Presentation
Fall from pushbike, falling onto handlebars. Landed on the ground on left side. Deformed clavicle.
Patient Data
The cardiac and mediastinal contours are within normal limits for projection. Minor atelectasis in the left base, no consolidation or collapse elsewhere. No pleural effusion or pneumothorax. Comminuted overlapping fracture of the left clavicle midshaft with adjacent soft tissue swelling. The glenohumeral and acromioclavicular alignments are within normal limits bilaterally. No rib fractures evident.
Displaced comminuted left clavicle fracture with an associated large left supraclavicular, infraclavicular and anterior chest wall/axillary hemorrhage with the hematoma extending intercostally and extra pleurally adjacent to the mediastinal pleura. The first part of the left axillary artery is irregular and there is a large anterior pseudoaneurysm. The remainder of the axillary artery and brachial artery opacify normally. The left common carotid and right brachiocephalic artery are normal in appearance.
Trace of hemorrhage extending along the anterior upper mediastinal pleura. No periaortic hematoma. No traumatic aortic injury. No hemothorax or pneumothorax. Minor dependent lung changes, no pulmonary contusion or laceration.
Left posterior 5th to 8th minimally displaced rib fractures and anterior 5th to 7th rib fractures adjacent to the costochondral junction. No scapular or sternal fracture. Left sternoclavicular joint is asymmetrically widened raising suspicion for traumatic capsular injury. Normal thoracic spine.
IMPRESSION
Left axillary artery pseudoaneurysm and large surrounding hematoma.
Multiple left-sided rib fractures with 5th-7th rib flail segment. Comminuted and displaced left clavicle fracture. Suspected left sternoclavicular joint injury with no significant anterior or posterior subluxation.
The patient was taken to the vascular hybrid theater where the vascular surgical team performed a left brachial cutdown and 7Fr sheath direct puncture and left groin USS guided 5Fr CFA puncture.
Angiogram shows a blush from the subclavian/axillary artery junction. A self-expanding covered stent was deployed successfully. Branches of the subclavian artery are still patent proximally including internal mammary and vertebral arteries.
Case Discussion
The patient recovered uneventfully.
The CT shows the importance of injecting contrast in the uninjured upper limb, as dense contrast in the veins on the left would have obscured the arterial injury.
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