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Treatment of combined brachial plexus and subclavian artery trauma
Injury (1993) 24, (6) 377-379
printed in Great Brifuin
377
Treatment of combined brachial plexus and subclavian artery trauma I. E. Hawthorn, J. Rochester and J. D. Beard Vascular Surgical Unit, Royal Hallamshire
Hospital, Sheffield, UK
Five cases of combined brachial plexus root am&on and subclavian artey trauma are presented. A policy of preoperative myelography and minimal vascular reconsfmcfion in the presence of roof disruption is discussed.
Introduction Injuries to the shoulder region or to an outstretched arm causing brachial plexus disruption are a common consequence of modem high-speed road traffic accidents. Over 70 per cent of such injuries follow road accidents (Narakas, 1978). Damage to the nerves is due either to direct laceration from fractured bone or by a crushing injury between clavicle and first rib. The other mechanism of injury is by stretching of the nerves during hyperextension (Birch, 1984). Associated significant chest injuries occur in 10 per cent of patients (Sturm and Perry, 1987). These include multiple rib fractures including the first rib, flail chest, pulmonary contusion, and haemopneumothorax. Upper extremity arterial injuries occur in at least 12 per cent of patients who sustain brachial plexus trauma (Sturm and Perry, 1987). The majority of these vascular injuries involve the distal subclavian artery or the proximal axillary artery. Mechanisms of injury are laceration, avulsion or more commonly intimal disruption causing vessel occlusion. Previous authors have suggested that exploration and vascular reconstruction is mandatory in all these injuries (Batey and Makin, 1982; Tomaszeck, 1984). We disagree with this principle and describe five cases of combined brachial plexus root and subclavian artery injury which illustrate our philosophy.
Case reports
had been avulsed at the roots and was seen to be lying freely in the superior part of the wound. Pulses were restored to the limb but no function was regained and an above-elbow amputation was performed 4 months later at the request of the patient.
CU.92 A 24-year-old male pedestrian was injured by a motor vehicle. Injuries sustained included head injury, fracture of the right radius and ulna and a fractured right tibia1 plateau. There was also a fractured right clavicle and scapula with fractures of the transverse process of C6 and C7. The right arm was pulseless and a haematoma was forming over the anterior right shoulder region. An arteriogram revealed a complete obstruction of the subclavian artery with refilling of the axillary artery distally. Exploration confirmed a venous tear causing the haematoma and the subclavian occlusion was bypassed using an S-mm Dacron graft. Further dissection revealed brachial plexus avulsion at the roots. No useful function was returned to the limb although pulses were restored. Case 3 A 21-year-old male motorcyclist was involved in a road traffic accident sustaining right clavicular, scapular and rib fractures and a haemopneumothorax. He also suffered a fractured distal radius, fractured scaphoid and a capsular haematoma of the right kidney. The right arm was paralysed and pulseless but warm and pink with reasonable capillary filling. Cervical myelography confirmed avulsion of the C8 and T1 roots. Because of the gross disruption at this level contrast did not reach the higher cervical pockets to confirm whether they too had been avulsed. No surgical procedure was performed for the vascular injury. There has been no return of function although some sensation has returned to the upper arm, and despite remaining pulseless the hand is well perfused.
Case 1
A 72-year-old man was struck on the left shoulder by the wing mirror of a petrol tanker on a narrow village street. The arm was pulseless and paralysed. An on-table arteriogram revealed an
occlusion of the subclavian artery. Proximal control of the subclavian artery was gained through a left thoracotomy and an intimal tear of the distal subclavian artery was confirmed by a supraclavicular approach. This section of vessel was excised and replaced by a Dacron graft. During the dissection it became clear that the brachial plexus 0 1993 Butterworth-Heinemann 0020-1383/93/060377-03
Ltd
Case 4 An lb-year-old female motorcyclist fell off at speed fracturing the right radius and ulna. She was also found to have a pulseless, paralysed arm which was warm and pink and reasonably well perfused. The forearm fracture was treated by open reduction, internal fixation and bone grafting and a cervical myelogram was performed. This confirmed brachial plexus nerve root avulsions at C7, C8 and TI (Figure I).
