Acute subclavian artery pseudoaneurysm after closed fracture of the clavicle

A sixty-year-old woman was admitted with an acute subclavian artery pseudoaneurysm after a closed fracture of the middle third of the right clavicle. This manifested itself a few days after the injury as a slowly growing, pulsatile and purple tumour-like mass in the right supraclavicular fossa. The distal pulses were normal, but this observation does not exclude a vascular trauma. This is an uncommon but potentially dangerous complication as it jeopardizes both the extremity and the life of the patient.     

A low energy paediatric clavicle fracture associated with acute brachial plexus injury and subclavian artery compression

Paediatric clavicle fractures are common injuries presenting to orthopaedic surgeons. The majority of these represent midshaft low energy fractures, which in the vast majority of cases are treated non-operatively and recover rapidly. The main indications to consider operative intervention include high energy of injury, >2cm shortening, open fractures and associated vascular or neurological injuries. Brachial plexus (BP) injuries are uncommon with variable outcomes. They often result from high energy motorcycle related accidents with potentially fatal associated injuries such as vascular disruption. Their management is complex, requiring expertise, and they are therefore usually managed in supraregional centres.We present a unique case of a low energy midshaft clavicle fracture in a paediatric patient in whom there was an acute BP injury and subclavian artery compression that has not been described previously.     

Endovascular treatment of acute subclavian pseudo-aneurysm after fracture of the clavicle

Pseudo-aneurysms of the subclavian artery remain a rare complication after fracture of the clavicle. Nerve compression has been described with delayed paralysis as a consequence. We report a case of delayed diagnosis of a subclavian pseudo-aneurysm after a closed fracture of the clavicle in a 93-year-old patient. Diagnosis was confirmed by ultrasound and multi-slice-Ct. Two attempts to treat the pseudo-aneurysm with percutaneous thrombin injection failed. Considering the age of the patient, it was decided to exclude the pseudo-aneurysm by endovascular approach. A Hemobahn endoprosthesis was inserted by the introduction of an 11F sheath after cutting down the brachial artery under local anaesthesia. Angiography revealed complete exclusion of the pseudo-aneurysm. Follow-up at 9 months by ultrasound confirmed exclusion of the pseudo-aneurysm. Plain X-ray of the endograft showed no stent fractures. Paresis of the arm had improved. This case illustrates that endovascular exclusion is a safe approach, with reduced morbidity, compared with open surgery. Concern about stent deformation and stent fractures has been expressed. With the introduction of highly flexible stents, one can hope that this complication is less likely to occur. Although follow-up is relatively short, we believe that endovascular exclusion of subclavian pseudo-aneurysms is preferable to a surgical approach.     

Interrupted left aortic arch and isolated right subclavian artery from the right pulmonary artery

We report a 10-day-old newborn, weighing 2.9 kg with an interrupted left aortic arch type B, a large subarterial ventricular septal defect and a right ductus connecting the right pulmonary artery to an isolated right subclavian artery. The patient underwent successful total surgical repair and the isolated right subclavian artery was ligated. He was discharged from hospital without complication and maintains excellent perfusion to the right arm via collaterals.     

Iatrogenic subclavian arteriovenous fistula: rare complication of plate osteosynthesis of clavicle fracture

Iatrogenic subclavian arteriovenous fistula is rare and has not been reported as a complication of plate osteosynthesis of clavicle fracture. This article describes the first case of iatrogenic subclavian arteriovenous fistula caused by plate osteosynthesis. A 36-year-old man sustained a right middle clavicle fracture in an injury and underwent open reduction and internal fixation with clavicular compression plate 3 days later in a local hospital. On the second postoperative day, a pulsatile mass and thrill were detected at the right supraclavicular region. The patient was discharged 3 days postoperatively with no extra inspection. Three months later, he was admitted to our institution because the mass was getting bigger and weakness was felt in his right upper limb. Digital subtraction angiography confirmed a subclavian arteriovenous fistula. Vascular surgeons treated the patient successfully using endovascular techniques. The subclavian arteriovenous fistula was eliminated with a fully expanded stent graft, and the plate was removed simultaneously. The result was satisfactory, and the postoperative course was uneventful. This case demonstrated that subclavian arteriovenous fistula could be an iatrogenic complication of screw-and-plate osteosynthesis of clavicle fracture. The operative manipulation in the process of fracture reduction and hole drilling should be meticulous, and the screw length must be accurate. Orthopedic surgeons should be aware of this uncommon complication with plate osteosynthesis of clavicle fracture. We recommend using an endovascular surgical technique for treatment of this complication.     

Traumatic aortic transection in a child with an anomalous right subclavian artery

We describe a child who presented with a traumatic aortic transection in the setting of anomalous origin of the right subclavian artery. This abnormal arch anatomy may influence the diagnosis, anatomic location, and technique of surgical repair of the injury.     

Fatal fat embolism following an isolated vertebral fracture

The authors report an unusual case of a fat embolism following an isolated lumbar vertebra wedge fracture. A 66-year-old gentleman sustained a lumbar wedge fracture following a fall. During routine mobilisation some days later he collapsed suddenly and became unresponsive. Shortly after, he suffered a fatal cardiac arrest. A post-mortem was performed which attributed the cause of death to fat embolism. Most previously reported cases of fat embolism are associated with long bone fractures and major bony surgery. No apparent case of fatal fat embolism following an isolated vertebral fracture has previously been described.     

Total mediastinal traverse with isolated internal mammary artery transection

Transmediastinal gunshot wounds are infrequent but life-threatening injuries. The course of the projectile and the bullet track often is unpredictable. Prompt and specific diagnostic and therapeutic interventions are necessary to quickly identify and repair potentially life-threatening injuries to the heart, great vessels, and the aerodigestive tract. Multiple diagnostic algorithms exist for work-up of these injuries, and the therapeutic interventions are diverse and challenging. We describe a patient with total mediastinal traverse, who presented with right-sided hemopneumothorax. The work-up revealed surprisingly an isolated left internal mammary artery transection with a significant hemorrhage that mandated surgical intervention in left chest.     

Bipolar segmental clavicle fracture

We present a case of a combined medial and lateral segmental clavicle fracture. Open reduction and internal fixation of both fractures was performed with a return to full activities. Combined medial and lateral fractures of the clavicle are exceptionally rare. The relevant medical literature and treatment of this injury is discussed.