentially debilitating condition that occurs in approximately 15% of upper-extremity DVT cases with symptoms consisting of pain, swelling, paresthesias, and functional limitation.

Deep venous thrombosis (DVT) is a well-known clinical entity seen in the orthopedic trauma patient population, most often occurring in the lower extremities following pelvic and long-bone fractures. These patients are frequently affected due to the tissue trauma suffered from the initial injury and the subsequent period of immobilization. This trauma sequence exposes patients to all 3 components of Virchow’s triad: interrupted blood flow (venous stasis), endothelial vessel wall damage, and hypercoagulability. However, it must be recognized that long-bone fractures of the upper extremity also carry a risk of DVT and the possibility of a subsequent life-threatening pulmonary embolism.

Upper-extremity DVT most frequently occurs secondary to a variety of medical comorbidities; however, several case reports of orthopedic-related upper-extremity DVT are present in the literature. This article reports a case of upper-extremity DVT in a humeral shaft fracture treated nonoperatively.

A 58-year-old, right-hand-dominant man presented with right elbow pain after a 6-foot fall from scaffolding 24 hours prior to evaluation. The patient’s past medical history was significant for a similar fall approximately 9 months prior, where he sustained a right proximal humeral shaft fracture treated with a locked intramedullary nail. He had an uneventful recovery from this operation and had returned to full-time work. Also of note, the patient was a long-time smoker.

On examination, the patient was noted to have gross deformity, swelling, and ecchymosis at the right distal humerus with intact skin. His hand was neurologically intact with a strongly palpable radial pulse. Radiologic examination revealed a completely displaced spiral distal humeral shaft fracture at the tip of the previously placed intramedullary nail (Figure 1).

Closed reduction was performed using a coaptation splint with the forearm wrapped, leaving the fracture in approximately 10° of varus alignment (Figure 2). Post-reduction examination revealed 4/5 strength of wrist extensors and extensor pollicis longus, but otherwise neurovascularly intact at the hand. The patient was discharged to home with appropriate follow-up.

Four days after his original injury the patient re-presented to the emergency room with increasing right forearm and hand swelling. The coaptation splint was removed and the patient was noted…

Upper-extremity deep venous thrombosis (DVT), although not as common as its lower-extremity counterpart, is a clinical entity with potentially devastating complications. Approximately 1% to 4% of all DVT cases involve the upper extremity, with 9% to 14% of these cases complicated by pulmonary embolism. Prompt diagnosis with duplex ultrasonography and subsequent anticoagulation are the gold standards for identification and treatment. The majority of these cases are secondary to medical comorbidities such as malignancy, hypercoagulable states, and indwelling catheters. Although rare, several case reports of orthopedic-related upper-extremity DVT are present in the literature. This article reports a case of upper-extremity DVT in a humeral shaft fracture treated nonoperatively.

A 58-year-old man presented with right elbow pain after a fall from scaffolding. Radiographs demonstrated a distal humeral shaft fracture at the tip of a previously placed intramedullary nail. Initial treatment consisted of closed reduction in a coaptation splint. The patient re-presented 4 days later with increasing forearm pain and swelling. An ultrasound revealed an extensive thrombus of the right brachial vein. A coaptation splint was replaced and the patient was admitted to the hospital for therapeutic anti-coagulation. After hematology consultation and a short hospitalization, the patient was discharged home on a 3-month course of Warfarin. The goal of treatment of upper-extremity venous thrombosis is to improve the patient’s acute symptoms and prevent both pulmonary embolism and post-thrombotic syndrome. Post-thrombotic syndrome is a chronic, potentially debilitating condition that occurs in approximately 15% of upper-extremity DVT cases with symptoms consisting of pain, swelling, paresthesias, and functional limitation.

