Orthopedics

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Case Reports 

Clavicular Fracture and Upper-Extremity Deep Venous Thrombosis

Mohammad Taghi Peivandi, MD; Zohreh Nazemian, MD

Abstract

Upper-extremity deep venous thrombosis (DVT) is considered an uncommon clinical event with considerable potential for morbidity. This article presents a case of upper-extremity DVT following a clavicular fracture. A 25-year-old man presented with pain and distortion of the left midclavicular area after falling on his left shoulder during martial arts practice. Following physical examination and radiography, he was diagnosed with a simple displaced clavicle fracture at the middle third. The patient had no previous surgery or medical problem, and did not smoke. No family history of blood clotting disorders were present and neurovascular examination appeared normal on the symmetric contralateral side. A figure-of-8 bandage was applied to support the arm and the patient was discharged. One week later, he returned with swelling and severe pain in his left arm. On examination, a DVT was suspected and the figure-of-8 brace was removed. A Doppler ultrasonography was performed and the presence of a thrombus extending from the brachial axillary veins to the distal subclavian vein with no flow in that segment was revealed. The patient was placed in a sling instead of a figure-of-8 bandage to immobilize the arm, while anticoagulation therapy with enoxaparin was started (1 mg/kg every 12 hours, 80 mg subcutaneous daily for 3 months). The swelling was reduced after 5 days. At 2-week follow-up, the patient had no pain and the swelling had completely disappeared.

Upper-extremity deep venous thrombosis (DVT) is an understudied condition and constitutes 1% to 4% of all deep-venous limb thromboses.1 In a recent population-based thrombophilia study in Malmö, Sweden, investigators found that 5% of patients with venous thromboembolism had upper-extremity DVT.2 The incidence of upper-extremity DVT is increasing due to awareness among health care professionals, availability of more advanced methods of detection, and increasing use of central upper-extremity catheters.3

Orthopedic procedures such as total hip and knee arthroplasty and hip fracture, are associated with a high risk of deep venous thrombosis. It is mainly due to the accompanying vessel trauma, venous stasis, coagulation activation, and older age of most patients. Yet, upper-extremity DVT is most commonly seen following cancers, central venous catheters, chemotherapy or radiotherapy, ovulation induction for in vitro fertilization, and weight lifting.4-6 Little evidence exists on the incidence of upper-extremity DVT in orthopedic practice. This article presents a case of upper-extremity DVT following conservative treatment of an acute clavicular fracture.

A 25-year-old man presented with pain and distortion of the left midclavicular area after falling on his left shoulder during martial arts practice. Following a physical examination and radiography, he was diagnosed with a simple displaced clavicle fracture at the middle third (Figure 1). The patient had no previous surgery or medical problem, and was not smoking. No family history of blood clotting disorders was found and neurovascular examination appeared normal on the symmetric contralateral side. A figure-of-8 bandage was applied to support the arm and the patient was discharged.

One week later, he returned with swelling and severe pain in his left arm. On examination, a DVT was suspected and the figure-of-8 brace was removed. Doppler ultrasonography was taken to confirm the diagnosis. The presence of a thrombus extending from the brachial axillary veins to the distal subclavian vein with no flow in that segment was revealed (Figure 2).

The patient was placed in a sling instead of a figure-of-8 bandage to immobilize the arm while anticoagulation therapy with enoxaparin was started (1 mg/kg every 12 hours, 80 mg subcutaneous daily for 3 months). The swelling was reduced after 5 days. At 2-week follow-up, the patient had no pain and the swelling had completely disappeared.

Upper-extremity DVT is an infrequent condition…

Abstract

Upper-extremity deep venous thrombosis (DVT) is considered an uncommon clinical event with considerable potential for morbidity. This article presents a case of upper-extremity DVT following a clavicular fracture. A 25-year-old man presented with pain and distortion of the left midclavicular area after falling on his left shoulder during martial arts practice. Following physical examination and radiography, he was diagnosed with a simple displaced clavicle fracture at the middle third. The patient had no previous surgery or medical problem, and did not smoke. No family history of blood clotting disorders were present and neurovascular examination appeared normal on the symmetric contralateral side. A figure-of-8 bandage was applied to support the arm and the patient was discharged. One week later, he returned with swelling and severe pain in his left arm. On examination, a DVT was suspected and the figure-of-8 brace was removed. A Doppler ultrasonography was performed and the presence of a thrombus extending from the brachial axillary veins to the distal subclavian vein with no flow in that segment was revealed. The patient was placed in a sling instead of a figure-of-8 bandage to immobilize the arm, while anticoagulation therapy with enoxaparin was started (1 mg/kg every 12 hours, 80 mg subcutaneous daily for 3 months). The swelling was reduced after 5 days. At 2-week follow-up, the patient had no pain and the swelling had completely disappeared.

