CLINICAL CASE REPORTS
Venous Occlusion Secondary to Subluxation of the Shoulder — A Case Report Sandor A. Friedman, M.D., F.A.C.A.* Rashmikant Doshi, M.D. Rajendra Patel, M.D. and Reza Hedayati, M.D. BROOKLYN, NEW YORK
Abstract This is the case report of an eighty-seven-year-old woman who was seen because of swelling of her left upper extremity and breast of one week’s duration. She had a history of severe arthritis of the knees and had been wheelchair-bound for seven years. Venography showed compression of the cephalic vein and thrombosis of the distal basilic vein with extension into the axillary and subclavian veins. To the author’s knowledge, this is the first case report of venous thrombosis in association with subluxation of the shoulder.
Case Report An eighty-seven-year-old woman, with a medical history of degenerative joint disease, was seen because of swelling of her left upper extremity and breast of one week’s duration. There was no history of trauma, fever, or chills. She gave a history of severe arthritis of the knees and had been wheelchair-bound for seven years. On examination, this elderly, obese woman was afebrile and had a regular pulse rate of 84/minute, blood pressure of 130/80 mm Hg, and respiration rate of 16/minute. There was pulseless jugular venous distension of the left side only, unaffected by position. Cardiac examination revealed a ii/vi systolic murmur at the apex, aortic area, and left sternal border. Abdominal examination was unremarkable. The entire left upper extremity showed marked pitting edema with mild tenderness medially around the elbow. There was edema of the left hemithorax with dilated veins over the left anterior chest. The left breast was pendulous and edematous with nipple retraction, but no mass was felt. Peripheral pulses From the
Department
of Medicine of the Coney Island
Hospital,
and the *State
University of New
New York
866
Downloaded from ang.sagepub.com at University of Manitoba Libraries on June 12, 2015
York at
Brooklyn, Brooklyn,
867
FIG. 1. Venography shows comof the cephalic vein and thrombus in the basilic vein. The axillary vein is not visualized. Subluxation of the humeral head is seen.
pression
tender with obvious distortion of the bony architecture and crepitus. Shoulder x-rays revealed upward displacement of both humeri with associated erosion of the acromion, suggestive of chronic rotator cuff tear. A tentative diagnosis of left innominate vein thrombosis was made, and the patient was administered intravenous heparin. Venography of the left upper extremity showed multiple filling defects within the lumen of the distal portion of the basilic vein and compression of the cephalic vein in both the abducted and adducted positions. The proximal basilic, axillary and subclavian veins were not visualized (Fig . 1). were
present in both upper extremities. Both knees
Laboratory
were
Data
Hemoglobin was 11.6 g/100 mL, hemotocrit was 33.4070, white blood cell count was 8.1 x 10’/mm. Thromboplastin time was 26.3/21.3 sec. The lupus inhibitor test was negative. Prothrombin time was 12.0/ 11.5 sec; the EKG reading was normal, and findings from mammography was normal.
Downloaded from ang.sagepub.com at University of Manitoba Libraries on June 12, 2015
868 Discussion
vein thrombosis is a well-described complication of the thoracic outlet syndrome,’’2 venous occlusion secondary to shoulder girdle injuries has rarely been reported. It has been seen with fractures of the humerus and with overt callus formation following clavicular fractures and operative procedures . To our knowledge, our patient is the first to be reported with venous thrombosis in association with subluxation of the shoulder. Venography showed compression of the cephalic vein and thrombosis of the distal basilic vein with extension into the axillary and subclavian veins. The presence of a dilated external jugular vein on the same side indicates extension of thrombus into the innominate vein. There is an increased incidence of shoulder cuff injuries and subluxation in patients confined to wheelchairs, owing possibly to a combination of chronic trauma related to transfer activities, poor posture, and immobilization.’ This case demonstrates that edema secondary to venous occlusion, rather than limitation of motion and pain, may be the first clinical symptom.
Although axillary-subclavian
Conclusion
prudent to advise careful observation of the shoulders and regular movement exercises in wheelchair-bound patients in order to minimize the incidence of a complication that can lead to pulmonary embolism and superior vena cava syndrome. Sandor A. Friedman, M.D., F.A. C. A. It
seems
Director of Medicine Coney Island Hospital 2601 Ocean Parkway Brooklyn, NY 11235
References 1.Glass BA: The relationship of axillary venous thrombosis to the thoracic outlet compression syndrome. Ann Thorac Surg 19:613-621, 1975. 2. Swinton NW Jr, Edgett JW Jr, Hall RJ: Primary subclavian-axillary vein thrombosis. Circulation 38:737-745, 1968.
3. Bartel M, Endmann P: Late complications of major vessels following shoulder joint injuries. 2 Arztl Fortbild (Jena) 71:153-157, 1977. 4. McCarty DJ: Arthritis and Allied Conditions: A textbook of Rheumatology, ed. 11. Philadelphia: Lea & Febiger, 1989 p 1526.
