Subclavian vessels injury:An underestimated complication of clavicular fractures

Clavicle fractures are frequent orthopedic injuries,often resulting from direct trauma or a fall.Most clavicle fractures are treated conservatively without any complications or adverse effects.Concomitant injuries of the subclavian vein or artery are rarely encountered and most commonly associated with high-energy trauma or comminuted clavicle fractures.They are potentially life-threatening conditions leading to hemorrhage,hematoma,pseudoaneurysm or upper limb ischemia.However,the clinical presentation might be obscure and easily missed,particularly in closed and minimally displaced clavicular fractures,and timely diagnosis relies on early clinical suspicion.Currently,computed tomography angiography has largely replaced conventional angiography for the assessment of subclavian vessel patency,as it demonstrates high accuracy and temporal resolution,acute turnaround time,and capability of multiplanar reconstruction.Depending on the hemodynamic stability of the patient and the severity of the injury,subclavian vessel lesions can be treated conservatively with observation and serial evaluation or operatively.Interventional vascular techniques should be considered in patients with serious hemorrhage and limb ischemia,followed by stabilization of the displaced clavicle fracture.This review aims to provide a comprehensive overview of the incidence,clinical presentation,diagnostic approaches,and current management strategies of clavicle fractures associated with subclavian vessel injuries.

Fat Embolism Syndrome in a Patient with Bilateral Tibial Fractures: Report of the Case and Review of the Literature

Background: Although the original clinical description of fat embolism syndrome (FES) dates from 1873, the condition remains a diagnostic challenge for modern clinicians. The syndrome is described as a serious consequence of fat emboli producing a distinct pattern of clinical symptoms and signs. It is mainly associated with fractures of the long-bones and the pelvis. The present paper describes the case of a trauma patient with bilateral tibial fractures that present the syndrome and highlights the importance of early identification and aggressive treatment of FES which is obligatory for the patient’s survival. Case Description: A 32 year-old man reached the hospital as a trauma call after a road traffic accident. Clinical examination was unremarkable with the only finding that the patient was unable to straight leg raise and weight bear. Both shins were painful and swollen at their middle third, while the left one was in varus and posterior displacement. Neurovascular status of both lower extremities was normal. Plain radiographic control (X-Rays) revealed an oblique right tibial fracture of the mid-shaft with a distal third fibular fracture and a comminuted fracture of the left tibia with a fracture of the fibula at the same level. The legs were immobilised on a splint and the decision was to treat the patient surgically. Within a few post admission hours the haemoglobin dropped by 2.9 mg/dL, however a source of active bleeding could not be allocated. The abdomen was soft and not tender in palpation and the central nervous system did not present any abnormalities. The following day the haemoglobin dropped but the new ultrasonography control did not reveal any free abdominal fluid. Both lower limbs were not compromised. The second post-injury day the patient went to theatre and the right tibia was stabilised with an antegrade nail (T2-Stryker) while the left one with an external fixation. During the reaming process the haemoglobin dropped to 7.1 gr/dL, so he was transfused with 3 blood units. Immediately after extubation, the patient desaturated on air and ABG values forced the anaesthetists to intubate him in recovery and place him in mechanical ventilation with high levels of positive end expiratory pressure (PEEP). Symptoms subsided rapidly and he was transferred to the IMU. Clinical image and CT scan were in favour of fat embolism syndrome. On the fifth post-operative day the patient was transferred back to ward and a week later he was discharged being completely free of symptoms. Clinical Relevance: Fat embolism syndrome is typically presented with the following triad: a) respiratory changes;b) neurologic abnormalities;c) petechial rash. These three constitute the major criteria described by Gurd and are pathognomonic for the condition. The patient—described in the present case report—developed progressively all those symptoms within the expected period of time. The FES is a well-known pathological condition that is well described in literature and should be familiar to those clinicians that manage trauma patients. Diagnosing the condition can be highly demanding since there are no laboratory investigations or radiographic imaging techniques specific for FES. Suspicion and diagnosis can be mainly placed based on the criteria described by Gurd, in 1970.