Krasnici et al. Patient Safety in Surgery 2013, 7:24http://www.pssjournal.com/content/7/1/24

SHORT REPORT Open Access

Fracture of the shoulder girdle in multiply injuredpatients - an imperative for a high level ofsuspicion for associated neurovascular injuriesSenat Krasnici*, Jörg Schmidt, Kolja Reimann, Wolfgang Ertel and Tobias Topp

Abstract

Background: The combination of a bony injury to the shoulder girdle and damage to the brachial plexus and thesubclavian vessels is a rare finding. The cases of this combined injury pattern described in the literature are mostnotably reported in multiply-injured patients after high velocity trauma.

Findings: Three cases were admitted to our hospital after motorcycle accidents resulting in a combination ofsevere bony injuries to the shoulder girdle, to the subclavian artery and a lesion to the brachial plexus. Based onthese three clinical cases the patterns of injury, as well as primary and secondary treatment approaches arepresented.

Conclusion: The early detection of these injuries can be difficult in given acute, life threatening injuries addressedfirst in these multiply injured patients. A high level of suspicion, in conjunction with standardized ATLS basedinstitutional protocols for secondary and tertiary survey, should increase the likelihood of a timely detection andearly management of these rare but potentially devastating injuries.

Keywords: Clavicle fractures, Scaphulothoracic dissociation, Multiply-injured patients, Associated injuries, Brachialplexus, Subclavian artery

BackgroundFractures of the shoulder girdle accompanied with vas-cular and plexus injuries are infrequent but can have apotentially devastating outcome. Injuries to the brachialplexus are either caused by distraction injuries as seen inscaphulothoracic injuries or direct injuries to the trunks,cords and nerves. Injuries to the brachial plexus occur inapproximately 5% of polytrauma patients involved inmotorcycle crashes [1]. Distraction injuries with definiteand unrecoverable neurological deficits are caused byroot avulsions, where the rootlets are torn out of thespinal cord. In contrast postganglionic stretch injuries orruptures show a better prognosis [2,3]. Brachial plexusinjuries are associated with a 10%–25% incidence ofarterial injury [2]. These injuries may lead to life threaten-ing bleedings in multiply injured patients and causehemodynamic instability. Both, the detection and treatment

* Correspondence: senat.krasnici@charite.deDepartment of Orthopaedic and Reconstructive Surgery, Charité UniversityMedicine Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12003Berlin, Germany

© 2013 Krasnici et al.; licensee BioMed CentralCommons Attribution License (http://creativecreproduction in any medium, provided the or

of an acute arterial injury as well as the treatmentof plexus injuries have to be integrated in treatment algo-rithms for polytrauma patients. Over a period of sixmonths, three patients were admitted to our hospital aftermotorcycle accidents resulting in a combination of injuriesto the bony shoulder girdle, the subclavian artery and bra-chial plexus. Based on these three clinical cases the injurypatterns, as well as treatment approaches are presented.

Case presentationCase IA multiply-injured (ISS 35) seventeen-year-old man whowas involved to a motorcycle accident was admitted toour emergency department after in the field intubation.The initial trauma management in our institution wasperformed according to ATLS guidelines with chest x-ray,pelvic a.-p.-view and a focused ultrasound assessmentfor trauma (FAST). Radiographs showed a displaced frac-ture of the left clavicle, a femoral fracture and ahemothorax with consequent hemodynamic deterioration.An emergency thoracotomy was performed to control

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haemorrhage. During the thoracotomy, several deep rup-tures of the lung in segment 9 and 10 were identified asbleeding sources and could be stopped. No major vesselswere injured, a clamping was not necessary. The femurfracture was stabilized by external fixation according todamage control rules in multiply-injured patients. Aftersurgery, a motoric dysfunction and complete loss of sensa-tion in the patients left arm was found. In the subse-quently performed MRI scan a disruption of the roots ofthe brachial plexus was seen (Figure 1). The definitiveosteosynthesis of the femoral and clavicle fractures wasperformed 8 days after trauma. One month after traumathe patient was transferred to a neurosurgical clinic forfurther treatment. In two steps, extra-plexular neuro-tizations, transferring spinal accessory nerve to thesuprascapular nerve and transferring the intercostal nervesIII and IV to the musculocutaneous nerve were per-formed. The patient was followed up 18 months aftertrauma. After this period the clavicle and the femoral frac-ture healed and a removal of the intramedullary femur nailwas performed. An active abduction of the arm up to 30°could be reached. The muscle strength of the biceps wasM2 (contraction with gravity eliminated) using the BritishMedical Research Council Grading System (M0-5).

