Annals of Vascular Surgery - Brief Reports and Innovations (Mar 2024)
Unrecognised thoracic outlet syndrome from a penetrating screw after clavicular fracture fixation: Case report and literature review
Abstract
Arterial thoracic outlet syndrome (TOS) following clavicular osteosynthesis/plating is a rare and often unrecognised post-operative complication. In this unique case, both the left subclavian artery and brachial plexus were impinged by an excessively long clavicular fixation screw causing neurogenic and ischaemic symptoms. The poorly matched penetrating screw resulted in left mid-subclavian artery thrombosis with limb threatening distal embolisation to the brachial artery and forearm vessels seven years following his fracture surgery.The patient was initially managed conservatively with six months of anticoagulation. He then underwent planned surgery to remove the plate, impinging screw and formally decompress the thoracic outlet. A supra-clavicular and infra-clavicular approach was used, and with this incision, all compression screws and plate were removed. Anticoagulation was then eschewed after three months without further thromboembolic sequelae and successful dissolution of the established embolism.Subclavian artery impingement may not be immediately apparent during clavicular surgery. This can cause thrombosis over time due to chronic irritation and damage of the vessel wall by the impinging screw. The authors suggest that an upper limb arterial examination with provocative stress manoeuvres of the shoulder, and cross-sectional studies may be performed in symptomatic post-clavicular surgery patients to enable earlier recognition of subclavian artery impingement, prior to the development of late-onset limb-threatening ischaemia. This case shows that subclavian artery thrombus due to an impinging screw can present with limb-threatening ischaemia. Although initially managed conservatively with anticoagulation, definitive treatment required surgical removal of the impinging metalwork which allowed the patient to stop anticoagulation, resolved his pain and improved shoulder function.
