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Brachial artery injury as a complication of closed elbow dislocation, and disguised as compartment syndrome

2023; Elsevier BV; Volume: 3; Issue: 4 Linguagem: Inglês

10.1016/j.xrrt.2023.05.010

2666-6391

Elham Khakbaz, S. Kantak, Jacob Fyhring Mortensen,

Orthopedic Surgery and Rehabilitation

Transection of the brachial artery associated with blunt trauma, such as a closed elbow dislocation, is a rare phenomenon (1Ayel J.E. Bonnevialle N. Lafosse J.M. Pidhorz L. Al Homsy M. Mansat P. et al.Acute elbow dislocation with arterial rupture. Analysis of nine cases.Orthop Traumatol Surg Res. 2009 Sep; 95: 343-351https://doi.org/10.1016/j.otsr.2009.04.013Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar,3Barkay G. Zabatani A. Menachem S. Yaffe B. Arami A Acute Compartment Syndrome of the Upper Extremity: Clinical Outcomes Following Surgical Treatment. A Retrospective Cohort Study.Isr Med Assoc J. 2021 Aug; 23: 516-520Google Scholar,12Phang Z.H. Miskon M.F.B. Ibrahim S.B. Blunt trauma to the antecubital fossa causing brachial artery injury and minor fractures around the elbow joint, an easily missed diagnosis with potential devastating consequences: a case report.J Med Case Rep. 2018 Jul; 12 (Zi Hao Phang, Mohd Fadhli B Miskon, Sa’adon B Ibrahim): 211https://doi.org/10.1186/s13256-018-1751-7Crossref Scopus (3) Google Scholar). Closed elbow dislocations account for approximately 25% of all elbow injuries, of which 5-13% result in arterial injury (2J B.C. Sampath D. HR N. Motukuru V. Complete Brachial Artery Transection following closed Posterior Elbow Dislocation: A Rare Case Report.Orthop Case Rep. 2015 Oct-Dec; 5 (JayanthKumar B C, Deepak Sampath, Hanumantha Reddy N, Vishnu Motukuru): 27-29https://doi.org/10.13107/jocr.2250-0685.338Crossref Google Scholar, 3Barkay G. Zabatani A. Menachem S. Yaffe B. Arami A Acute Compartment Syndrome of the Upper Extremity: Clinical Outcomes Following Surgical Treatment. A Retrospective Cohort Study.Isr Med Assoc J. 2021 Aug; 23: 516-520Google Scholar, 4Cepková J. Ungermann L. Ehler EJana Acute Compartment Syndrome.Acta Medica (Hradec Kralove). 2020; 63 (Cepková, Leoš Ungermann, Edvard Ehler): 124-127https://doi.org/10.14712/18059694.2020.26Crossref Scopus (1) Google Scholar). Acute compartment syndrome (ACS) or brachial artery transection may follow a closed elbow dislocation (2J B.C. Sampath D. HR N. Motukuru V. Complete Brachial Artery Transection following closed Posterior Elbow Dislocation: A Rare Case Report.Orthop Case Rep. 2015 Oct-Dec; 5 (JayanthKumar B C, Deepak Sampath, Hanumantha Reddy N, Vishnu Motukuru): 27-29https://doi.org/10.13107/jocr.2250-0685.338Crossref Google Scholar,4Cepková J. Ungermann L. Ehler EJana Acute Compartment Syndrome.Acta Medica (Hradec Kralove). 2020; 63 (Cepková, Leoš Ungermann, Edvard Ehler): 124-127https://doi.org/10.14712/18059694.2020.26Crossref Scopus (1) Google Scholar,16Saoudi F. Benhazim O. Bassir R. Boufettal M. Albardouni A. Kharmaz M. Saoudi F. et al.RARE CASE OF ACUTE COMPARTMENT SYNDROME OF THE FOREARM FOLLOWING AN ELBOW DISLOCATION.Int J Adv Res. 2018; 6 (O Benhazim, R Bassir, M Boufettal, A Albardouni, M Kharmaz, et al.): 20-22https://doi.org/10.21474/IJAR01/6820Crossref Google Scholar). ACS, which is a surgical emergency, arises clinically from trauma or other circumstances that cause bleeding, edema, or impaired blood flow in the limbs (5Guo J. Yin Y. Jin L. Zhang R. Hou Z. Zhang Y. Acute compartment syndrome: Cause, diagnosis, and new viewpoint.Medicine (Baltimore). 