Multidisciplinary approaches for clavicle fracture with neurovascular injuries: A case report.

To the Editor: Neurovascular injury is an uncommon complication of clavicle fractures, and occurs in at most 1% of all clavicle fractures. Neurovascular injury is mostly caused by high-energy blunt injury to the clavicle.[1] Because its symptoms are less prominent, these vascular injuries are easily neglected and may result in severe consequences. However, few studies have reported a standardized management for this rare trauma. Here, we present a case of a 30-year-old man who suffered an open clavicle fracture with acute subclavian artery and brachial plexus injuries. After treating this case, we concluded that neurovascular examinations and multidisciplinary therapeutic strategies are urgently needed for clavicle fractures with associated neurovascular injury.The authors certify that they have obtained the patient's consent to the publication of information about him in a journal or thesis. The information will be published without the patient's name attached and every attempt will be made to ensure anonymity. A 30-year-old man was admitted to the hospital due to pain, bleeding, and limited activity of the right shoulder caused by a traffic accident 7 hours before admission to the hospital. Physical examination revealed a large skin bruise on the right shoulder with an 8-cm wound on the right clavicular. There was an obvious oozing of the blood, and the broken ends of the right clavicle were visible. The brachial, ulnar, and radial pulses of the right upper limb were absent. The temperature at the distal limb end was acceptable. Right shoulder joint, elbow joint, and wrist joint range of motion as well as finger flexion were limited, the extensor muscle strength was graded 0, and the muscle tone was normal. The right upper arm, forearm, hand, and finger presented with skin hypoesthesia. The Revised Trauma Score for this case was 7.8408. Regarding radiographic examinations, the radiographic findings of the clavicle showed a fracture of the middle third of the right clavicle, and computed tomography (CT) images demonstrated comminuted fracture of the right acromial end of the clavicle [Figure 1A,B]. CT angiography revealed an occlusion (7.5 cm) between two the ends of the right subclavian vessels [Figure 1C].Figure 1: (A) Middle third fracture of the right clavicle (radiography). (B) Comminuted fracture of the right acromial end (CT). (C) Occlusion (7.5 cm) between two ends of the right subclavian vessels (angiography). (D) Fractured right clavicle and intact appearance of the subclavian artery during surgery. (E) Occlusion in the subclavian artery. (F) Interventional guidewire insertion into an artery. (G) Revascularization after extraction of a catheter. (H) Right clavicular fixation plate and subclavian artery implanted stent on a postoperative chest radiographic image. (I, J) Peripheral effusion, extensive contusions, and edema in the right brachial plexus. (K, L) Swelling of the cervical spinal cord and T1–T2 thoracic spinal cord. CT: Computed tomography.The following treatment regimen was adopted for the patient: (1) maintenance of vital signs and (2) multidisciplinary consultation with cardiac surgery and interventional surgery (analysis of arteries, veins, and nerves) departments. Subsequently, with the assistance of the cardiac surgery department, we performed an emergency surgery, which included the following procedures in the right clavicular region: neurovascular tendon exploration, clavicle fracture reduction, and internal fixation. Intraoperative exploration showed that the clavicular–acromioclavicular joint and sternoclavicular joint were loose. The right subclavian vessels were intact, and no obvious rupture or bleeding was observed [Figure 1D]. Brachial plexus contusion was obvious, and its continuity was normal. On the second day after the emergency surgery, the patient was sent to the interventional room for right upper limb angiography. During the surgery, a 10 mm length of the right subclavian artery was occluded from the distal opening of the right vertebral artery [Figure 1E]. The occlusion length was about 80 mm, and the right distal subclavian artery was supplied by the collateral artery. An interventional guidewire was inserted into the right subclavian artery to revascularize the artery [Figure 1F,G]. A percutaneous stent was implanted into the right subclavian artery [Figure 1H]. Re-examination revealed a right subclavian artery with local stenosis. The right distal brachial, ulnar, and radial arteries were well-developed, and no thrombosis was observed. The right distal limb artery was palpable after the surgery, but the sensation and motor function on the right side was absent. A complete magnetic resonance imaging (MRI) examination was then conducted, which