Intermittent subclavian artery occlusion following clavicular fracture

Although fractures of the clavicle are common, complications are rare. A 41 year old painter developed two uncommon complications of clavicular fracture, mechanical intermittent subclavian artery occlusion and subclavian vein thrombosis. Both conditions were clearly identified on the clinical symptoms and signs and confirmed with dynamic angiography and computerised tomography. Operative intervention led to complete resolution of symptoms.     

Case Report: Delayed Subclavian Vein Injury Secondary to Clavicular Malunion

Background

Fractures of the clavicle are extremely common, representing 2.6–12% of all fractures and 35–44% of all shoulder girdle injuries; 69–82% of these fractures occur in the middle third of the clavicle. Vascular injuries relating to clavicle fracture are usually due to extreme force applied to the clavicle in an acute setting. No other reports of delayed subclavian vein laceration were found on literature search.

Objectives

We present this case to increase awareness among emergency physicians of the potential delayed presentation of this rare condition.

Case Report

A 21-year-old man presented to the Emergency Department with acute swelling of the base of the neck after carrying a heavy load on his left shoulder the night before. He had been recovering from a clavicle fracture for 2 months. Malunion of his left midshaft clavicle fracture led to subclavian vein injury and formation of a large hematoma secondary to reinjury that occurred at work the night before presentation. Computed tomography revealed a 9-cm hematoma at the fracture site. The patient was found to have a subclavian vein injury without evidence of arterial injury or nervous system involvement. The patient was admitted for observation and subsequently discharged without need for surgical intervention.

Conclusion

Subclavian vein laceration is a rare complication of clavicle fracture. Patient education at discharge after conservative management is important due to the risk of vascular complications from malunion and reinjury.     

双Endobutton钢板结合锁骨钢板治疗锁骨中段骨折合并肩锁关节脱位

背景：锁骨中段骨折合并肩锁关节脱位是一种罕见的损伤,目前对其内固定治疗方法尚无统一意见。目的：探讨锁骨中段骨折合并肩锁关节脱位这种罕见损伤的治疗方案。方法：回顾性分析2005至2011年收治的3例锁骨中段骨折合并肩锁关节脱位患者,分别采用锁骨解剖锁定钢板＋钢丝喙突下环扎、锁骨解剖锁定钢板＋锁骨钩钢板、锁骨解剖锁定钢板＋双Endobutton钢板重建喙锁韧带的方法行内固定。比较3种方案的治疗效果,包括手术时间、出血量及肩关节功能评估等。结果与结论：1例病例漏诊,仅诊断为锁骨中段骨折。3例病例均得到12个月以上的门诊随访,骨折全部愈合,分别在内固定后12,9,11个月后取出内固定,病例3的Endobutton钢板未取,取出内固定后无再脱位发生。在患者取出内固定前及取出内固定后对疼痛、日常功能、活动度及肌力进行综合评估,3例患者取出内固定前评分分别为64,71和92,取出内固定后评分分别为68,79和95。使用双Endobutton钢板结合锁骨锁定钢板治疗的病例功能恢复最好。提示双Endobutton钢板结合锁骨钢板是治疗锁骨中段骨折伴肩锁关节脱位的理想内固定选择。     

Une cause rare du syndrome de Paget-Schroetter : un Swing de trop !

Effort thrombosis of the axillo/subclavian vein (Paget-Schroetter syndrome) is often a misdiagnosed syndrome, which consists of a venous compression at the upper thoracic outlet. It affects athletes, and workers with repetitive, forceful, or overhead arm activities. Treatment algorithms are varied and controversial, surgical approach should be directed toward the specific pathology. Through this article, the authors describe a rare case of Paget-Schroetter syndrome in a golf player caused by a clavicular osteochondroma.     

