TOS following ORIF clavicle surgery

by Ros
(UK)


Hi,
I have just found your website and think it is excellent.
10 weeks ago, I fell downstairs and badly fractured my right clavicle - mid shaft comminuted and displaced. This was treated conservatively with a sling. Two weeks on I noticed that my right arm was a bluish/red colour when out of the sling and down at my side. I also had pain in my upper arm which felt as though a blood pressure cuff was continuously tightening extending the pain down my whole arm to my hand which started to swell. I was experiencing a lot of shoulder muscle spasms due to the fracture at the same time.

At night time when lying down, the arm symptoms would be relieved until rising again in the morning. Also I noticed that doing anything strenuous such as brushing teeth, cutting vegetables, styling hair would exacerbate the symptoms. One worrying symptom was that once, I raised my arm in the air to try and relieve the symptoms and after 2 or 3 minutes I realised that my arm was completely white, nails and everything. I quickly dropped it and the normal colour returned.

Upon follow-up at the hospital it was decided that I had TOS with tenting of the artery caused by the displaced fracture and needed surgery as a trauma case. I had ORIF with a plate 2 weeks ago.

I have since noticed that I still have the original symptoms including white arm if I hold it up. Last night I woke up and had a numb ring and pinkie finger on that side which I haven't had before. Could this be due to the after effects/swelling from the surgery and is it likely to settle. My surgeon did say that the surgery might not cure the TOS and I would have to be referred to vascular for further investigation. Should I be concerned?

Hello Ros,
Yes, unfortunately you should be concerned but, unless things take a turn for the worse, I would give it some time after the surgery. Both the original injury, and the aftermath of the surgery will have caused swelling, potentially affecting both the five nerves and the artery passing through the inter scalene triangle; the lowermost trunk is most commonly affected producing the tingling in the ring finger and pinkie.

In the circumstances, I think the open reduction and internal fixation was probably unavoidable; it would be interesting to ask the surgeon what he actually saw; how was the artery being affected? I'd love a photo if he took one!

Cutting off the blood supply to the arm when you raise it above your head is very typical. Don't hang washing for a bit.

The specific procedure is called Adson's test; it's difficult to do objectively but you probably have a very positive sign, and it will give you a measure of the progress if you can master it; see lower down.

This is a serious injury; you must accept that for a month at least you should be relatively inactive; I'm sure the surgeon spelt it out.

Let me know how you get on.

Dr B


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