Case 1

G.G., male, 50 years old

The patient was referred to our hospital after colliding with a car while riding his motorcycle. He was haemodynamically unstable. After initial x-ray and resuscitative manoeuvres (fluid and blood infusion, intubation, left chest tube), the total body CT scan revealed a subdural haematoma, fractures of C7, T3, T4, T11, T12, left lung contusion, left apical pneumothorax, bilateral fracture of XII rib, left sternoclavicular separation, and scapulothoracic dissociation (Fig. 1) with complete interruption of axillary artery. The left upper limb was cold and pulseless.

CT 3d reconstruction: left scapulothoracic dislocation

The patient was immediately treated for the vascular injury. Angiography (Fig. 2) with endovascular recanalization was tried, unsuccessfully; therefore an axillo-brachial by-pass with autologous saphenous vein graft was done. The brachial plexus was completed disrupted and a large haematoma was evacuated from the axilla. He was then taken to ICU for observation and continued resuscitation.

Angiography showing bleeding from complete lesion of the axillary artery

On 1^st post-op day, as a compartment syndrome after revascularization was present, volar and dorsal fasciotomies of the left upper limb were done. Following an infection of the fasciotomy wounds, an above-the-elbow amputation was redeemed necessary because of wet gangrene.

The neurosurgeons performed cervical and dorsal decompression and fixation (incomplete tetraplegia). The patient was also treated surgically for a right wrist fracture and conservatively for a right undisplaced tibial plateau fracture.

The patient underwent an i.v. antibiotic treatment for sepsis while in hospital.

The patient was discharged 50 days after admission and transferred to a neurologic rehabilitative hospital.