378
Injury: InternationalJournalof the Care of the Injured(1993) Vol. 24/No. 6
In view of the good limb perfusion and closed vessel injury emergency exploration was not undertaken. The brachial plexus was explored on day 4. The C5, C6 and C7 roots were noted to be avulsed from the cord and the CS and Tl roots were much attenuated. As the circulation to the limb was not critical arterial repair was not undertaken.
Discussion
Figure 1. Cervical myelogram (Case 4) demonstrating the C7, C8 and Tl root avulsions with pooling of contrast in the supraclavicular fossa.
No vascular procedure was performed for the subclavian disruption and the arm remains pulseless but well perfused and paralysed. Case 5
A 52-year-old
man was injured in a motor vehicle accident as a driver of a car. His main injuries were to the left chest and shoulder and he reported to the ambulance crew at the scene that he could not move or feel his left upper limb. Shortly after admission he was paralysed, intubated and ventilated, preventing further neurological assessment of his arm. The left brachial pulse was noted to be absent, although his forearm and hand were warm and pink with good capillary return. Chest radiograph (CR) revealed dislocation of both ends of fhe clavicle and fractures of the left first to eighth ribs. Arch aortography was prompted by the suggestion of a widening mediastinum. Intra-arterial digital subfraction arch aortography showed no major vessel injury but an occluded left subclavian artery at the level of the first rib with good collaterals.
The acute management of patients with multiple injury is challenging and a multidisciplinary approach is beneficial. Combined brachial plexus and major vessel injuries require early involvement of a specialist in brachial plexus trauma and a vascular surgeon in addition to those concerned with the concomitant injuries. Preganglionic injuries of the brachial plexus, in which the spinal roots are avulsed from the spinal cord, are irreparable (Narakas, 1978; Bonney, 1983). A limb having suffered the insult of a brachial plexus root disruption will remain permanently paralysed. Tomaszek (1984) reported on four patients with bra&al plexus trauma and arterial disruption, of whom three underwent vascular reconstruction with return of function in none. Batey and Makin (1982) reported on eight patients with similar injuries; only two limbs regained any useful function but seven had undergone vascular reconstruction. Clearly a predictive test of longterm outcome would be of value in determining acute management and the avoidance of unnecessary vascular intervention. Our experience is that the injured limb remains viable with acceptable perfusion despite arterial occlusion. This is attributable to the good collateral circulation around the shoulder and the ‘autosympathectomy’ which occurs after the cervical root avulsion. Considering the poor prognosis after root disruption and the non-critical nature of the arterial ir,jury, our policy is to assess the level of brachial plexus injury before making a decision on any form of exploration and reconstruction (Figure2). The most accurate method is cervical myelography performed as an emergency soon after admission. In patients with root avulsion, contrast is able to leave the subarachnoid space via the avulsed root and pools in the neck (Figtrre I). Root avulsion predicts that there will be no neurological recovery and there is no indication for arteriography or vascular reconstruction, provided haemorrhage is contained. This policy was followed in the latter two patients in our series with no adverse consequences. Patients with limited avulsions of the lower roots of the plexus have a favourable prognosis because of recovery potential in roots C5-0 and should therefore undergo acute vascular reconstruction. In some patients, an enlarging haematoma will require urgent exploration without preoperative myelography or arteriography. In this situation proximal vascular control should be via a thoracotomy and the brachial plexus explored by a supraclavicular approach. Root avulsion is immediately obvious and ligation of the injured vessel would be the simplest form of vascular treatment. In this way patients who have sustained severe, often multiple injuries may avoid a lengthy vascular reconstruction which can be of no benefit. Should the preoperative myelogram show intact roots indicating a lesion elsewhere in the plexus then exploration and primary vascular reconstruction is mandatory if neurological recovery is to be optimized and later claudication in the arm avoided.