Deep venous thrombosis (DVT) is a well-known clinical entity seen in the orthopedic trauma patient population, most often occurring in the lower extremities following pelvic and long-bone fractures. These patients are frequently affected due to the tissue trauma suffered from the initial injury and the subsequent period of immobilization. This trauma sequence exposes patients to all 3 components of Virchow’s triad: interrupted blood flow (venous stasis), endothelial vessel wall damage, and hypercoagulability. However, it must be recognized that long-bone fractures of the upper extremity also carry a risk of DVT and the possibility of a subsequent life-threatening pulmonary embolism.

Upper-extremity DVT most frequently occurs secondary to a variety of medical comorbidities; however, several case reports of orthopedic-related upper-extremity DVT are present in the literature. This article reports a case of upper-extremity DVT in a humeral shaft fracture treated nonoperatively.

Case Report

A 58-year-old, right-hand-dominant man presented with right elbow pain after a 6-foot fall from scaffolding 24 hours prior to evaluation. The patient’s past medical history was significant for a similar fall approximately 9 months prior, where he sustained a right proximal humeral shaft fracture treated with a locked intramedullary nail. He had an uneventful recovery from this operation and had returned to full-time work. Also of note, the patient was a long-time smoker.

On examination, the patient was noted to have gross deformity, swelling, and ecchymosis at the right distal humerus with intact skin. His hand was neurologically intact with a strongly palpable radial pulse. Radiologic examination revealed a completely displaced spiral distal humeral shaft fracture at the tip of the previously placed intramedullary nail (Figure 1).

Figure 1A: Radiograph of the right humerus Figure 1B: Radiograph of the right humerus Figure 2A: Radiograph of the right humerus Figure 2B: Radiograph of the right humerus
Figure 1: Pre-reduction AP (A) and lateral (B) radiographs of the right humerus, identifying a distal one-third humeral shaft fracture at the tip of an intramedullary nail. Figure 2: Post-reduction AP (A) and lateral (B) radiographs of the right humerus.

Closed reduction was performed using a coaptation splint with the forearm wrapped, leaving the fracture in approximately 10° of varus alignment (Figure 2). Post-reduction examination revealed 4/5 strength of wrist extensors and extensor pollicis longus, but otherwise neurovascularly intact at the hand. The patient was discharged to home with appropriate follow-up.

Four days after his original injury the patient re-presented to the emergency room with increasing right forearm and hand swelling. The coaptation splint was removed and the patient was noted to have swelling about the distal humerus down to the hand. He was noted to have 0/5 extensor pollicis longus strength, 2/5 wrist extensor strength, decreased sensation in the radial nerve distribution, and a strong palpable radial pulse. Ultrasound revealed a near occlusive thrombus of the right brachial vein extending from the level of the mid-arm to the brachial/axillary vein junction (Figure 3).

Figure 3: Duplex ultrasound of the right brachial vein
Figure 3: Duplex ultrasound of the right brachial vein identifying limited flow, consistent with a nearly occlusive thrombus.

The coaptation splint was replaced resulting in acceptable alignment. The patient was admitted and started on therapeutic enoxaparin as a bridge to Warfarin. Hematology consultation attributed his upper-extremity DVT to local trauma with subsequent immobilization and did not feel that patient required a hypercoagulable work-up.

After an uneventful hospital course, the patient was discharged on day 4, with plans for 3 months of Warfarin therapy. At 2-month follow-up, the patient was doing well with significantly decreased pain. He exhibited 4/5 strength in his wrist extensors, radiographs revealed abundant callus formation at the fracture site with only slight varus malalignment, and he had begun therapy for range of motion exercises. He exhibited no further clinical sequelae from his DVT.

