Delayed thrombosis of all upper limb arteries following closed posterior elbow dislocation: Case report

A rare case of delayed thrombosis of all upper limb arteries following closed posterior elbow dislocation has been reported in  a case reported in journal of American College of Emergency Physicians (JACEP Open)

Hamid Ilyas et al have presented an interesting case of delayed extensive thrombosis of upper limb arteries (axillary, brachial, radial, and ulnar arteries) that developed after 2weeks of posterior elbow dislocation managed by surgical thrombectomy.

The elbow is one of the most common large joints dislocated with an incidence of 5.21/100,000/year in the United States, predominantly in men and young adolescents. More than 90% of the affected elbows are posteriorly dislocated, with 54% involving a fracture as well. There are only a few cases reported of elbow dislocation complicated with brachial artery thrombosis.

A 48-year-old male presented to the emergency department (ED) with a complaint of severe left elbow pain after he slipped on a wet floor and fell on his outstretched left hand. Significant blunt trauma in the same joint as well as the right foot occurred about four weeks ago as well when he did not present to any hospital.

Physical examination revealed a visible deformity and swelling of ≈2 × 2 cm2 at the posterior aspect of the left elbow, along with tenderness over the olecranon process and medial valgus instability. Extension at the elbow joint was restricted to almost 20– 30◦C. Distal neurovascular status was reassuring with normal, palpable, and comparable bilateral radial and ulnar pulses with no radioradial delay and normal sensations over the respective areas.

An x-ray revealed a posteriorly dislocated left elbow joint with adjacent bony fragments. In view of this radiological evidence, an orthopedic surgeon was consulted for possible open reduction and internal fixation of the complex elbow dislocation. After a detailed discussion and the patient's history of an unattended old elbow trauma, a mutual decision was made to attempt a closed reduction initially. A closed elbow reduction was performed in the ED under sedation with 200 mg of propofol with a reassuring postreduction x-ray.

Examination after the reduction also revealed an acceptable range of motion along with normal neurovascular status. After immobilizing the elbow joint with a posterior long arm splint, the patient was discharged with instructions and was referred to the orthopedic outpatient department for followup after 2 weeks.

He returned to the ED on the 17th day after discharge with symptoms of gradual onset of pain in his left forearm. A mild pain started 5 days earlier, rated as 2/10 on a numerical rating scale of pain from 0–10, with 0 indicating no pain and 10 indicating the worst pain ever experienced. To relieve his pain, he removed his posterior long arm splint on his own. Despite removal of the splint, the pain intensified to as high as 8/10 on the day of presentation to the ED.

His heart rate, blood pressure, respiratory rate, and temperature were 74 bpm, 137/93 mmHg, 18 breaths/minute, and 36.6◦C, respectively. Physical examination revealed a cold, tender left forearm with non-palpable radial, ulnar, and brachial arteries compared with the right side. Capillary refill time (CRFT) was delayed (about 5 seconds) in the left arm, which was <2 seconds on the right side. Otherwise, there had been no obvious swelling, discoloration, or motor or sensory impairment in either of the limbs.

There was no audible blood flow in the left brachial, radial, or ulnar arteries during bedside Doppler ultrasonography. A computed tomography (CT) angiography revealed a blockage of almost the entire length of the brachial artery, spanning about 21 cm,with opacification of both the radial and ulnar arteries. CT also demonstrated a non-displaced fracture of the coronoid process of the left ulna as was evident in the initial x-ray. After that, a conventional angiography replicated the same findings and revealed a complete occlusion of the left axillary artery with perfusion of the upper limb by the collaterals.

A heparin infusion was started at a rate of 16 units/Kg per minute, and the patient was admitted to the vascular surgery department.

During his hospital stay, the patient was investigated extensively

for thrombophilia. All of the results, except protein S level, came back normal. The protein S level was low (33.2%), which was expected because of the acute thrombosis.

On the third day of his stay, he had a left brachial artery exploration and thrombectomy as well as a left subclavian artery angioplasty. Perfusion of the affected limb improved significantly after surgery, with palpable radial and ulnar arteries, normal CRFT, and better pain control. The patient was discharged on the sixth postoperative day on oral anticoagulants (OAC) with a target international normalized ratio of 2–3.

On 2weeks follow up no postoperative complications were observed. There was no evidence of induced thrombosis.

The authors opined that this patient presented very late despite an extensive thrombosis starting from the proximal axially artery all the way down to the proximal ulnar and radial arteries. This could be because the radial recurrent artery, superior and inferior ulnar collateral arteries, middle and radial collateral arteries, anterior and posterior ulnar recurrent arteries, and anterior and posterior interosseous arteries form a rich anastomosis around the elbow joint, providing excellent collateral circulation.

The authors concluded that brachial artery thrombosis is a rare but devastating complication of elbow joint dislocation. As there is multiple convincing evidence that patients might be asymptomatic with brachial artery thrombosis; a proper and repeated physical examination along with bedside Doppler ultrasound is warranted in all cases of joint dislocations in the ED as well as in outpatient follow-up.

Further reading :

Delayed thrombosis of all upper limb arteries: A rare complication in the closed posterior elbow dislocation in the emergency department.

Hamid Ilyas MBBS Muhammad Abd Ur Rehman MBBS Hina AkramMBBS

https://doi.org/10.1002/emp2.12612