Upper-extremity deep venous thrombosis (DVT) is an understudied condition and constitutes 1% to 4% of all deep-venous limb thromboses.1 In a recent population-based thrombophilia study in Malmö, Sweden, investigators found that 5% of patients with venous thromboembolism had upper-extremity DVT.2 The incidence of upper-extremity DVT is increasing due to awareness among health care professionals, availability of more advanced methods of detection, and increasing use of central upper-extremity catheters.3

Orthopedic procedures such as total hip and knee arthroplasty and hip fracture, are associated with a high risk of deep venous thrombosis. It is mainly due to the accompanying vessel trauma, venous stasis, coagulation activation, and older age of most patients. Yet, upper-extremity DVT is most commonly seen following cancers, central venous catheters, chemotherapy or radiotherapy, ovulation induction for in vitro fertilization, and weight lifting.4-6 Little evidence exists on the incidence of upper-extremity DVT in orthopedic practice. This article presents a case of upper-extremity DVT following conservative treatment of an acute clavicular fracture.

Case Report

A 25-year-old man presented with pain and distortion of the left midclavicular area after falling on his left shoulder during martial arts practice. Following a physical examination and radiography, he was diagnosed with a simple displaced clavicle fracture at the middle third (Figure 1). The patient had no previous surgery or medical problem, and was not smoking. No family history of blood clotting disorders was found and neurovascular examination appeared normal on the symmetric contralateral side. A figure-of-8 bandage was applied to support the arm and the patient was discharged.

Figure 1: Simple displaced clavicle fracture at the middle third
Figure 1: Simple displaced clavicle fracture at the middle third.

One week later, he returned with swelling and severe pain in his left arm. On examination, a DVT was suspected and the figure-of-8 brace was removed. Doppler ultrasonography was taken to confirm the diagnosis. The presence of a thrombus extending from the brachial axillary veins to the distal subclavian vein with no flow in that segment was revealed (Figure 2).

Figure 2A: A thrombus extending from the brachial axillary veins Figure 2B: A thrombus extending from the brachial axillary veins
Figure 2C: A thrombus extending from the brachial axillary veins Figure 2: A Doppler ultrasonography confirmed the diagnosis and showed a thrombus extending from the brachial axillary veins to the distal subclavian vein with no flow in that segment.

The patient was placed in a sling instead of a figure-of-8 bandage to immobilize the arm while anticoagulation therapy with enoxaparin was started (1 mg/kg every 12 hours, 80 mg subcutaneous daily for 3 months). The swelling was reduced after 5 days. At 2-week follow-up, the patient had no pain and the swelling had completely disappeared.

Discussion

Upper-extremity DVT is an infrequent condition most commonly found in the axillary or subclavian veins.7-9 Although considered a self-limiting process, it has considerable potential for complications including pulmonary embolism, loss of vascular access, superior vena cava syndrome, and postthrombotic venous insufficiency.7,10 It can be classified as primary and secondary on the basis of pathogenesis.

Primary upper-extremity DVT is a rare disorder while the secondary thrombosis accounts for most cases of upper-extremity DVT. The knowledge on the cause, complications, and clinical outcome of patients with upper-extremity DVT is not well defined because of the scarcity of the disease and most of the available information is from case reports or studies of small sample size.4

Joffe et al10 recently published a prospective registry of 592 patients with upper-extremity DVT. They reported that upper-extremity DVT risk factors differ from the conventional risk factors for lower-extremity DVT. Their findings identify deficiencies in current understanding of prophylaxis of upper-extremity DVT and generate hypotheses for future research efforts.

The diagnosis of this condition in the past was made on clinical grounds with frequent errors. In fact, individual symptoms and signs were proven to be insensitive and nonspecific for DVT diagnosis. Upper-extremity DVT in approximately 50% of cases are completely asymptomatic or patients only report neck or shoulder discomfort.8 A need for an alternative diagnosis was felt before starting the treatment, and with availability of venography it became more evident that objective testing must accompany clinical examination to confirm diagnosis.9 With the advent of ultrasonography as a noninvasive test, a direct visualization of deep venous structures were made possible and it proved to be a sensitive and reliable test for DVT diagnosis.11 Ultrasound is inexpensive, noninvasive, reproducible, and the initial test of choice.

Upper-extremity deep vein thrombosis may result in pulmonary embolism and death, therefore a timely diagnosis and treatment is needed to avoid severe complications or recurrence in patients with underlying medical problems. In recent literature, the overall prevalence of pulmonary embolism of 9.4% and 1% prevalence of fatal pulmonary embolism has been reported in a large group of patients with proven venous thrombosis of the upper extremity.12 In another recent study, the incidence of pulmonary embolism related to upper-extremity thrombosis is reported as 12% to 36%, where <16% of cases were fatal.13 Treatment options for upper-extremity DVT are not as well defined as those for lower-extremity thrombosis. Therefore, early diagnosis and prevention of thrombosis are considered are necessary for a successful outcome in these patients. Since upper-extremity DVT is a rare event following clavicular fracture, medical prevention cannot be offered to these patients; however, physicians should be aware of the possibility of upper-extremity DVT after clavicular fracture.