Discussion

An estimated 1% to 4% of all DVT cases involve the upper extremity.1 While the vast majority of these are related to comorbid medical conditions, the orthopedic literature has included several case reports for shoulder arthroscopy, shoulder dislocation, proximal humerus fracture, clavicle fracture, and following open reduction and internal fixation of a humeral nonunion.2-6

Upper-extremity DVT can be categorized into 2 subdivisions: primary and secondary. Primary is uncommon (2 per 100,000 person years), consisting of either effort dependent thrombosis (Paget Schroetter Syndrome) or idiopathic.7 Paget Schroetter Syndrome is a rare entity whereby affected individuals suffer microtrauma to upper-extremity vessel wall intima, often during strenuous exercise, which initiates the coagulation cascade resulting in thrombosis.7 These patients also often have a congenitally narrow thoracic inlet that puts them at increased risk for primary venous thrombosis, secondary to stasis and vessel intimal wall damage (2/3 of Virchow’s triad). The idiopathic subdivision refers to patients for which no identifiable cause of the thrombosis can be identified. This is a diagnosis of exclusion, although many feel that the patients that receive this diagnosis have an occult malignancy causing a hypercoagulable state.7

Secondary upper-extremity DVTs have an underlying trigger or disease process that increases the risk of subsequent thrombosis. The most common is malignancy, particularly lung, breast, and colorectal, which generate a hypercoagulable state. The second most frequent is thrombosis secondary to indwelling catheters including central lines, port systems, peripheral lines, and pacemakers.7 Our patient fits into this classification with upper-extremity trauma, treated with immobilization, resulting in venous stasis and clot formation.

Patients with upper-extremity DVTs present classically with vague arm, shoulder, or neck pain, depending on the location and extent of thrombosis. They can also have swelling, edema, and occasionally a palpable tender cord.7 Systemically, these patients can have mild tachycardia and low-grade fevers. High fevers are concerning for a septic thrombophlebitis. When tachycardia is accompanied by cyanosis, concern exists for development of a pulmonary embolism, which can complicate 9% to 14% of identified upper-extremity DVT.6,8

Duplex ultrasound has become the imaging modality of choice for the diagnosis of upper-extremity DVT, as it is noninvasive with high sensitivity and specificity.7 The known limitation of this study is the acoustic shadowing produced by the clavicle, which can obstruct complete visualization of the subclavian vein.7 Second-line imaging choices include contrast venography, computed tomography angiography, and magnetic resonance angiography. Each of these include a contrast load and its possible resulting complications (allergic reaction and nephrotoxicity). These secondary imaging modalities may be required if upper-extremity DVT suspicion persists despite a negative ultrasound.7

The treatment goal is improving the patient’s acute symptoms and prevention of both pulmonary embolism and post-thrombotic syndrome.7 Pulmonary embolism can complicate upper-extremity DVT in 9% to 14% of cases, although the actual percentage may be higher, as frequently emboli are asymptomatic. Post-thrombotic syndrome is a chronic, potentially debilitating condition that occurs in approximately 15% of patients with upper-extremity DVT.1 This syndrome is characterized by pain, swelling, heaviness, paresthesias, and functional limitation of the arm. Post-thrombotic syndrome can be functionally debilitating in the upper extremity.7 Our patient has shown no evidence of this syndrome.

The mainstay of venous thrombosis treatment is anticoagulation. Acutely, unfractionated, or low-molecular-weight heparin are used as a bridge to long-term Warfarin therapy. The goal of anti-coagulation therapy is to prevent further clot propagation, while allowing natural thrombolysis to occur. Similarly to lower-extremity DVT treatment, anticoagulation is recommended for a 3- to 6-month course, with a goal international normalized ratio of 2-3.7

Thrombolysis is also an option in the early treatment of upper-extremity DVT. The ideal patient for this therapy is a young, otherwise healthy individual. The classic thrombolytics are streptokinase, urokinase, and alteplase (tPA), all of which are delivered intravenously. Following administration of a thrombolytic, a patient is then begun on a standard course of anti-coagulation (as previously described). Absolute contraindications for thrombolysis include allergy to thrombolytics, active or recent internal bleeding (within the past 6 months), history of hemorrhagic stroke, active intracranial neoplasm, and recent (<2 months) intracranial surgery or trauma.7

Surgical interventions for upper-extremity DVT are primarily for prevention of recurrent thrombosis. This mostly applies to primary upper-extremity DVT, and the purpose is to alleviate extrinsic sources of venous compression. These procedures may include partial clavicle resection, first rib resection, and scalene muscle resection.7

