Injury, 7, 29-32

Subclavian

29

artery rupture

(An unusual seat-belt

injury)

R. N. W. Chan and R. G. M. Duffield The Royal United Hospital,

Bath

Summary

A case of blunt injury to the subclavian artery in the absence of bony injury or dislocation sustained while wearing a seat belt is described. Its rarity and diagnostic pitfalls are discussed. The mechanism of the injury is analysed. The value of angiography is emphasized. It is suggested that, even in the presence of collateral circulation, exploration and repair should be undertaken.

Operative access was gained initially by osteotomy of the clavicle in its medial third and later extended by splitting the sternum. The subclavian, innominate and right common carotid arteries were then exposed. Severe subadventitial splitting was noted in the proximal 2 cm. of the subclavian artery, with total occlusion of the lumen. No bony injury was seen. The ruptured portion of the artery was resected and replaced by a Teflon graft with restoration of

INTRODUCTION THAT seat belts can cause a well-recognized pattern of injury has been widely known since Garrett and Braunstein (1962) coined the phrase ‘seatbelt syndrome’ (Lister and Milsom, 1963; Gissane and Bull, 1968; Michelinakis, 1971; Shennan, 1973). Isolated new and rare injuries are being reported with the increasing use of seat belts (Beresford, 1971; Eastwood, 1972; Anderson, 1974). In view of its rarity, it is not generally recognized that it can cause severe injury to major blood vessels in the neck and thoracic inlet (Editorial, ZTZ&V~, 1974). Shennan’s comprehensive review of the seat-belt syndrome does not mention it. CASE REPORT A 40-year-old male was admitted to the Royal United Hospital, Bath in June, 1973, following a head-on collision with a tree. He had been driving a mini-bus, wearing a diagonal-lap type seat belt with a rear-seat passenger who was not. On admission, his pulse rate was 88 and his blood pressure was 110/60 mmHg. He complained of pain in his right shoulder and neck. Examination revealed marked ecchymosis over his right clavicle (Fig. 1). Neither the right brachial nor the right radial pulse was palpable. At no time did he complain of paraesthesia or cold sensation in his right upper limb. Radiography showed no fracture or dislocation of the clavicle. Angiography showed obstruction of the right subclavian artery at its origin from the innominate artery and subsequent radiographs showed good collateral circulation (Figs. 2 and 3).

Fig. 1. To show ecchymosis over right clavicle due to seat-belt compression.

good distal flow and return of a good radial pulse. Total blood lost was 3 litres. Recovery was uneventful and the patient was discharged on the tenth day. At review 1 year later he was found to have returned to his previous job, which entailed heavy work. The sole complaint was reluctance to resume his hobby of bell ringing. Examination showed no detectable difference in circulation in the upper limbs, there was no bruit in the neck, and shoulder function was virtually normal Inspection of the vehicle and analysis of the mechanism of this rare injury revealed 2 points of interest. First, the seat-belt fixation point on the side pillar was considerably higher than the recommended safe

30

Injury: the British Journal of Accident Surgery Vol. ~/NO. 1

DISCUSSION

position, i.e. 3 cm above the shoulder. Secondly, considerable damage had been caused to the driver’s seat by the passenger behind being thrown forward at the time of impact. The result was severe compression of the driver’s chest and right clavicle by pressure from behind and restraint by the seat belt in front, coupled with hyperextension of the cervical spine (Fig. 4).

Even in wartime, subclavian artery injuries account for less than one per cent of all arterial injuries (DeBakey and Simeone, 1946; Hughes, 1954; Rich et al., 1973). Civilian reports originate mainly from the United States, and the majority

Fig. 2. Angiogram subclavian artery.