2019 Jul; 98 (Jialiang Guo, Yingchao Yin, Lin Jin, Ruipeng Zhang, Zhiyong Hou, Yingze Zhang)e16260https://doi.org/10.1097/MD.0000000000016260Crossref Scopus (29) Google Scholar). ACS is defined as an increase in intracompartmental pressure and can result in severe ischemia of nerve and muscle tissue in the limbs (6Lee Y.K. Lee S.H. Kwon T.Y. Acute compartment syndrome of the forearm associated with transradial coronary intervention.J Hand Surg Eur. 2020 Oct; 45 (Young-Keun Lee, Se-Hwan Lee, Tae-Young Kwon): 852-856https://doi.org/10.1177/1753193419899007Crossref Scopus (4) Google Scholar, 7Marcheix B. Chaufour X. Ayel J. Hollington L. Mansat P. Barret A. et al.Transection of the brachial artery after closed posterior elbow dislocation.J Vasc Surg. 2005 Dec; 42 (Bertrand Marcheix, Xavier Chaufour, Jacques Ayel, Lucy Hollington, Pierre Mansat, André Barret, et al.): 1230-1232https://doi.org/10.1016/j.jvs.2005.07.046Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 8McMillan T.E. Gardner W.T. Schmidt A.H. Johnstone A.J. Diagnosing acute compartment syndrome-where have we got to?.Int Orthop. 2019 Nov; 43 (Tristan E McMillan, William Timothy Gardner, Andrew H Schmidt, Alan J Johnstone): 2429-2435https://doi.org/10.1007/s00264-019-04386-yCrossref Scopus (30) Google Scholar). Timely diagnosis and surgical management of both forms are difficult and crucial.We report a case in which extreme and persistent pain, swelling, and lack of pulse in the radial and ulnar arteries after elbow dislocation were misinterpreted as ACS rather than brachial artery injury. A 53-year-old man entered our emergency department after having stumbled, landed on his hyperextended left arm, resulting in dislocation of his left elbow. The elbow dislocation was spontaneously reduced after he stood up from the ground. The patient presented severe pain in his left elbow and forearm, swelling, and limited mobility in the elbow in the emergency department. During physical examination, the left forearm was swollen, the hand was numb, and the pulse in the radial and ulnar artery was absent. The active function of the left arm was considerably reduced due to the pain, but there was no pain in the upper arm or shoulder during palpation. The patient was otherwise stable. The primary x-ray of the entire arm showed no obvious signs of fractures or dislocation in the elbow, although a discreet intraarticular fluid accumulation was seen (Figure 1). Computed tomographic (CT) scanning showed an undislocated intraarticular fracture of radial head and medial humerus condyle (Figure 2A, 2B). Unfortunately, the possibility of the use of CT-angiography was not considered at the time the patient in our case was brought to the hospital in the middle of the night. The fasciotomy was performed without delay. In Denmark the clinical symptoms are determining the diagnosis of ACS by standard and the compartment pressure monitoring is not applied.Figure 2A: Undislocated intraarticular fracture in radial head. B: Undislocated fracture in medial humerus condyleView Large Image Figure ViewerDownload Hi-res image Download (PPT) Acute compartment syndrome was the first and most suspected diagnosis based on the extreme and persistent pain, despite administration of strong analgesics; received intravenous morphine (15 mg) and fentanyl (200 μg) within one hour. The limited elbow movement along with numbness in the hand and lack of pulse in radial artery helped confirming the diagnosis of ACS. The patient was transported to the surgery room for decompression - fasciotomy - under general anesthesia, approximately one and a half hours after arrival at the emergency room. The forearm fasciotomy was made by a volar incision through the superficial and deep compartment. The suspicion of ACS was disproved during the fasciotomy, while damage to the proximal flexor muscles and the rupture of