Shoulder Injury - Motor Vehicle Accident in a Tennis Player

Abstract

HISTORY: A 31-year-old male tennis player and musician was in motor vehicle accident. He was the restrained driver, flipped upside down hanging by seatbelt, no airbag deployment. Developed left shoulder pain with electricity sensation and a pulsing sensation near left midshaft clavicle. PHYSICAL EXAM: No tenderness of sternoclavicular or acromioclavicular joint, clavicle. Flexion and abduction 0-180 degrees, external rotation 0-90 degrees, internal rotation to T6. Negative Jobe’s, Neer’s and Hawking’s. Full strength of rotator cuff. Mild tenderness to palpation and thrill of left subclavian artery superior to midshaft clavicle. Positive Wright’s and Roos. Negative Spurling, Lhermitte, Naffziger sign. Hypoesthesia to anterior cervical triangle. DIFFERENTIAL DIAGNOSIS: 1. arteriovenous malformation of subclavian artery 2. thoracic outlet syndrome 3. pseudoaneurysm 4. subclavian artery thrombus 5. clavicle fracture 6. brachial plexopathy TESTS AND RESULTS: - XR left clavicle (2 weeks): No acute fracture. Mild deformity of left first rib, more suggestive of old trauma. - MRI L brachial plexus (2 weeks): Mild left brachial plexus edema suggesting mild neuritis or stretching injury. - CT neck and chest with IV contrast (10 weeks): No soft tissue mass noted at left supraclavicular region. There is fracture at 1st rib with superior angulation of the fracture site deep to the area of interest. - office ultrasound (12 weeks): L subclavian artery 7mm x 3.8cm, corresponds to patient’s location of pain. - vascular ultrasound (15 weeks): no evidence of subclavian artery aneurysm. - CT angiography chest (16 weeks): Pseudoarthrosis of hypoplastic left first rib with lateral second rib. Pseudoarticulation abuts undersurface of mid left subclavian artery without significant extrinsic compression. Left subclavian artery is slightly dilated with questionable surrounding stranding, may suggest stretch injury. No aneurysm or dissection. FINAL/WORKING DIAGNOSIS: left subclavian artery shear/stretch injury TREATMENT/OUTCOME Initially treated with rest and NSAIDs. About 4 weeks post-injury, 7-day course of prednisone 50mg given for brachial plexus injury. Physical therapy started at 13 weeks to stretch scalenes, pectoralis minor, first rib glide. Has not yet returned to activity (at time of submission).