Downloaded from ang.sagepub.com at University of Manitoba Libraries on June 12, 2015
Venous Occlusion Secondary to Subluxation of the Shoulder — A Case Report Sandor A. Friedman, M.D., F.A.C.A.* Rashmikant Doshi, M.D. Rajendra Patel, M.D. and Reza Hedayati, M.D. BROOKLYN, NEW YORK
Abstract This is the case report of an eighty-seven-year-old woman who was seen because of swelling of her left upper extremity and breast of one week’s duration. She had a history of severe arthritis of the knees and had been wheelchair-bound for seven years. Venography showed compression of the cephalic vein and thrombosis of the distal basilic vein with extension into the axillary and subclavian veins. To the author’s knowledge, this is the first case report of venous thrombosis in association with subluxation of the shoulder.
Case Report An eighty-seven-year-old woman, with a medical history of degenerative joint disease, was seen because of swelling of her left upper extremity and breast of one week’s duration. There was no history of trauma, fever, or chills. She gave a history of severe arthritis of the knees and had been wheelchair-bound for seven years. On examination, this elderly, obese woman was afebrile and had a regular pulse rate of 84/minute, blood pressure of 130/80 mm Hg, and respiration rate of 16/minute. There was pulseless jugular venous distension of the left side only, unaffected by position. Cardiac examination revealed a ii/vi systolic murmur at the apex, aortic area, and left sternal border. Abdominal examination was unremarkable. The entire left upper extremity showed marked pitting edema with mild tenderness medially around the elbow. There was edema of the left hemithorax with dilated veins over the left anterior chest. The left breast was pendulous and edematous with nipple retraction, but no mass was felt. Peripheral pulses From the
Department
of Medicine of the Coney Island
Hospital,
and the *State
University of New
New York
866
Downloaded from ang.sagepub.com at University of Manitoba Libraries on June 12, 2015
York at
Brooklyn, Brooklyn,
867
FIG. 1. Venography shows comof the cephalic vein and thrombus in the basilic vein. The axillary vein is not visualized. Subluxation of the humeral head is seen.
pression
tender with obvious distortion of the bony architecture and crepitus. Shoulder x-rays revealed upward displacement of both humeri with associated erosion of the acromion, suggestive of chronic rotator cuff tear. A tentative diagnosis of left innominate vein thrombosis was made, and the patient was administered intravenous heparin. Venography of the left upper extremity showed multiple filling defects within the lumen of the distal portion of the basilic vein and compression of the cephalic vein in both the abducted and adducted positions. The proximal basilic, axillary and subclavian veins were not visualized (Fig . 1). were
present in both upper extremities. Both knees
Laboratory
were
Data
Hemoglobin was 11.6 g/100 mL, hemotocrit was 33.4070, white blood cell count was 8.1 x 10’/mm. Thromboplastin time was 26.3/21.3 sec. The lupus inhibitor test was negative. Prothrombin time was 12.0/ 11.5 sec; the EKG reading was normal, and findings from mammography was normal.
Downloaded from ang.sagepub.com at University of Manitoba Libraries on June 12, 2015
868 Discussion
vein thrombosis is a well-described complication of the thoracic outlet syndrome,’’2 venous occlusion secondary to shoulder girdle injuries has rarely been reported. It has been seen with fractures of the humerus and with overt callus formation following clavicular fractures and operative procedures . To our knowledge, our patient is the first to be reported with venous thrombosis in association with subluxation of the shoulder. Venography showed compression of the cephalic vein and thrombosis of the distal basilic vein with extension into the axillary and subclavian veins. The presence of a dilated external jugular vein on the same side indicates extension of thrombus into the innominate vein. There is an increased incidence of shoulder cuff injuries and subluxation in patients confined to wheelchairs, owing possibly to a combination of chronic trauma related to transfer activities, poor posture, and immobilization.’ This case demonstrates that edema secondary to venous occlusion, rather than limitation of motion and pain, may be the first clinical symptom.
Although axillary-subclavian
Conclusion
prudent to advise careful observation of the shoulders and regular movement exercises in wheelchair-bound patients in order to minimize the incidence of a complication that can lead to pulmonary embolism and superior vena cava syndrome. Sandor A. Friedman, M.D., F.A. C. A. It
seems
Director of Medicine Coney Island Hospital 2601 Ocean Parkway Brooklyn, NY 11235
References 1.Glass BA: The relationship of axillary venous thrombosis to the thoracic outlet compression syndrome. Ann Thorac Surg 19:613-621, 1975. 2. Swinton NW Jr, Edgett JW Jr, Hall RJ: Primary subclavian-axillary vein thrombosis. Circulation 38:737-745, 1968.
3. Bartel M, Endmann P: Late complications of major vessels following shoulder joint injuries. 2 Arztl Fortbild (Jena) 71:153-157, 1977. 4. McCarty DJ: Arthritis and Allied Conditions: A textbook of Rheumatology, ed. 11. Philadelphia: Lea & Febiger, 1989 p 1526.
Downloaded from ang.sagepub.com at University of Manitoba Libraries on June 12, 2015