Hawthorn et al.: Treatment of artery trauma
379
Combined major vascular and brachial plexus injury
I
I
Poorly perfused limb
I
I
Well perfused limb
Expanding haematoma
Determine level of plexus injury with acute myelography
Urgent exploration
Equivocal or distal plexus injury
Root avulsions
Distal plexus
No chande of neurological recovery
Chance of neurological recovery
I Chanie of neurological recovery
I Determine level of injury with arteriography
I Vascular reconstruction
ConsAvative management
Ligation of vessel
Figure 2. Clinical algorithm for the management injury.
Conclusion The prognosis for a limb after brachial plexus root avulsion is extremely poor. In a patient with concomitant brachial plexus and vascular injury with a pulseless but viable limb, myelography to assess the level of brachial plexus injury should be performed. Confirmation of root disruption renders vascular reconstruction unnecessary as the longterm outlook remains equally bleak with or without arterial repair.
authors
permission permission
of combined major vascular and brachial plexus
Birch R. (1984) Traction lesions of the bra&al plexus. Br. 1. Hosp. Med. 38, 140. Bonney G. (1983) In: Harris N. H. (ed.) Clinical Orf&uedics. Bristol: Wright P.S.G. 719. Narakas A. (1978) Surgical treatment of traction injuries of the brachial plexus. C&n. Orfhop. 147,210. Stun-n J. T. and Perry J. F. (1987) Brachial plexus injuries from blunt trauma-a harbinger of vascular and thoracic injury. Ann. Emwg. Med. 16, 404. Tomaszek D. E. (1984) Combined subclavian artery and bra&al plexus injuries from blunt upper extremity trauma. 1. Trauma 24, 161.
Acknowledgements The
Vascular reconstruction
would like to thank Mr M. L. Ayres to report Case I and Mr C. L. Welsh to report Case 2 and Case 5.
for for
Paper accepted 21 January 1993.
References Batey N. R. and Makin G. S. (1982) Neurovascular of the upper limb root. Br. 1. Surg. 69,s~.
traction injuries
Requests for reprints shouti be addressed to: Mr J. D. Beard, Room 120,
Royal Hallamshire Hospital, Glossop Road, Sheffield SlO 2JF, UK.
printed in Great Brifuin
377
Treatment of combined brachial plexus and subclavian artery trauma I. E. Hawthorn, J. Rochester and J. D. Beard Vascular Surgical Unit, Royal Hallamshire
Hospital, Sheffield, UK
Five cases of combined brachial plexus root am&on and subclavian artey trauma are presented. A policy of preoperative myelography and minimal vascular reconsfmcfion in the presence of roof disruption is discussed.
Introduction Injuries to the shoulder region or to an outstretched arm causing brachial plexus disruption are a common consequence of modem high-speed road traffic accidents. Over 70 per cent of such injuries follow road accidents (Narakas, 1978). Damage to the nerves is due either to direct laceration from fractured bone or by a crushing injury between clavicle and first rib. The other mechanism of injury is by stretching of the nerves during hyperextension (Birch, 1984). Associated significant chest injuries occur in 10 per cent of patients (Sturm and Perry, 1987). These include multiple rib fractures including the first rib, flail chest, pulmonary contusion, and haemopneumothorax. Upper extremity arterial injuries occur in at least 12 per cent of patients who sustain brachial plexus trauma (Sturm and Perry, 1987). The majority of these vascular injuries involve the distal subclavian artery or the proximal axillary artery. Mechanisms of injury are laceration, avulsion or more commonly intimal disruption causing vessel occlusion. Previous authors have suggested that exploration and vascular reconstruction is mandatory in all these injuries (Batey and Makin, 1982; Tomaszeck, 1984). We disagree with this principle and describe five cases of combined brachial plexus root and subclavian artery injury which illustrate our philosophy.
Case reports
had been avulsed at the roots and was seen to be lying freely in the superior part of the wound. Pulses were restored to the limb but no function was regained and an above-elbow amputation was performed 4 months later at the request of the patient.