the elbow capsule were revealed. Due to a lack of pulse in the radial artery in the wrist, the artery was dissected out along the forearm, where the rupture of the brachial artery was found in the cubital fossa. Then, a distal non-pulsatile stump and a proximal pulsatile stump were recognized as two ends of the brachial artery in the cubital fossa, and the anastomosis of the two ends of the ruptured brachial artery was then performed. The surgical wound was not completely closed because of edema, leaving the anterior site of the proximal forearm open. The elbow was stabilized with Steinmann-pind by transfixing in 90 degrees. As the radial artery was still pulseless and persistent bleeding seeping from the proximal part of the wound was observed, the suspicion of the leakage of brachial artery was raised. The patient was immediately transferred to a vascular surgery department at a centralized hospital for acute revascularization; using a vein patch from right groin. The partial skin transplantation from the left thigh was performed (Figure 3A) 6 days later (Figure 3B). Meanwhile the patient was transported back to and remained hospitalized in the local hospital for observation and postoperative wound care. The surgical wound was closed by plastic surgeons with partial skin transplantation from the left thigh (Figure 3A) 6 days later (Figure 3B). At 2-month follow-up, the range of flexion was 120 degrees, lacking 10-20 degrees of full flexion, and the range of extension was just 25 degrees in the left elbow. The pronation was normal; however, there was 5 degree supination. There was some movement limitation in flexion of the left thumb and middle finger. The range of motion of the elbow stopped improving after the 4 month follow-up where the flexion defect remained unchanged, but the extension defect was better at 15 degrees. Both pronation and supination were normal. At 9 month follow-up there was no further progress, and at 2-year follow-up (Figure 3C), the full extension of the elbow was still lacking, most likely due to tight distal biceps tendon in the elbow. Pronation and supination as well movement of the left wrist were normal. The closed elbow dislocation, associated with a laceration of the proximal flexor muscles, and brachial artery lesion as well as the fasciotomy have had some, probably lifelong, consequences for the patient in this case report. The patient still suffers from numbness in the radial three and half digits of the left hand as well as limited flexion, extension, and supination of the left forearm. The transplanted skin is attached to the muscles and the patient has pain superficially in the skin transplanted area, especially when he tries to lift heavy objects. The patient is still waiting for a thorough skin reconstruction. Symptoms of closed elbow dislocation associated with artery injury may be misinterpreted as acute compartment syndrome (ACS), since extreme pain is a common main clinical symptom. ACS as well as arterial ruptures can be a consequence of closed elbow dislocation (16Saoudi F. Benhazim O. Bassir R. Boufettal M. Albardouni A. Kharmaz M. Saoudi F. et al.RARE CASE OF ACUTE COMPARTMENT SYNDROME OF THE FOREARM FOLLOWING AN ELBOW DISLOCATION.Int J Adv Res. 2018; 6 (O Benhazim, R Bassir, M Boufettal, A Albardouni, M Kharmaz, et al.): 20-22https://doi.org/10.21474/IJAR01/6820Crossref Google Scholar). Although brachial artery injury after closed dislocation of the elbow is rare, it should not be underestimated (3Barkay G. Zabatani A. Menachem S. Yaffe B. Arami A Acute Compartment Syndrome of the Upper Extremity: Clinical Outcomes Following Surgical Treatment. A Retrospective Cohort Study.Isr Med Assoc J. 2021 Aug; 23: 516-520Google