Case IIA thirty one-year-old man (ISS 41) was admitted to ouremergency department following a motorcycle accident.On admission he was alert and oriented. Primary surveyyielded tachycardia and a massive hematoma of the leftshoulder. Focused examination of the left upper limb re-vealed paralysis of the entire arm with the radial pulse nei-ther being palpable nor traceable by Doppler ultrasound.Chest x-ray showed a fracture of the left clavicle. Thepatient was emergently taken to the operating room,where the suspicion of a ruptured subclavian artery wasconfirmed. A vessel repair using an interpositional PTFE

Figure 1 MRI of infraclavicular level. Abnormal exposure of theright brachial plexus, indicating a partial injury.

graft between the subclavian and the axillary artery wasperformed. In addition a complete brachial plexus avulsionwas found. The displaced fracture of the clavicle was sim-ultaneously fixed by plating. Femoral fractures on bothsides and a tibial fracture on the left side were treated byexternal fixation. Definitive osteosynthesis was done10 days after trauma. In addition, the CT scan performedafter emergency surgery showed a subdural haematoma,and a pneumothorax. The patient was transferred to aneurosurgical clinic 7 weeks after trauma for the recon-struction of the plexus injury. A neurotization from thespinal accessory nerve to the musculocunaeous nerveusing a suralis nerve graft and a neurotization using thephrenic nerve to the musculocutaneous nerve wasperformed. The last follow up was 1 year after trauma, thepatient still showed a complete loss of function of the leftarm. The strength of the biceps muscle was only M1 (fas-ciculations observed in the muscle).

Case IIIA thirty two-year-old male (ISS 43) who suffered a motor-cycle accident, primary trauma survey yielded a pulmon-ary contusion and left scapular body fracture. Immediateintubation of the patient in the emergency room due torespiratory insufficiency was performed. Subsequent CTscan confirmed a massive contusion of the lung and re-vealed an active extravasation of contrast agent at the levelof the left shoulder (Figures 2 and 3). Clinically, pulse-lessness of the left arm was realized whilst the hemo-dynamic condition had deteriorated. An emergencyvascular intervention was performed to bypass the rup-tured subclavian artery to the brachial artery using a ven-ous graft. A rupture of the plexus could not be detected.Postoperatively, the conscious patient perceived a com-plete palsy of the left arm. MRI scans showed no pregan-glionic lesions but postganlionic fraying from C6 to C8and a complete rupture of all truncs with a surrounding

Figure 2 Polytrauma CT scan. Extravasation of contrast agent inleft subclavian artery indicating rupture.

Figure 3 CT-3D-reconstruction of shoulder girdle. Visualization ofdisplaced scapula fracture on the left side. Note also the extravasationof contrast agent and the missing presentment of the ipsilateralsubclavian artery.

regularpulse status /

API > 0,9

Dysvascular limb / API <0,9

computertomography + contrast agent

extravasation ofcontrast agent

no extravasation ofcontrast agent

subsidiary MRICT-myelography

vessel repair

microsurgical repair (< 6 months)

plexus lesion

partial or globalneurological deficit

noneurological deficit

secondarysurvey

„stable hemodynamics“a

regularpulse status /

Dysvascular limb / API <0,9

„unstable hemodynamics“

controlof thoracic, abdominal and pelvic hemorrhage

persistenthemodynamic instability

stablehemodynamics

b

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edema (Figure 4). Electromyography showed a severeaxonal lesion of the whole plexus with a complete loss offunction. The scapular fracture was treated by conserva-tive immobilization. Six weeks after the accident the pa-tient was admitted to a neurosurgical clinic for furthertreatment. A neurotization of the musculocutaneous nerveusing the intercostal nerves III and IV was performed. Inaddition the intercostal nerves V and VI were transferredto the forearm using the superficial branch of the radialnerve as a graft. This was done to prepare a gracilis trans-fer in case of sufficient innervation of the graft. Thepatient was lost to follow up.

DiscussionInjuries of the brachial plexus and subclavian vessels canbe associated with bony injuries of the shoulder girdle.They are found in approximately 5% of polytrauma pa-tients suffering a motorcycle accident [1]. Zelle et al. pub-lished a study presenting long term outcomes after

Figure 4 MRI of left shoulder girdle. Tear of the left brachial plexus.

API > 0,9

subsidiary MRI

microsurgical repair ( < 6 months)

plexus lesion

vessel repairsecondary surveyICU

Figure 5 Algorithm for the management of injuries to thesubclavian vessels and brachial plexus in multiply-injuredpatients in hemodynamically stable (a) and unstable (b)condition. (API = Arterial Pressure Index).