CU.92 A 24-year-old male pedestrian was injured by a motor vehicle. Injuries sustained included head injury, fracture of the right radius and ulna and a fractured right tibia1 plateau. There was also a fractured right clavicle and scapula with fractures of the transverse process of C6 and C7. The right arm was pulseless and a haematoma was forming over the anterior right shoulder region. An arteriogram revealed a complete obstruction of the subclavian artery with refilling of the axillary artery distally. Exploration confirmed a venous tear causing the haematoma and the subclavian occlusion was bypassed using an S-mm Dacron graft. Further dissection revealed brachial plexus avulsion at the roots. No useful function was returned to the limb although pulses were restored. Case 3 A 21-year-old male motorcyclist was involved in a road traffic accident sustaining right clavicular, scapular and rib fractures and a haemopneumothorax. He also suffered a fractured distal radius, fractured scaphoid and a capsular haematoma of the right kidney. The right arm was paralysed and pulseless but warm and pink with reasonable capillary filling. Cervical myelography confirmed avulsion of the C8 and T1 roots. Because of the gross disruption at this level contrast did not reach the higher cervical pockets to confirm whether they too had been avulsed. No surgical procedure was performed for the vascular injury. There has been no return of function although some sensation has returned to the upper arm, and despite remaining pulseless the hand is well perfused.
Case 1
A 72-year-old man was struck on the left shoulder by the wing mirror of a petrol tanker on a narrow village street. The arm was pulseless and paralysed. An on-table arteriogram revealed an
occlusion of the subclavian artery. Proximal control of the subclavian artery was gained through a left thoracotomy and an intimal tear of the distal subclavian artery was confirmed by a supraclavicular approach. This section of vessel was excised and replaced by a Dacron graft. During the dissection it became clear that the brachial plexus 0 1993 Butterworth-Heinemann 0020-1383/93/060377-03
Ltd
Case 4 An lb-year-old female motorcyclist fell off at speed fracturing the right radius and ulna. She was also found to have a pulseless, paralysed arm which was warm and pink and reasonably well perfused. The forearm fracture was treated by open reduction, internal fixation and bone grafting and a cervical myelogram was performed. This confirmed brachial plexus nerve root avulsions at C7, C8 and TI (Figure I).
378
Injury: InternationalJournalof the Care of the Injured(1993) Vol. 24/No. 6
In view of the good limb perfusion and closed vessel injury emergency exploration was not undertaken. The brachial plexus was explored on day 4. The C5, C6 and C7 roots were noted to be avulsed from the cord and the CS and Tl roots were much attenuated. As the circulation to the limb was not critical arterial repair was not undertaken.
Discussion
Figure 1. Cervical myelogram (Case 4) demonstrating the C7, C8 and Tl root avulsions with pooling of contrast in the supraclavicular fossa.
No vascular procedure was performed for the subclavian disruption and the arm remains pulseless but well perfused and paralysed. Case 5
A 52-year-old
man was injured in a motor vehicle accident as a driver of a car. His main injuries were to the left chest and shoulder and he reported to the ambulance crew at the scene that he could not move or feel his left upper limb. Shortly after admission he was paralysed, intubated and ventilated, preventing further neurological assessment of his arm. The left brachial pulse was noted to be absent, although his forearm and hand were warm and pink with good capillary return. Chest radiograph (CR) revealed dislocation of both ends of fhe clavicle and fractures of the left first to eighth ribs. Arch aortography was prompted by the suggestion of a widening mediastinum. Intra-arterial digital subfraction arch aortography showed no major vessel injury but an occluded left subclavian artery at the level of the first rib with good collaterals.
