Thrombosis of the brachial artery – a rare and devastating complication after a simple closed posterolateral elbow dislocation

Abstract

Dislocation of the elbow joint is the second most common dislocation after the shoulder joint. Although this pathology is relatively common, concomitant vascular injuries are rare. We present a case of a patient who sustained a fall on his arm with an outstretched elbow that resulted in a closed simple posterolateral elbow dislocation and delayed thrombosis of the brachial artery followed by two revascularisation surgeries. The physician must always maintain a high index of suspicion for a concomitant vascular injury before and after closed reduction of the elbow joint and have in mind that complete ischemia without any pulsations could be absent because the elbow is surrounded by rich collateral anastomoses. Suspicion should be even stronger in the presence of bony lesions or open injuries. A team of trauma and vascular surgeons has to work hand in hand as surgical treatment with a saphenous graft or direct suture is the first method of choice with the prior requirement of a stable elbow joint.

Delayed thrombosis of all upper limb arteries: A rare complication in the closed posterior elbow dislocation in the emergency department

“…Most patients develop symptoms within 24 hours of the injury. 5 , 6 Only a single patient was reported with delayed presentation after 10 days, 8 whereas our patient developed symptoms after 2 weeks and presented to the ED 17 days after the initial injury.…”

“…This makes the forearm able to remain fairly perfused despite devastating brachial artery injuries, described in children as "pink pulseless hands" by Brahmamdam et al, 11 and sometimes the patient might be totally asymptomatic. 6 Endean et al found a strong correlation between open dislocation, absence of a radial pulse before reduction of the dislocation, and coexistent systemic injuries with arterial injury in elbow dislocation in a multicenter, 10-year, retrospective analysis of 62 patients. 12 On the contrary, our patient had palpable distal pulses in his initial presentation, which can be explained by either perfusion by collateral circulation or partial injury to the arterial wall that led to extensive thrombosis as a delayed presentation when there were no radial or ulnar pulses.…”

“…This makes the forearm able to remain fairly perfused despite devastating brachial artery injuries, described in children as “pink pulseless hands” by Brahmamdam et al, 11 and sometimes the patient might be totally asymptomatic. 6 …”

“…However, bedside Doppler ultrasonography can also be done to confirm patency or insufficiency. 6 Some investigators discourage the later investigation because of its subjective nature. While investigating this case for other possible causes of thrombophilia, we found that the protein S level was low.…”

“…2 There are only a few cases reported of elbow dislocation complicated with brachial artery thrombosis. [5][6][7][8] The proximity of the brachial artery to the elbow joint makes it vulnerable to damage in elbow dislocations, but its incidence is much smaller as compared to popliteal artery injury in knee dislocations, which is as high as 1.6%. 9 This can be explained by the difference in the anatomy of both arteries.…”