Scholar). This rare complication can present itself in different clinical parameters. The presence of distal pulses alone is not always sufficient to exclude arterial injury (2J B.C. Sampath D. HR N. Motukuru V. Complete Brachial Artery Transection following closed Posterior Elbow Dislocation: A Rare Case Report.Orthop Case Rep. 2015 Oct-Dec; 5 (JayanthKumar B C, Deepak Sampath, Hanumantha Reddy N, Vishnu Motukuru): 27-29https://doi.org/10.13107/jocr.2250-0685.338Crossref Google Scholar). This is because the brachial artery injury disrupts at least one of the collateral arteries around the elbow, and the thrombosis of the collaterals with the spreading hematoma leads to delayed disappearance of the distal pulse in some patients (2J B.C. Sampath D. HR N. Motukuru V. Complete Brachial Artery Transection following closed Posterior Elbow Dislocation: A Rare Case Report.Orthop Case Rep. 2015 Oct-Dec; 5 (JayanthKumar B C, Deepak Sampath, Hanumantha Reddy N, Vishnu Motukuru): 27-29https://doi.org/10.13107/jocr.2250-0685.338Crossref Google Scholar,3Barkay G. Zabatani A. Menachem S. Yaffe B. Arami A Acute Compartment Syndrome of the Upper Extremity: Clinical Outcomes Following Surgical Treatment. A Retrospective Cohort Study.Isr Med Assoc J. 2021 Aug; 23: 516-520Google Scholar). Immediate CT angiography prior to surgical repair is the gold standard for evaluating arterial injury associated with closed elbow dislocation to diagnose arterial interruptions (1Ayel J.E. Bonnevialle N. Lafosse J.M. Pidhorz L. Al Homsy M. Mansat P. et al.Acute elbow dislocation with arterial rupture. Analysis of nine cases.Orthop Traumatol Surg Res. 2009 Sep; 95: 343-351https://doi.org/10.1016/j.otsr.2009.04.013Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar, 2J B.C. Sampath D. HR N. Motukuru V. Complete Brachial Artery Transection following closed Posterior Elbow Dislocation: A Rare Case Report.Orthop Case Rep. 2015 Oct-Dec; 5 (JayanthKumar B C, Deepak Sampath, Hanumantha Reddy N, Vishnu Motukuru): 27-29https://doi.org/10.13107/jocr.2250-0685.338Crossref Google Scholar, 3Barkay G. Zabatani A. Menachem S. Yaffe B. Arami A Acute Compartment Syndrome of the Upper Extremity: Clinical Outcomes Following Surgical Treatment. A Retrospective Cohort Study.Isr Med Assoc J. 2021 Aug; 23: 516-520Google Scholar,9Miranda-Klein J. Howell C.M. Davis-Cheshire M. Recognizing and managing upper extremity compartment syndrome.JAAPA. 2020 May; 33 (Jacqueline Miranda-Klein, Christopher M Howell, Michael Davis-Cheshire): 15-20https://doi.org/10.1097/01.JAA.0000660124.51074.e5Crossref Scopus (2) Google Scholar). Urgent surgical exploration and primary vascular repair is the only acceptable treatment for arterial injury associated with elbow dislocation (2J B.C. Sampath D. HR N. Motukuru V. Complete Brachial Artery Transection following closed Posterior Elbow Dislocation: A Rare Case Report.Orthop Case Rep. 2015 Oct-Dec; 5 (JayanthKumar B C, Deepak Sampath, Hanumantha Reddy N, Vishnu Motukuru): 27-29https://doi.org/10.13107/jocr.2250-0685.338Crossref Google Scholar,3Barkay G. Zabatani A. Menachem S. Yaffe B. Arami A Acute Compartment Syndrome of the Upper Extremity: Clinical Outcomes Following Surgical Treatment. A Retrospective Cohort Study.Isr Med Assoc J. 2021 Aug; 23: 516-520Google Scholar). However, fasciotomy is indicated if there is increased pressure in the forearm compartment, significant concomitant soft tissue damage, or a prolonged period of time between the injury and the trauma (2J B.C. Sampath D. HR N. Motukuru V. Complete Brachial Artery Transection following closed Posterior Elbow Dislocation: A Rare Case Report.Orthop Case Rep. 2015 Oct-Dec; 5 (JayanthKumar B C, Deepak Sampath, Hanumantha Reddy N, Vishnu Motukuru): 27-29https://doi.org/10.13107/jocr.2250-0685.338Crossref Google Scholar,9Miranda-Klein J. Howell C.M. Davis-Cheshire M. Recognizing and managing upper extremity compartment syndrome.JAAPA. 