The acute management of patients with multiple injury is challenging and a multidisciplinary approach is beneficial. Combined brachial plexus and major vessel injuries require early involvement of a specialist in brachial plexus trauma and a vascular surgeon in addition to those concerned with the concomitant injuries. Preganglionic injuries of the brachial plexus, in which the spinal roots are avulsed from the spinal cord, are irreparable (Narakas, 1978; Bonney, 1983). A limb having suffered the insult of a brachial plexus root disruption will remain permanently paralysed. Tomaszek (1984) reported on four patients with bra&al plexus trauma and arterial disruption, of whom three underwent vascular reconstruction with return of function in none. Batey and Makin (1982) reported on eight patients with similar injuries; only two limbs regained any useful function but seven had undergone vascular reconstruction. Clearly a predictive test of longterm outcome would be of value in determining acute management and the avoidance of unnecessary vascular intervention. Our experience is that the injured limb remains viable with acceptable perfusion despite arterial occlusion. This is attributable to the good collateral circulation around the shoulder and the ‘autosympathectomy’ which occurs after the cervical root avulsion. Considering the poor prognosis after root disruption and the non-critical nature of the arterial ir,jury, our policy is to assess the level of brachial plexus injury before making a decision on any form of exploration and reconstruction (Figure2). The most accurate method is cervical myelography performed as an emergency soon after admission. In patients with root avulsion, contrast is able to leave the subarachnoid space via the avulsed root and pools in the neck (Figtrre I). Root avulsion predicts that there will be no neurological recovery and there is no indication for arteriography or vascular reconstruction, provided haemorrhage is contained. This policy was followed in the latter two patients in our series with no adverse consequences. Patients with limited avulsions of the lower roots of the plexus have a favourable prognosis because of recovery potential in roots C5-0 and should therefore undergo acute vascular reconstruction. In some patients, an enlarging haematoma will require urgent exploration without preoperative myelography or arteriography. In this situation proximal vascular control should be via a thoracotomy and the brachial plexus explored by a supraclavicular approach. Root avulsion is immediately obvious and ligation of the injured vessel would be the simplest form of vascular treatment. In this way patients who have sustained severe, often multiple injuries may avoid a lengthy vascular reconstruction which can be of no benefit. Should the preoperative myelogram show intact roots indicating a lesion elsewhere in the plexus then exploration and primary vascular reconstruction is mandatory if neurological recovery is to be optimized and later claudication in the arm avoided.
Hawthorn et al.: Treatment of artery trauma
379
Combined major vascular and brachial plexus injury
I
I
Poorly perfused limb
I
I
Well perfused limb
Expanding haematoma
Determine level of plexus injury with acute myelography
Urgent exploration
Equivocal or distal plexus injury
Root avulsions
Distal plexus
No chande of neurological recovery
Chance of neurological recovery
I Chanie of neurological recovery
I Determine level of injury with arteriography
I Vascular reconstruction
ConsAvative management
Ligation of vessel
Figure 2. Clinical algorithm for the management injury.
Conclusion The prognosis for a limb after brachial plexus root avulsion is extremely poor. In a patient with concomitant brachial plexus and vascular injury with a pulseless but viable limb, myelography to assess the level of brachial plexus injury should be performed. Confirmation of root disruption renders vascular reconstruction unnecessary as the longterm outlook remains equally bleak with or without arterial repair.
authors
permission permission
of combined major vascular and brachial plexus
Birch R. (1984) Traction lesions of the bra&al plexus. Br. 1. Hosp. Med. 38, 140. Bonney G. (1983) In: Harris N. H. (ed.) Clinical Orf&uedics. Bristol: Wright P.S.G. 719. Narakas A. (1978) Surgical treatment of traction injuries of the brachial plexus. C&n. Orfhop. 147,210. Stun-n J. T. and Perry J. F. (1987) Brachial plexus injuries from blunt trauma-a harbinger of vascular and thoracic injury. Ann. Emwg. Med. 16, 404. Tomaszek D. E. (1984) Combined subclavian artery and bra&al plexus injuries from blunt upper extremity trauma. 1. Trauma 24, 161.
Acknowledgements The
Vascular reconstruction
would like to thank Mr M. L. Ayres to report Case I and Mr C. L. Welsh to report Case 2 and Case 5.
for for
Paper accepted 21 January 1993.
References Batey N. R. and Makin G. S. (1982) Neurovascular of the upper limb root. Br. 1. Surg. 69,s~.
traction injuries
Requests for reprints shouti be addressed to: Mr J. D. Beard, Room 120,
Royal Hallamshire Hospital, Glossop Road, Sheffield SlO 2JF, UK.