Subclavian vessel injury from chest-drain malposition in the treatment of a pneumothorax in the presence of a lateral third open clavicular fracture()

Objective: We report the unorthodox injury of the subclavian vessels by the malposition of a chest drain, for the treatment of a pneumothorax in the presence of a lateral third open fracture of the left clavicle. This case presents the first report of a ruptured subclavian vein and cephalic vein after the insertion of a chest drain for a pneumothorax. A systematic search performed in MEDLINE, EMBASE, Cochrane Library, and Web of Science found no similar cases documented in the literature. Methods: A Chest tube was inserted into the second intercostal space mid-clavicular line. Immediately postinsertion the left-hand digits were cyanosed with an absent radial pulse. An intraoperative haematoma was noted surrounding the chest drain insertion point. Vascular surgeons provided assistance and detected ruptured cephalic and subclavian veins and a punctured subclavian artery. The subclavian artery was repaired and both veins tied. The chest drain was re-inserted as per the ATLS protocol into the 4th intercostal space mid-axillary line. Upon healing of vascular repair of the subclavian artery injury the clavicle fracture was treated by use of a hook plate. Results: The patient made a good recovery, follow-up radiographs showed signs of fracture healing with complete resolution of pneumothorax and the patient was discharge from the department of orthopedic care. Conclusion: We believe that strict adherence to ATLS principles is vital as fractures of the lateral third of the left clavicle can distort anatomical landmarks. This can increase the incidence of injury to subclavian vessels due to malposition of the chest drain. Insertion of the chest drain in the fourth intercostal space mid-axillary line provides sound decompression of a pneumothorax as per ATLS protocol and reduces iatrogenic risk.