The proposed treatment modalities are grouped into 4 categories: (1) symptomatic therapy, (2) anticoagulants, (3) thrombolysis, and (4) surgical intervention.7

In the present case, following confirmation of upper-extremity DVT using Doppler ultrasound, we recommended the patient rest to relieve pain and symptoms of deep thrombosis. Anticoagulant therapy proved to be effective as the patient had no swelling 5 days after starting the anticoagulant and at 2-week follow-up, the swelling had completely disappeared.

We hypothesize that clot formation in upper-extremity DVT is a result of direct trauma to the venous wall, and vein stasis has no role in pathogenesis. Therefore blood clots that formed in the injury site of the vein move toward the distal part of the upper extremity, while in the lower extremity the blood clot is mostly due to vein stasis following orthopedic procedures.

To the best of our knowledge, this is the second report of upper-extremity DVT following an acute clavicle fracture.1 We recommend that clavicular fracture is added to the list of risk factors for upper-extremity DVT in the same way that lower limb fractures are well known to cause lower limb DVT.

References

  1. Adla DN, Ali A, Shahane SA. Upper-extremity deep-vein thrombosis following a clavicular fracture. Eur J Orthop Surg Traumatol. 2004; 14(3):177-179.
  2. Isma N, Svensson PJ, Gottsäter A, Lindblad B. Upper extremity deep venous thrombosis in the population-based Malmö thrombophilia study (MATS). Epidemiology, risk factors, recurrence risk, and mortality [published online ahead of print April 20, 2010]. Thromb Res. 2010; 125(6):335-338.
  3. Ellis MH, Manor Y, Witz M. Risk factors and management of patients with upper limb deep vein thrombosis. Chest. 2000; 117(1):43-46.
  4. Muñoz FJ, Mismetti P, Poggio R, et al. Clinical outcome of patients with upper-extremity deep vein thrombosis [published online ahead of print October 9, 2007]. Chest. 2008; 133(1):143-148.
  5. Seong SW, Park JH, Shin SK, Jin SA, Park YK, Choi SW. A case with upper extremity deep vein thrombosis after in vitro fertilization [published online ahead of print September 30, 2010]. J Cardiovasc Ultrasound. 2010; 18(3):98-100.
  6. Girma F. Upper extremity deep vein thrombosis in a 25 year old apparently healthy man. Pan Afr Med J. 2010; 9(4):2.
  7. Willis AA, Verma NN, Thornton SJ, Morrissey NJ, Warren RF. Upper extremity deep vein thrombosis after anterior shoulder dislocation and closed reduction. J Bone Joint Surg Am. 2005; 87(9):2086-2090.
  8. Chuter GSJ, Weir DJ. Upper extremity deep vein thrombosis following a humeral fracture: a case report and literature review. Injury Extra. 2005; (36):249-252.
  9. Fraser JD, Anderson DR. Deep venous thrombosis: recent advances and optimal investigation with US. Radiol. 1999; 211(1):9-24.
  10. Joffe HV, Kucher N, Tapson VF, Goldhaber SZ; Deep Vein Thrombosis (DVT) FREE Steering Committee. Upper-extremity deep vein thrombosis: a prospective registry of 592 patients [published online ahead of print September 7, 2004]. Circulation. 2004; 110(12):1605-1611.
  11. Gaitini D, Kaftori JK, Pery M, Weich YL, Markel A. High-resolution real-time ultrasonography in the diagnosis of deep vein thrombosis. Rofo. 1988; 149(1):26-30.
  12. Becker DM, Philbrick JT, Walker FB. Axillary and subclavian venous thrombosis. Prognosis and treatment. Arch Intern Med. 1991; 151(10):1934-1943.
  13. Smith TO, Daniell H, Hing C. Upper extremity deep vein thrombosis in orthopaedic and trauma surgery: a systematic review [published online ahead of print July 13, 2010]. Eur J Orthop Surg Traumatol. 2010; 21(2):79-85.

Authors

Dr Peivandi is from the Department of Orthopedic Surgery, Shahid Kamyab Hospital, Mashhad University of Medical Sciences and Dr Nazemian is the Deputy of Treatment Affairs, Mashhad University of Medical Sciences, Mashhad, Iran.

Drs Peivandi and Nazemian have no relevant financial relationships to disclose.

Correspondence should be addressed to: Mohammad Taghi Peivandi, MD, Department of Orthopedic Surgery, Shahid Kamyab Hospital, Mashhad University of Medical Sciences, 10 Fadaian Eslam St, Mashhad, Iran (drpeivandy@yahoo.com).

doi: 10.3928/01477447-20110124-28

10.3928/01477447-20110124-28

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