Thrombose veineuse profonde du membre supérieur compliquant une fracture de la clavicule. À propos d’un cas

Deep venous thrombosis (DVT) of upper extremity is a rare clinical entity, its intervening after a bony fracture is exceptional. The authors report the case of an amateur judoka who's developed a thrombosis of the deep humeral vein following a clavicular fracture, the diagnosis was suspect clinically and confirmed by the ultrasound scan. Anticoagulation was the cornerstone of therapy and the evolution was good.     

锁骨钩钢板治疗锁骨远端骨折术后肩关节的康复锻炼

目的探讨锁骨钩钢板治疗锁骨远端骨折术后早期肩关节功能锻炼的方法。方法对2006年8月至2007年7月接受锁骨钩钢板治疗的16例锁骨远端骨折患者术后分阶段进行肩关节功能锻炼。结果根据肩关节疾患治疗成绩判断标准评分,13例〈50岁患者的评分为（93．00±4．66）分,3例50-60岁患者评分为（85．00±4．66）分。结论锁骨钩钢板治疗锁骨远端骨折具有固定确切、操作简单、安全可靠、不损关节面等优点,同时,早期功能锻炼最大限度地减少了并发症。     

Prise en charge des fractures récentes de la clavicule

Fractures of the clavicle are extremely frequent (2,6 to 5% of all the fractures). They typically occur in male children or young adults before 25 years. Because of anatomical particularity of the bone, these fractures are involving the middle third of the bone in 69% to 82% of cases. Satisfactory results are often achieved with an orthopedic treatment. However, in some cases, increasing risks of poor functional outcomes, higher risk of pseudarthrosis, ungraceful results or delayed work resumption lead to choose a surgical treatment. Many surgical procedures are described by authors to treat these fractures, but actually, there is no common consensus for surgical indication. The admitted shortening value for a surgical treatment is 20 mm. However, Altamini has shown the superiority of a surgical treatment in terms of functional results and decreasing cases of nonunion and pseudarthrosis in cases of fractures involving the middle third part of the bone.     

Complications of regional anesthesia

Perioperative nerve injuries have long been recognized as a complication of regional anesthesia. Although severe or disabling neurologic complications are rare, recent epidemiologic series suggest the frequency of some serious complications is increasing. Risk factors contributing to neurologic deficit after regional anesthesia includes neural ischemia (hypothesized to be related to the use of vasoconstrictors or prolonged hypotension), traumatic injury to the nerves during needle or catheter placement, infection, and choice of local anesthetic solution. In addition, postoperative neurologic injury due to pressure from improper patient positioning or from tightly applied casts or surgical dressings, as well as surgical trauma are often attributed to the regional anesthetic. Patient factors such as body habitus and pre-existing neurologic dysfunction may also contribute. The safe conduct of regional anesthesia involves knowledge of the laboratory studies, large patient series as well as individual case reports of neurologic deficits following regional anesthetic techniques. Prevention of complications, along with early diagnosis and treatment are important in the management of regional anesthetic risks.     

La fracture de Tillaux chez l’enfant et l’adolescent. À propos d’une série de 11 cas

Background

Tillaux fracture in child correspond to Salter and Harris type III fracture involving the anterolateral portion of the distal tibial epiphysis. These are intra-articular fracture. The aim of this study was to analyze the therapeutic modalities and long-term clinical and radiological outcome.

Patients and methods

We reviewed retrospectively 11 Tillaux fractures. All underwent surgical treatment.

Results

The average age was 13.5 years. Patients were treated by open reduction and screw fixation. At mean follow-up of 28 months, results were rated well in nine of 11 cases.

Conclusion

The prognosis of Tillaux fracture in child is good as was observed in our studies and in series reported in the literature.     