2020 May; 33 (Jacqueline Miranda-Klein, Christopher M Howell, Michael Davis-Cheshire): 15-20https://doi.org/10.1097/01.JAA.0000660124.51074.e5Crossref Scopus (2) Google Scholar). Due to the lack of adequate length of the injured vessels, it is often not possible to perform a complete vascular reconstruction immediately after fasciotomy and exploration of the injured arteries (6Lee Y.K. Lee S.H. Kwon T.Y. Acute compartment syndrome of the forearm associated with transradial coronary intervention.J Hand Surg Eur. 2020 Oct; 45 (Young-Keun Lee, Se-Hwan Lee, Tae-Young Kwon): 852-856https://doi.org/10.1177/1753193419899007Crossref Scopus (4) Google Scholar). Complete vascular reconstruction of an anastomosis is proceeded by using an inverted autologous vein graft, preferably from the great saphenous vein of an uninjured lower extremity (3Barkay G. Zabatani A. Menachem S. Yaffe B. Arami A Acute Compartment Syndrome of the Upper Extremity: Clinical Outcomes Following Surgical Treatment. A Retrospective Cohort Study.Isr Med Assoc J. 2021 Aug; 23: 516-520Google Scholar,9Miranda-Klein J. Howell C.M. Davis-Cheshire M. Recognizing and managing upper extremity compartment syndrome.JAAPA. 2020 May; 33 (Jacqueline Miranda-Klein, Christopher M Howell, Michael Davis-Cheshire): 15-20https://doi.org/10.1097/01.JAA.0000660124.51074.e5Crossref Scopus (2) Google Scholar). Although ACS associated with an elbow dislocation is a rare condition (16Saoudi F. Benhazim O. Bassir R. Boufettal M. Albardouni A. Kharmaz M. Saoudi F. et al.RARE CASE OF ACUTE COMPARTMENT SYNDROME OF THE FOREARM FOLLOWING AN ELBOW DISLOCATION.Int J Adv Res. 2018; 6 (O Benhazim, R Bassir, M Boufettal, A Albardouni, M Kharmaz, et al.): 20-22https://doi.org/10.21474/IJAR01/6820Crossref Google Scholar), the following clinical findings are the gold standard in the diagnosis of ACS (10Miyazaki AN, Fregoneze M, Santos PD, do Val Sella G, Checchia CS, Checchia SL, Alberto Naoki Miyazaki, Marcelo Fregoneze, Pedro Doneux Santos, Guilherme do Val Sella, Caio Santos Checchia, Sergio Luiz Checchia. Brachial artery injury due to closed posterior elbow dislocation: case report. Vol. 51, Revista brasileira de ortopedia. 2016. p. 239–243. doi: 10.1016/j.rboe.2016.02.007.Google Scholar,11Newton E.J. Love J. Acute complications of extremity trauma.Emerg Med Clin North Am. 2007 Aug; 25 (Edward J Newton, John Love) (iv): 751-761https://doi.org/10.1016/j.emc.2007.06.003Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar). The 5 "P's", pain, pallor, pulselessness, paralysis, and paresthesia, as clinical criteria) are the symptom of ACS. However, the pain, which is extreme and persistent pain, the so-called pain out of proportion to injury, is the main symptom of ACS. The extreme pain associated with the mechanism of injury should raise suspicion of ACS (13Biswas S. Healy C. Complex Posterior Elbow Dislocation Causing Complete Brachial Artery Transection . A Rare Complication of a Common Orthopedic Injury.Archives of Emergency Medicine and Intensive Care. 2018; 1: 22-26Crossref Google Scholar,14Rasid M.F. Ahmad A. Baharuddin K.A. Salim A.A. Savarirajo J.C. Abdullah M.S. Acute compartment syndrome of the forearm: A case report of radius fracture with concomitant brachial artery transaction.Med J Malaysia. 