Fig. 3. Angiogram showing distal filling of subclavian artery with good collateral circulation.

showing

obstruction

of right

Fig. 4. Driver’s seat: note high side-pillar anchorage and forward deformation of seat; note torsional deformity left side being further forwardly displaced.

of these concern missile injuries (Pate and Wilson, 1964; Bricker et al., 1970). Though uncommon, it is well known that both fracture of the clavicle and retrosternal dislocation of the sternoclavicular joint can cause vascular injury (Dash and Handler, 1960; Stankler, 1962; Penn, 1964; Mehta et al., 1973; Sturm et al., 1974). While rupture of the innominate artery due to a seat belt is known (Wexler and Silverman, 1970), injury to the subclavian vessels while wearing a seat belt without an associated fracture or dislocation, has, to our knowledge, not previously been reported. In addition our case illustrates certain aspects which merit emphasis. Diagnosis in both penetrating and blunt injuries can be extremely difficult; many reported cases in the literature escaped early detection. In Pate and Wilson’s series (1964), 4 out of 12 cases were initially missed. A high degree of clinical awareness is probably more important than any investigation one might use, particularly since the very nature of the injury often

Chan and Duffield

: Subclavian

Artery

Rupture

precludes time-consuming tests (Porter, 1967). Absence of pulses and difference in pulse pressure, when present, are important and must be taken seriously. That ecchymosis is an important physical sign suggesting concealed trauma to thoracic and abdominal contents is well known (Michelinakis, 1971), and Hamilton (1968) goes as far as to recommend laparotomy in its presence. It was ecchymosis over the right clavicle that first cast suspicion on possible underlying injury in our case. Matloff and Morton (1968) have made similar observations. The value of angiography and its clinical application in the diagnosis and management of major arterial trauma has been well documented (Freed and Bosher, 1968 ; Eller and Ziter, 1970; Sturm et al., 1974). Sturm et al. describe it as the corner-stone in the diagnosis and management of subclavian injury. Its value is well shown in our case. However, it must be emphasized that the feasibility of angiography is determined by the clinical state of the patient concerned, because blood replaced can vary from 0 to 18,000 ml (Rich et al., 1973). In the latter case, immediate operation is the first step in resuscitation and no time can be wasted. Failure in early diagnosis and treatment can result in death, thrombosis, embolism, intimal dissection, aneurysm, arteriovenous fistula and subclavian steal syndrome (Clarke, 1964; Pate and Wilson, 1964; Penn, 1964; Sweetman, 1965; Rojas et al., 1966; Yao et al., 1970). The nature of the injury seen in our case suggests that, if left, it would have either ruptured or become a false aneurysm with all its disastrous sequelae. Thus, even if angiography shows adequate collateral circulation, as in this case, exploration is still essential. The best result is obtained by early diagnosis and treatment by repair. Operation is not so much to forestall ischaemic changes, which seldom occur in the upper limb, as to prevent complications and restore full function (Pate and Wilson, 1964). The mechanism of subclavian injury in the seat-belt syndrome is not known. In their analysis of innominate arterial rupture Wexler and Silverman (1970) state that for the vessel to rupture the impact force must be associated with torsion and lateral motion with hyperextension of the cervical spine, the axis of the rotational force being the diagonal strap. Our case shows that such injury can occur in the absence of Fracture or dislocation, the mechanism of injury being similar. Fig. 4 illustrates this well, the seat being deformed further forward on the left side than the right. The fact that most blunt injuries

31

to the subclavian artery occur within the first part of the vessel close to the innominate artery (as in this case report), supports this view. This case draws attention to the rare occurrence of subclavian injury by a seat belt, with associated ecchymosis as part of the seat-belt syndrome. It also confirms the belief that high anchorage of a seat belt on the side pillar can cause severe soft-tissue injury to the neck (Anderson, 1974). It also illustrates the present illogical legislation and fashion of having seat belts in the front only, as it could be argued that, in this particular case, had the rear-seat passenger been suitably belted the injury might never have occurred.

Acknowledgements The authors wish to thank Mr H. T. John for permission to report his case, Mrs G. Machin for her photographic assistance, and Miss M. Gardiner for her secretarial help.