AO锁骨钩钢板治疗肩锁关节脱位和锁骨远端骨折

目的：探讨AO锁骨钩钢板治疗TossyⅢ型肩锁关节脱位和NeerⅡ型锁骨远端骨折的临床疗效。方法：对2001年5月-2006年10月28例TossyⅢ型肩锁关节脱位和30例NeerⅡ型锁骨远端骨折患者均采用AO锁骨钩钢板治疗。结果：所有患者得到随访,随访8～42个月,平均21个月。所有患者均获得良好复位和固定,X线片未见肩锁关节半脱位,无内固定松动或断裂,肩关节功能恢复良好。结论：AO锁骨钩钢板治疗肩锁关节脱位和锁骨远端骨折具有手术操作简便、内固定牢固、可早期活动等优点,是一种良好的方法。     

La fracture de fatigue du col fémoral chez le sportif d’endurance : l’importance d’un diagnostic précoce

Stress fractures of the femoral neck are rare traumatic events but they are far from being exceptional within the high level sportsmen community and even less rare within the military. The authors report the case of a 19 years old young man enlisted in the French Foreign Legion. He came up with a right femoral neck stress fracture as a result of intense physical exercices. Although painful prodromic signs had been evolving for 15 days, the right diagnosis wasn’t made until the fracture moved to Garden III. The surgical treatment consisted in a reduction with a triple screwing of the femoral neck. One year later, the fracture was set to anatomic position, the hip function was normal and the femoral head showed no signs of osteonecrosis. The patient was then lost for further follow-up. When there has been no slipping, these fractures develop favourably with an ad integrum hip restoration. On the other hand, a secondary slipping leads to a pathology that has to be taken care of in a quite different way, with an often catastrophic outcome at the functional level. Nearly constant prodromic signs come in usefully for an early diagnosis. Secondary slipping of the femoral neck stress fractures should happen less frequently by an appropriate awareness campaign aimed at all the health professionals including sports trainers.     

Avulsion de l’insertion fémorale du ligament croisé antérieur chez un adulte de 20 ans. À propos d’un cas

The cruciate ligament (ACL) injury is known in adults and his surgical treatment is often necessary. In addition, avulsion fracture of the ligament's tibial insertion especially interested. Indeed, only a few cases of avulsion or proximal femoral ACL have been reported and always concerned children. Through this article, the authors describe a rare case of femoral osteochondral avulsion fracture of ACL in a young adult of 20 years which followed a sports accident.     

Syndrome du défilé thoraco-brachial artériel sur sténose de l’artère subclavière droite

Thoracic outlet syndrome is a set of expressions to various clinical conditions. Some imprecision may result, which caused us trouble in a young patient, this condition is no longer considered as preferentially affecting the aging person or athlete traumatized upper extremity. Substantial progress in first line medical imaging examinations are changing, which should guide the practitioner to better respect for maximum safety. Through the case of this young patient, we wanted to deal with a development of the syndrome thoracic outlet.     

Subclavian stents and stent-grafts: cause for concern?

PURPOSE: To report cases of stent and stent-graft fracture in the subclavian vessels. METHODS AND RESULTS: Three patients with self-expanding stents of 3 different types in 1 subclavian artery and 2 subclavian veins presented with recurrent symptoms 6 months to 2 years after stenting. All devices showed signs of compression with stent fracture. The covered stent in the subclavian artery was excised. Of the 2 venous patients, 1 was treated with first rib resection and the other refused further treatment. CONCLUSIONS: The subclavian vessels are prone to flexion during movement, and the vessels may be compressed by external structures, including the clavicle and first rib. Stents that have not been designed to withstand these forces may be damaged.     

Fractures simultanées de la base et du col du cinquième métacarpien. À propos d’une association lésionnelle rare

We report the case of a rare combination of a fracture-dislocation of the base and a neck fracture of the 5th metacarpal, the mechanism was direct, result of a punch in a young sportsman. We made a closed reduction of both fractures with a pinning of the neck of the fifth metacarpal in L according to Vives, and intermetacarpal plinning of the base. Evolution over 12 months was satisfactory.     

