Upper extremity deep vein thrombosis after elbow trauma: a case report of a rare occupational accident

Upper extremity deep vein thrombosis (UEDVT) is rare, especially after benign trauma. We report the case of a 31-year-old male nurse with UEDVT after elbow trauma with no fracture. This occupational accident caused thrombosis of basilica vein extended to humeral and axillary veins, collateral circulation in the arm and the right cervical and axillary regions. Thrombophilic tests and assessment of malignant tumor were negative. Treatment by low molecular weight heparin (LMWH) then by vitamin K antagonists was conducted and evaluation by Doppler ultrasonography realized 18 months after trauma showed recanalization of basilica and humeral veins and thrombosis of axillary and subclavian veins. Management of occupational activity was prescribed including eviction of heavy loads handling and repetitive gestures of upper limbs. Pan African Medical Journal. 2016; 23:251 doi:10.11604/pamj.2016.23.251.9107 This article is available online at: http://www.panafrican-med-journal.com/content/article/23/251/full/ © Maher Maoua et al. The Pan African Medical Journal ISSN 1937-8688. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Pan African Medical Journal – ISSN: 19378688 (www.panafrican-med-journal.com) Published in partnership with the African Field Epidemiology Network (AFENET). (www.afenet.net) Case report Open Access


Introduction
Upper deep vein thrombosis (UEDVT), which was considered as a rare benign phenomenon in the past, has become more frequent since the 1970s because of the use of central venous catheters (CVCs) transvenous pacers [1]. Approximately 4-10% of all cases of venous thrombosis involve the subclavian, axillary or brachial veins [2][3][4]. UEDVT is classified as primary or secondary on the basis of pathogenesis [5]. Trauma is a rare cause of secondary UEDVT. Few cases of traumatic UEDVT were reported but elbow trauma seems to be rarely involved in this reports.

Patient and observation
A 31-year-old male nurse, with no medical history of any past illness, non-smoker, consulted our department of occupational medicine with symptoms of pain, elbow and shoulder discomfort and arm edema. Patient described the occurrence of moderateintensity trauma of his right elbow during his night shift. The patient's elbow was accidentally hurt by a door handle. Immediate pain and swelling of the right elbow motivated the patient to consult. Initial Doppler ultrasound showed a dilatation of the basilica vein with no signs of thrombosis. Analgesic treatment was prescribed but had no effect on symptoms.
Fifteen days after the trauma, medical re-examination revealed mild cyanosis of the upper right extremity, arm and hand edema and supraclavicular fullness. CT angiography was immediately performed and showed thrombosis of basilica vein extended to humeral and axillary veins, collateral circulation in the arm and the right cervical and axillary regions ( Figure 1). This exam revealed the absence of thrombosis of superior vena cava or intra-thoracic tumor ( Figure 2). Antithrombin III, and protein C and S levels were normal. Factor V Leiden mutation was absent.
Treatment was based on anticoagulation initially by low molecular weight heparin (LMWH) then by vitamin K antagonists. Evaluation by Doppler ultrasonography realized 18 months after trauma showed recanalization of basilica and humeral veins and thrombosis of axillary and subclavian veins. Declaration of occupational accident was performed since the first reporting of the trauma. Management of occupational activity was prescribed including eviction of heavy loads handling and repetitive gestures of upper limbs.

Discussion
Incidence of UEDVT is about 3 per 100.000 in the general population [6]. This incidence is much less than that of the lower extremity because of fewer and smaller valves in the veins of upper extremity, less hydrostatic pressure in the arms [6] and increased fibrinolytic activity in the endothelium of upper arm as compared to the lower arm [7][8].
Common risk factors for UEDVT are cancer, CVCs, and thrombophilia. Cancer is diagnosed in 63% of patients with UEDVT [9]. Coon and willis classified UEDVT into two divisions: traumatic (including internal and external trauma) and spontaneous [10]. Few reports of post-traumatic UEDVT included bone fractures. Concerned bones were mainly humerus [11] and clavicule [12]. Bibiche Y. and Kanjaa N. reported a case of traumatic subclavian vein thrombosis without clavicular fracture [13]. Swelling of the upper extremity is the most frequent sign of UEDVT [14]. However, most patients with UEDVT are asymptomatic and most of these cases are CVC-associated [15]. Other symptoms include pain, functional impairment and paresthesias, vague shoulder or neck discomfort with edema and collateral veins [16].
Physical examination may reveal cyanosis of the arm, supraclavicular fullness and visible subcutaneous veins over the evolved shoulder and chest wall, or elevated jugular venous distension [17].
Clinical evaluation remains poorly sensitive and specific and only 50% of objective investigations confirmed thrombosis in patients with symptoms of UEDVT [16]. Objective tests include venography, ultrasound, CT angiography, magnetic resonance angiography, radionuclide venography and D-dimer [14]. Ultrasound and CT angiography are frequently performed for their convenience and accessibility.
Possible complication are pulmonary embolus (PE) or recurrent PE, recurrent deep vein thrombosis (DVT) and SVC syndrome. Post thrombotic syndrome may be observed as sequel [14]. Mortality rates are variable and depend on underlying risk factors for thrombosis [14]. The 3-month mortality varies between 3.5% (nonmalignancy-associated UEDVT) and 22% in case of associated malignancy.
Decrease of venous return causing stasis and thrombosis may be an explanation of our patient's UEDVT after his elbow trauma. Traumatic vascular damage can't be excluded and may participate in the genesis of the thrombus. Other etiologies were excluded by negative thrombophilic tests and normal radiological assessment. Patients with Paget-Shroetter Syndrome develop spontaneous UEDVT after strenuous activity which was not the case of our patient.

Conclusion
Post-traumatic UEDVT is a rare condition and may cause dramatic complications and sequelae even if trauma seems benign. Early management and close monitoring are required. Occupational impairment in our case was consequent and professional redeployment is envisaged.