Thoracic outlet syndrome in patients with clavicle fracture: Case report and national analysis

Thoracic outlet syndrome (TOS) is a neurovascular condition caused by compression of the brachial plexus or subclavian vessels as they pass through the thoracic outlet. Since the clavicle border the thoracic outlet, injury to the clavicle and potentially post-traumatic callus formation, malunion, or scarring may precipitate compression and TOS. This study aims to determine the incidence and key predictors of TOS after clavicle fracture.

We present a representative case description illustrating the clinical course and diagnostic considerations of post-traumatic TOS. We also conducted a large-scale retrospective analysis using a national claims database to identify patients with clavicle fracture and evaluate the incidence and factors of TOS development.

A 53-year-old woman developed TOS 10 months after undergoing surgical fixation of a displaced mid diaphyseal (Allman Tyle 1) clavicle fracture sustained in a motor vehicle accident. She presented with swelling and discoloration of the left upper extremity, where computed tomographic contrast imaging demonstrated five centimeter left subclavian vein thrombosis. The patient underwent hardware removal and first-rib resection, which resulted in complete resolution of symptoms. On database analysis, TOS most frequently occurs in middle-aged adults (40-64 years) and is more common following displaced clavicle fractures fixed with open reduction and internal fixation, as observed in this case. Comorbid conditions such as hypercoagulable states, obesity, and tobacco use along with displaced fracture pattern and congenital factors-including cervical ribs or cervical scoliosis-may further elevate risk.

Thoracic outlet syndrome should be considered in patients with history of recent clavicle fracture that develop symptoms such as paresthesia, swelling, or chronic pain of the ipsilateral upper extremity.