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A misdiagnosed potentially dangerous shoulder injury
  1. P M Jarrett
  1. Correspondence to:
 Mr Paul M Jarrett, Department of Orthopaedic Surgery, Princess Alexandra Hospital, Harlow, Essex CM20 1QX, UK; 

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Answers on p 360.

A 40 year old engineer presented with a history of chronic left upper limb fatigue and pallor upon limb abduction and intermittent dysphagia. These symptoms caused significant interference with his daily life and had started after a fall onto his left shoulder during a rugby tackle nine years previously. Following the original injury he had attended an accident and emergency department where it was noted that he had a swollen discoloured neck and left upper limb, paraesthesia in the left hand and forearm, and an inability to actively move his shoulder. Asymmetry was noted between the medial ends of his clavicles and he was tender over his medial left clavicle. Plain radiographs of his neck, chest, and shoulder after the injury were reported as normal. A diagnosis of muscle sprain and mild brachial plexus traction injury was made and he was observed in hospital for one day.

At representation nine years after the injury, examination revealed the medial aspect of his left clavicle to be less prominent than the right. Otherwise with his limbs resting by his side, his neck, shoulders, and upper limbs were normal to examination. On abduction the left upper limb gradually became white and after the limb was held abducted for one minute it became temporarily cyanosed upon returning it to the resting position. Neurological examination of his upper limbs was normal. His peripheral pulses were normal in the resting position but on the left were absent with the limb abducted. Computed tomography (fig 1) and arteriography with the limb in the resting (fig 2) and abducted positions (fig 3) were performed to aid in diagnosis.

Figure 1

Three dimensional computed tomogram reconstruction of the thoracic outlet.

Figure 2

Arteriogram of his left subclavian artery with his arm in the resting position.

Figure 3

Arteriogram of his left subclavian artery with his arm in abduction.


  1. What is the diagnosis?

  2. What is demonstrated by arteriography?

  3. How should be injury have been managed upon initial presentation?

  4. What are the management options nine years after injury?

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