Superior vena cava filters have been successfully used for the prevention of pulmonary embolism in patients with upper-extremity DVT, for whom anticoagulation is contraindicated. Using a percutaneous technique, this has been shown to be a safe and effective method to prevent symptomatic pulmonary embolism.9

Many reports exist in the literature on central venous thrombosis resulting in cranial nerve palsies, but rarely has extremity thrombosis resulting in nerve palsy been reported. Bendszus et al10 reported a case of peroneal nerve palsy caused by crural vein thrombosis, but otherwise these reports are scarce in the literature. This patient’s initial partial radial nerve palsy was most likely secondary to his humeral shaft fracture, not his extensive brachial vein thrombosis. A reported 11.8% incidence of radial nerve palsies is associated with humeral shaft fractures.11

Upper-extremity DVT, although not as common as its lower-extremity counterpart, is a real clinical entity that must be appropriately diagnosed and treated to avoid devastating complications, such as pulmonary embolism. Although seen most frequently in patients with malignancy and central venous catheters, several case reports exist in the orthopedic literature on both fracture and postoperative care.

References

  1. Elman E, Kahn S. The post-thrombotic syndrome after upper extremity deep venous thrombosis in adults: A systematic review [published online ahead of print July 6, 2005]. Thrombosis Research. 2006; 117(6):609-614.
  2. Creighton RA, Cole B. Upper Extremity deep venous thrombosis after shoulder arthroscopy: a case report [published online ahead of print September 1, 2006]. J Shoulder Elbow Surg. 2007; 16(1):e20-22.
  3. Willis A, Verma N, Thornton S, Morrissey N, Warren R. Upper-extremity deep vein thrombosis after anterior shoulder dislocation and closed reduction. A case report. J Bone Joint Surg Am. 2005; 87(9):2086-2090.
  4. Chuter G, Weir D. Upper extremity deep vein thrombosis following a humeral fracture: a case report and literature review. Injury Extra. 2005; 36(7):249-252.
  5. Adla DN, Ali A, Shahane SA. Upper Extremity deep-vein thrombosis following clavicular fracture. Eur J Orthop Surg Traumatol. 2004; 14(3):177-179.
  6. Pearsall AW IV, Stokes DA, Russell GV Jr. Internal jugular deep venous thrombosis after surgical treatment of a humeral nonunion: a case report and review of the literature. J Shoulder Elbow Surg. 2004; 13(4):459-462.
  7. Joffe HV, Goldhaber SZ. Upper-extremity deep vein thrombosis. Circulation. 2002; 106(14):1874-1880.
  8. Muñoz FJ, Mismetti P, Poggio R, et al; RIETE Investigators. Clinical outcome of patients with upper-extremity deep vein thrombosis [published online ahead of print October 9, 2007]. Chest. 2008; 133(1):143-148.
  9. Spence L, Gironta M, Malde H, Mickolick C, Geisinger M, Dolmatch B. Acute upper extremity deep venous thrombosis: safety and effectiveness of superior vena caval filters. Radiology. 1999; 210(1):53-58.
  10. Bendszus M, Reiners K, Perez J, Solymosi L, Koltzenburg M. Peroneal nerve palsy caused by thrombosis of crural veins. Neurology. 2002; 58(11):1675-1677.
  11. Shao YC, Harwood P, Grotz MR, Limb D, Giannoudis PV. Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review. J Bone Joint Surg Br. 2005; 87(12):1647-1652.

Authors

Drs Sawyer and Hayda are from Brown Medical School-Rhode Island Hospital, Providence, Rhode Island.

Drs Sawyer and Hayda have no relevant financial relationships to disclose.

Correspondence should be addressed to: Gregory A. Sawyer, MD, Rhode Island Hospital, Department of Orthopedics, 593 Eddy St, Providence, RI 02903 (gregory_sawyer@brown.edu).

doi: 10.3928/01477447-20101221-27

10.3928/01477447-20101221-27

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