Delayed Upper Extremity Deep Vein Thrombosis in the context of Traumatic Brachial Plexus Injury

Case Diagnosis: Delayed Upper Extremity Deep Vein Thrombosis in the context of Traumatic Brachial Plexus Injury

Case Description or Program Description: A previously healthy 32-year-old male suffered a motorcycle accident resulting in a traumatic right transfemoral amputation, a right brachial plexus injury (BPI) and other associated injuries. Right brachial plexus magnetic resonance imaging elucidated preganglionic nerve root injury from C5-T1 and avulsion of C7, C8. T1 nerve roots. Patient had 3 week hospital course prior to presentation to acute rehabilitation. Exam was pertinent for monoplegia of the right upper extremity (UE) with minimal recruitment of elbow flexors and shoulder abductors.

Setting: Inpatient acute rehabilitation

Assessment/Results: Ten days into inpatient rehabilitation course the patient complained of pain at the proximal right UE and worsening edema. The patient had been on heparin for deep vein thrombosis (DVT) prophylaxis. Doppler ultrasound was performed revealing DVT of the axillary vein. Patient was started on apixaban.

Discussion (relevance): We postulate that traumatic BPI may inherently increase the risk of UE DVT compared to patients with monoplegia from other causes. Interestingly with this case there was a delay in the development of symptomatic DVT until almost 30 days after the injury with the initiation of range of motion exercises in therapy. We hypothesize that the repetitive movement of the affected limb during early rehabilitation could contribute to DVT formation through a mechanism like that seen in Paget-Schroetter Syndrome (PSS) where repetitive movements cause compression of the neurovascular bundle as it exits the thoracic outlet contributing to DVT formation.

Conclusions: Further studies are needed to investigate how therapy programs affect DVT risk with BPI. Preventative measures including chemical DVT prophylaxis, avoiding blood draws on the involved arm and screening with doppler ultrasound should be considered in this population.