suggested that the cervical spinal cord and T1–T2 thoracic spinal cord were swollen. Therefore, contusion was suspected [Figure 1K,L]. The right brachial plexus was injured, and extensive contusions and edema were observed in the soft tissues around the adnexa of the cervical vertebra and the neck region, closer to the right shoulder [Figure 1I,J]. The patient was given anti-infection, nerve nutrition, and anticoagulant treatment postoperatively and was discharged 15 days after the surgery. Six months after discharge, the distal brachial, ulnar, and radial arteries of the right upper limb were examined. There was muscle atrophy of the right upper limb, and the skin in that region was warm but not swollen. The patient could perform basic daily activities with his right upper limb. Acute neurovascular injury caused by clavicle fracture is rare. Although it has been reported to occur in <1% of all clavicle fractures, it can lead to serious consequences.[1] An anatomical study of the subclavicular vessels revealed that in the middle of the clavicle, the subclavicular vein and artery are the closest to the clavicle (within 2 cm). Therefore, the mid-clavicle is prone to subclavian vessel injury. The mechanism of injury is mostly direct high-energy blunt injury to the clavicle. Displaced clavicle fracture components or bone fragments can compress the brachial plexus and cause neurological symptoms. Blunt injury to the subclavian artery usually occurs at the proximal and middle portions of the vessels. Clinical features include hematoma in the clavicular region, bruising or vascular defects in the upper extremities, and hemodynamic instability. Preoperative medical history, physical examination, and imaging diagnosis played a decisive role in the later diagnosis and treatment of our case. Subclavian vascular injuries must be considered in patients who sustain high-energy injuries to the shoulder and chest. Physical examination should focus on skin color, temperature, sensation, hand function, and pulse. Angiography or CT angiography with three-dimensional reconstruction demonstrates the degree of vascular injury, the severity of the injury, and extent of vascular involvement as well as any external compression by hematoma. In these rare cases, interdisciplinary approaches involving the orthopedic, vascular interventional, and, potentially, cardiothoracic specialties are of great importance. Multidisciplinary collaboration can improve the survival rate of affected limbs. Bone stability should be achieved before vascular repair because the tension on the graft can lead to the failure of a repaired vessel with an unrepaired fracture. The youngest patient among previously reported cases was 13 years old, and the oldest patient was 93 years old. Fractures are mainly caused by high-energy injuries, such as falls from heights, car accidents, sports, etc.[2,3] Therapy for patients suspected of subclavian vascular injury varies and includes the following. (1) Open repair of the subclavian artery: Thoracotomy bypass, claviculectomy, and first rib resection. Open repair is difficult due to the risk of massive blood loss and damage to nearby structures. Therefore, it is not the first-line treatment. (2) Interventional therapy: Endovascular therapy for subclavian artery disease is considered an effective treatment due to its initial success rate, clinical efficacy, and long-term primary patency.[4] In contrast to surgical therapy, which has midterm patency and associated complications such as a higher incidence of stroke and death, interventional therapy has high patency and low complications in stent series. In recent years, the endovascular intervention has been proven to be an effective method to treat blunt injuries[5] and an effective first-line treatment for subclavian arterial occlusions.[4] Funding The study was supported by grants from the Guangdong Basic and Applied Basic Research Foundation (Grant Nos. 2021A1515011285, 2019A1515010800), the Major Project under the Science and Technology Development Scheme of Guangdong Province (Grant Nos. 210715106900918, [2020]53–129), the Shantou Science and Technology Plan Medical and Health Category Project (Grant No. 211114216492935), and the Shantou Science and Technology Plan Medical and Health Category Project (Grant No. 211114216492935).Foundation:The study was supported by the Guangdong Basic and Applied Basic Research Foundation (Grant Nos. 2021A1515011285, 2019A1515010800), the Major Project under the Science and Technology Development Scheme of Guangdong Province (Grant Nos. 210715106900918, [2020]53–129), the Shantou Science and Technology Plan Medical and Health Category Project (Grant No. 211114216492935), and the Shantou Science and Technology Plan Medical and Health Category Project (Grant No. 211114216492935). Conflicts of interest None.