2021 Jul; 76 (M F Rasid, A Ahmad, K A Baharuddin, A A Salim, J C Savarirajo, M S Abdullah): 603-605Google Scholar), and arterial injuries should not be underestimated. Ultrasonography, MRI (10Miyazaki AN, Fregoneze M, Santos PD, do Val Sella G, Checchia CS, Checchia SL, Alberto Naoki Miyazaki, Marcelo Fregoneze, Pedro Doneux Santos, Guilherme do Val Sella, Caio Santos Checchia, Sergio Luiz Checchia. Brachial artery injury due to closed posterior elbow dislocation: case report. Vol. 51, Revista brasileira de ortopedia. 2016. p. 239–243. doi: 10.1016/j.rboe.2016.02.007.Google Scholar), Duplex ultrasound, and especially CT angiography (15Raza H. Mahapatra A. Acute Compartment Syndrome in Orthopedics : Causes , Diagnosis , and Management.Adv Orthop. 2015; 2015 (Hasnain Raza, Anant Mahapatra) (2015;2015)543412https://doi.org/10.1155/2015/543412Crossref Scopus (39) Google Scholar) after reduction of the elbow have been suggested as important complementary investigations to clarify and finally specify the injured arteries when there is doubt about the patency of the vessels (9Miranda-Klein J. Howell C.M. Davis-Cheshire M. Recognizing and managing upper extremity compartment syndrome.JAAPA. 2020 May; 33 (Jacqueline Miranda-Klein, Christopher M Howell, Michael Davis-Cheshire): 15-20https://doi.org/10.1097/01.JAA.0000660124.51074.e5Crossref Scopus (2) Google Scholar). The timing of fasciotomy in patients with ACS is highly discussed in the literature. Jialiang Guo et al (5Guo J. Yin Y. Jin L. Zhang R. Hou Z. Zhang Y. Acute compartment syndrome: Cause, diagnosis, and new viewpoint.Medicine (Baltimore). 2019 Jul; 98 (Jialiang Guo, Yingchao Yin, Lin Jin, Ruipeng Zhang, Zhiyong Hou, Yingze Zhang)e16260https://doi.org/10.1097/MD.0000000000016260Crossref Scopus (29) Google Scholar) suggest that urgent fasciotomy should be performed before irreversible tissue necrosis occurs, especially in patients who are considered high-risk and/or have abnormal clinical findings. Accordingly, the performance of prophylactic fasciotomy is recommended in some literatures and cited as an important factor in limb salvage and preservation of function, especially in patients with vascular trauma. The need for emergency surgical treatment, such as vascular repair, is especially necessary when dislocation of the elbow has caused interruption of arterial blood flow due to artery laceration (3Barkay G. Zabatani A. Menachem S. Yaffe B. Arami A Acute Compartment Syndrome of the Upper Extremity: Clinical Outcomes Following Surgical Treatment. A Retrospective Cohort Study.Isr Med Assoc J. 2021 Aug; 23: 516-520Google Scholar,17Tan L. Xia Y. Su Z. Wen Q. Zhang J. Yu T. Brachial muscle injury resulting in acute compartment syndrome of the upper arm: a case report and literature review.BMC Musculoskelet Disord. 2021 Jun; 22 (Lei Tan, Yongning Xia, Zilong Su, Qiangqiang Wen, Jiting Zhang, Tiecheng Yu): 545https://doi.org/10.1186/s12891-021-04318-1Crossref Scopus (2) Google Scholar). Unfortunately complications, such as pain, persistent muscle weakness, chronic venous insufficiency and cosmetic problems can occur after fasciotomy and surgical reconstruction with skin grafting or revascularization (14Rasid M.F. Ahmad A. Baharuddin K.A. Salim A.A. Savarirajo J.C. Abdullah M.S. Acute compartment syndrome of the forearm: A case report of radius fracture with concomitant brachial artery transaction.Med J Malaysia. 2021 Jul; 76 (M F Rasid, A Ahmad, K A Baharuddin, A A Salim, J C Savarirajo, M S Abdullah): 603-605Google Scholar). It is challenging to distinguish ACS from arterial transection, when the patient´s dislocated elbow has already spontaneously been repositioned before arriving at the hospital. The patient is extremely in pain, pulseless in the radial artery, and has edema in the elbow and forearm. Besides, there is no particular sign of a fracture in the X-ray, and the CT shows just some very small avulsions in the elbow.