REFERENCES

ANDERSONJ. (1974) An unusual seat-belt injury. Injury 5, 185. BERESFORDH. R. (1971) Meralgia paraesthetica after seat-belt trama. J. Trauma 11,629. BRICKERD. L., Noon G. P., BEALLA. C. and DEBAKEY M. E. (1970) Vascular injuries of the thoracic inlet. J. Trauma 10,1. CLARKE D. B. (1964) Traumatic aneurysm of the innominate artery at its origin from the aortic arch. Br. /. Suvg. 51,668. DASH U. N. and HANDLER D. A. (1960) A case of compression of subclavian vessels by a fractured clavicle treated by excision of the first rib. J. Bone Joint Surg. 42A,798. DEBAKEY M. E. and SIMEONEF. A. (1946) Battle injuries of the arteries in World War 2. Ann. Surg.

123,534. EASTWARD D. S. (1972) Subcutaneous rupture of the breast. Br. J. Surg. 59, 491. ELLER J. C. and ZITER F. M. H. (1970) Avulsion of the innominate artery from the aortic arch. Radiology 94, 75. FREEDT. A. and BOSHERL. H. (1968) Arteriographic demonstration of laceration of great vessels secondary to blunt chest trauma. Radiology 90, 88. GARRETT J. W. and BRAUNSTEINP. W. (1962) The seat-belt syndrome. J. Trauma 2, 220. GISSANE W. and BULL J. P. (1968) Seat-belt injuries. Br. Med. J. 4, 64 1. HAMILTONJ. B. (1968) Seat-belt injuries. Br Med. J. 4, 485. HUGHES C. W. (1954) Acute vascular trauma in Korean War casualties : an analysis of 180 cases. Surg. Gynecol. Obstet. 99, 91. INJURY: EDITORIAL(1974) Car seat-belts. Injury 5,185.

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Injury:

LISTER R. D. and belts: an analysis

MILSOMB. M. (1963) Car seatof the injuries sustained by the

the British Journal

of Accident

Surgery

Vol. ~/NO. 1

ROJAS R. H., LEVITSKYS. and STANSELH. C. (1966)

Acute traumatic subclavian steal syndrome. J. Thorac. Cardiovasc. Surg. 51,113. occupants. Practitioner 191, 332. SHENNANJ. (1973) Seat-belt syndrome. Br. J. Hosp. MATLOFF D. B. and MORTON J. H. (1968) Acute Med. 10,199. trauma to the subclavian arteries. Am. J. Surg. 115, 615.

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PATE J. W. and WILSONH. (1964) Arterial injuries of the base of the neck. Arch. Surg. 89, 1106. PENNI. (1964) The vascular complications of fractures of the clavicle. J. Trauma 4, 819. PORTERM. F. (1967) Arterial injuries in an accident unit. Br. J. Surg. 54, 100 RICH N. M., HOBSON R. W., JARSTFERB. S. and GEER T. M. (1973) Subclavian artery trauma. J. Trauma 13, 485.

Requests for rqwinfr

should be addrezsrd

fo: R. N. W.

STANKLERL. L. (1962) Posterior dislocation of the clavicle. Br. J. Surg. 50, 164. STURM J. T., STRATE R. G., MOWLEM A., QUATTLEBAUMF. W. and PERRYJ. R. (1974) Blunt trauma to the subclavian artery. Surg. Gynecol. Obstet. 138, 915. SWEETMANW. R. (1965) Subclavian steal syndrome following trauma. Am. Surg. 31, 463. WEXLERL. and SILVERMANJ. (1970) Traumatic rupture of the innominate artery-a seat-belt injury. N. Engl. J. Med. 282, 1186. YAO J. K. Y., SURI R., PATT N. L.,‘F~ELDENR. H. N. and BAKER C. B. (1970) An unusual subclavian artery injury. J. Trauma 10,176.

Chan, Royal United

Hospital,

Combe

Park,

Bath.

Avon

Subclavian artery rupture (an unusual seat-belt injury).

A case of blunt injury to the subclavian artery in the absence of bony injury or dislocation sustained while wearing a seat belt is described. Its rar...
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