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scapulothoracic dissociations. 25 patients were includedto the study over a period of 24 years. Poor functionaloutcome after complete plexus lesions was found [4].Even with modern reconstruction techniques providingfar greater restoration than was possible a few years ago,sequelae such as persistent neurological deficits or func-tional loss of the entire arm and even unbearable neuro-pathic pain can cause patients to request for amputation.Acute plexus injuries originate from a torsion-distraction

-like movement to the upper extremity in which the headand neck distends away from the ipsilateral shoulder orfrom hyperextension-distraction injuries of the upper limb,as seen in the three high velocity motorcycle accident casespresented above. Rupture or incomplete tear of subclavianvessels can account for hemodynamic instability, alongwith bleeding into large body cavities. In sedated or un-conscious patients, the inability to adequately examine thenervous system of the upper extremity challenges the ini-tial evaluation. To detect and treat these life-threateninginjuries during the primary trauma survey, strict adher-ence to ATLS based algorithms is essential. As presentedin case I and II, in hemodynamic unstable patients, emer-gent surgical treatment to establish haemostasis may pre-cede a trauma CT scan. In Case II and III the injuredextremity was pulseless. Patients with severe extremitytrauma and suspected arterial injury should undergo im-mediate surgery if hard signs like: pulsatile bleeding,expanding hematoma, palpable thrill and audible bruit arepresent [5,6]. Literature validated the use of ankle brachialor arterial pulse indexes (ABI and API respectively), whichwere shown to reliably detect arterial injury to a limb andare easily performed in the Emergency room [5,7]. Inhemodynamic stable patients (Case III) a CT scan (includ-ing ateriography) can be indicated as part of the primarysurvey th detect the exact location of the bleeding.Further diagnostics such as MRI scans can be performed

during secondary survey in the hemodynamic stable pa-tient. Once a neurological deficit of the upper extremity isdetected, an MRI scan is indicated, even if the lesion ofthe brachial plexus has been defined within the context ofsurgery, e.g. for an active bleeding. While clinical examin-ation is the gold standard, the knowledge of the extendand the exact localization of the lesion as seen in MRI im-aging can aid in the concerted planning of further treat-ment options. The current gold standard imaging forevaluation of root-level injuries is computed tomographywith myelography [2]. The development of a pseudo-meningoceles, 3–4 weeks after injury highly indicates aroot avulsion [2,8]. There is no general agreement on thetiming for treatment of injuries of the plexus. Penetratinginjuries are indications for immediate or early explorationonce the patient is stable and, if possible, direct end-to-end repair. The early functional reconstruction in the firstmonths is recommended when there is a high suspicion of

root avulsion [9]. Given the chance in treatment protocolsin the last decade in favour of local nerve transfers manyauthors recommend this approach in root avulsions iftransfer options remain, when the patient has recoveredfrom the early trauma aftermath. These nerve transfersare done outside the zone of injury and tedious dissectionof scarred plexal anatomy can be avoided. This is in con-trast to direct reconstruction of postganglionic plexus in-juries, where one needs to explore the injured regiondirectly. Here an early surgical exploration before the de-velopment of scar and neuroma may allow an easier ex-ploration and identification if injured structures [2,9]. Inmultiple injured patients with concomitant severe injuriesan earlier exploration or reconstruction is often not pos-sible. In these cases surgical exploration is recommended3–6 months after trauma, if no signs of reinnervation arefound in clinical exam and electroneurographic studies[2]. Figure 5 provides an algorithm for the management ofthese injuries in multiply-injured patients with stable (a)and unstable hemodynamics (b) (Figure 5).

ConclusionIn high speed complex injuries of the shoulder girdle,one must always suspect and actively rule out combinedinjuries to the brachial plexus and the axillary or sub-clavian vessels.

Competing interestsThe authors declare that they have no competing interests.

Authors’ contributionsSK conceived the study, drafted and reviewed the manuscript. JSparticipated in study design, coordination and manuscript drafting. KRparticipated in data aquisition. TT was involved in drafting and revising themanuscript and gave final approval together with WE. All authors read andapproved the final manuscript.

Received: 1 March 2013 Accepted: 24 June 2013Published: 7 July 2013

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doi:10.1186/1754-9493-7-24Cite this article as: Krasnici et al.: Fracture of the shoulder girdle inmultiply injured patients - an imperative for a high level of suspicion forassociated neurovascular injuries. Patient Safety in Surgery 2013 7:24.

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