Delayed diagnosis of a ruptured brachial artery after posterior dislocation of the elbow

hjury Vol. 29, No. 5, pp. 390-392, 1998 0 1998 Elsevier Science Ltd. All rights reserved Printed in Great Britain 0020.1383/98

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Delayed diagnosis of a ruptured brachial after posterior dislocation of the elbow H. Eijer’, F. T. Ballmerl,

artery

H. B. Ris’ and R. Hertel’

Departments of ‘Orthopaedic Surgery and 2Vascular Surgery, University Switzerland

Hospital,

Inselspital,

3010 Berne,

Injury, Vol. 29, No. 5, 390-392, 1998

Introduction Traumatic rupture of the brachial artery is a known complication following posterior dislocation of the elbow. It is mainly found in young adults and in children’“. Both intimal lesions and complete ruptures of the artery have been reported. Review articles describe this complication to be rare and serious’,-‘. Even after appropriate operative treatment of the arterial lesion and the dislocation, important sequelae have been reported”. We describe a patient who sustained a posterior dislocation of the elbow associated with a complete rupture of the brachial artery. Interposition of a long saphenous vein graft followed by reconstruction of the medial collateral ligament of the elbow resulted in a satisfactory

outcome

despite a delay in diagnosis

of more than

24 h.

Case report An 18year-old right-handed student fell onto his left elbow while snowboarding. He describeda popping sensationin his elbow during the impact. Clinical and radiographic examination in a local casualty department revealed normal alignment of the elbow without bony lesions.The next day the arm was so swollen that he presented to another casualty department from where he was referred to us. On admissionthe patient complained of numbness in the thumb and the index finger. Clinically a gross swelling of the elbow and decreasedskin temperature of the forearm were noted. Elbow motion was reduced owing to pain and swelling. A strong radial pulse was palpable. Two-point discrimination was reduced on the thumb and the index finger. There was no weaknessin the muscles innervated by the ulnar, radial or median nerve. Repeated

(4

conventional X-rays of the elbow made in our institution showed no dislocation or subluxation (Figure 1). Angio-

graphy revealed an occlusion of the brachial artery 3 cm proximal to the elbow joint (Figure 2). A dislocation-related rupture of the brachial artery was therefore suspected. At operation on the same day a complete rupture of the artery was confirmed. Blood flow to the forearm was

(b) 3. Conventional AP (a) and lateral (b) X-rays taken more than 24h after the initial injury. No dislocation or bony lesions can be seen. Figure

Case reports

Figure 2. Angiography reveals occlusion stem arteries in the forearm.

of the brachial

artery 3 cm proximally

restored by interposition of a reversed long saphenous vein. The elbow was found to be grossly unstable on the medial side. The origin of the medial collateral ligament complex (MCLC) and the flexor pronator unit (FPU) were avulsed from the medial epicondyle. They were reinserted using four bone anchors and non-resorbable sutures. Through a subtotal rupture of the brachial muscle and the anterior joint capsule, small chondral lesions of the trochlea were identified and debrided. The median nerve was found to be intact. Postoperatively, a protective splint was applied to the elbow and the patient was heparinised. Gentle 70-110” flexion was allowed out of the splint. He was discharged

Figure 3. Excellent motion 4 months flexion/extension of 130-15-O.

postoperatively

with

to the elbow

joint

with visualisation

of the

7 days after admission with a well perfused arm and intact sensibility. The splint was completely removed 6 weeks postoperatively. At follow-up after 4 months he had an excellent motion of the elbow with flexion/extension of and full pronation and supination. The 130-15-O (Fipw3) patency of the graft was verified with Doppler sonography.

Discussion Complex lesions of the elbow are found in 29 per cent of all elbow fractures”. Of these, 25 per cent are complicated by arterial lesions, mostly of the brachial artery’. Dislocations are not frequently associated with arterial lesions and only a few dozen are reported in the literature’. Injuries of the brachial artery are described as serious injuries requiring immediate repair’,‘. Delay of more than 4 h is related to poor outcome”. The rupture of the brachial artery in this patient must have been caused by a closed posterior dislocation of the elbow that reduced spontaneously. Symptoms of the dislocation were few. The medial instability of the joint could not be diagnosed because of the large haematoma and pain. The arterial rupture was not diagnosed initially because the radial pulse was palpable. Excessive swelling was the major sign that made the patient return to a casualty department. On careful examination the findings of a decreased skin temperature and numbness of the thumb and the index finger also rose suspicion about the severity of the injury. This latter must have been caused by compression of or

392

Injury:

International

traction on the median nerve, which accompanies the brachial artery at the site of the rupture. The arterial injury was diagnosed more than 24 h after the initial injury. Frequently, blunt trauma will damage the intima layer of a vessel leaving the adventitia intact. This may result in an initially intact circulation with insidious deterioration of the limb perfusion several hours after the injury owing to formation of intimal lesionrelated thrombosis. Obviously, this was not the case in our patient, since a frank complete rupture of the brachial artery was found. Sufficient circulation of the forearm and hand was therefore related to the well-functioning collateral circulation (Figure 2)‘.‘. The diagnosis of an injury of the brachial artery following posterior dislocation of the elbow may not be easy. A dislocation may have reduced spontaneously and instability may be hidden. An arterial lesion may not result in typical symptoms of acute ischaemia and a palpable radial pulse does not exclude an injury of the brachial artery. Therefore, any casualty officer should know about this possible pitfall and rely on angiography in case of suspicion.

References 1 Manouel M., Minkowitz B., Shimotsu G., Haq I. and Feliccia J. Brachial artery laceration with closed posterior

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5

6

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Journal

of the Care of the Injured

Vol. 29, No. 5,1998

dislocation in an eight year old. C/ill. Outhu,t~. Rcl. RL’s. 1993; 296: 109. Schaefer W. W. and Voight S. J. Rupture of the brachial artery from closed posterior dislocation of the elbow in a wrestler. Orthopedics 1993;16(i’): 820. Seidman G. D. and Koerner P. A. Brachial artery rupture associated with closed posterior elbow dislocation: a case report and review of the literature. 1. 7’ra~r~ 1995; 38(2): 318. Slowik G. M., Fitzimmons M. and Rayhack J. M. Closed elbow dislocation and brachial artery damage. /. Outhop. Tramza 1993; 7(6): 558. Regel G., Seekamp M., Blauth M., Klemme R., Kuhn K. and Tscherne H. Die Komplexverletzung des Ellbogengelenks. U~$dlchirurg 1996; 99: 92. Bongard F. S., White G. H. and Klein S. R. Management strategy of complex extremity injuries. Am. 1. Sur$. 1989; 158: 151. Kerin R. Elbow dislocation and its association with vascular disruption. J. Bone It Surg. A 1969; 51A: 756. Louis D. S., Ricciardi J. E. and Spengler D. M. Arterial injury: a complication of posterior elbow dislocations: a clinical and anatomical study. J. &oile Jt S~Q. A 1974; 56A: 1331.

Paper

accepted

20 January

1998.

Rc~wsts for rc~virlts sh~/d bc addressed to: Dr H. Eijer, University Hospital, Inselspital, 3010 Berne, Switzerland.