Un deuxième métacarpien flottant. À propos d’un cas

We present the case of fracture-dislocation of the second metacarpal and a dislocation of the metacarpophalangeal joint (floating second metacarpal) combined with a fracture of the fourth metacarpal occurred in a 29-year-old man. We report the mechanism of injury and management of this uncommon injury. The “floating second metacarpal” and the third metacarpal fracture were reduced and fixed by percutaneous pinnig. Twelve months later, the patient had a full range of wrist and finger movement and he was pain-free.     

Luxation antérieure de l’épaule associée à une fracture de la diaphyse humérale homolatérale (à propos d’un cas)

The association of shoulder dislocation with ipsilateral humeral shaft fracture remains rare. Is presented along with a review of the literature regarding 18 reported cases. The prognosis depends on that of the shoulder. The authors report a case of shoulder dislocation with ipsilateral humeral shaft fracture at a patient of 34 years an accident of sport (cyclocross). After closed reduction of the anterior shoulder dislocation. The treatment was surgical, required open reduction of the humeral fracture with compression plating. At recession of one year, the clinical examination finds amplitudes comparable to the shoulder controlatéral without instability.     

Fracture de fatigue du sésamoïde tibial. Présentation d’un cas et revue de la littérature

Sesamoids are accessory peripheral bones around the metatarsophalangial joint of the first toe. They are almost constant although some rare congenital absences have been described. They work like a pulley and increase the traction power of muscles during the last stage of the step. Clinical diagnosis of stress fracture is often difficult to establish because different pathologies are usually intertwined. Sensitive elective palpation of the sesamoids, local tumefaction, painful passive metatarsophalangial extension and walk with supination of the forefoot lead to one of the following diagnoses: static or microtraumatic pathologies, osteonecrosis, microcrystalline arthropathy, rheumatoid arthritis, infections, developmental abnormalities, perisesamoidal soft tissue injuries, or even less common etiologies. Radiologic examinations (Guntz view) allow for a precise evaluation of the sesamoid bones. According to the suspected diagnosis, computed tomodensitometry, magnetic resonance or scintigraphy can be performed. The initial treatment is a conservative one; if it is not responsive, surgical treatment can be suggested but usually leads to muscular instability.     

Les complications neurologiques des fractures du bassin. À propos d'une série de 44 cas

In a retrospective study conducted on 44 patients admitted to a rehabilitation centre over a 4-year period with the diagnosis of pelvic fracture, signs of nerve injury as a result of fracture were recorded in 16% of patients. Double vertical fractures or sacral lesions were the most common type. Eighty-five per cent of the patients presented a motor or sensitive peripheral deficit in the lower limbs, simultaneously involving several nerve roots, especially L5-S1. The authors emphasise, in the face of the delayed diagnosis (43% in their study), the interest of a systematic, early neuroperineal examination which must be repeated. If there exists a clinical disturbance, a CT scan of the pelvis, functional explorations (EMG-urodynamic examination) and a myelo CT scan should be associated.     

AO／ASIF锁骨钩钢板治疗锁骨远端骨折和肩锁关节脱位术后的早期功能训练

目的：评估术后早期功能训练对AO／ASIF锁骨钩钢板治疗锁骨远端骨折和肩锁关节脱位的疗效。 方法：18例锁骨远端骨折和肩锁关节脱位的患者采用AO／ASIF锁骨钩钢板联合术后早期功能训练；对照组16例仅采用常规的AO／ASIF锁骨钩钢板手术治疗。分别于术后14d和术后半年对患者的疗效进行评定。结果：术后14d，早期行功能训练患者疗效明显优于单纯手术患者．患肩活动范围的改善程度也明显优于单纯手术患者：术后半年．虽然两组疗效差异无显著性意义，但早期行功能训练患者患肩外展上举范围仍较单纯手术患者有明显的改善。结论：AO／ASIF锁骨钩钢板术后早期功能训练是治疗锁骨远端骨折和肩锁关节脱位的有效方法．患者症状缓解更快。