Axillary Vein Thrombosis Mimicking Muscular Strain 233
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Axillary vein thrombosis mimicking muscular strain 233 Discussion The overall incidence of imperforate hymen is unknown. In an American series of 254 vaginal J Accid Emerg Med: first published as 10.1136/emj.16.3.233 on 1 May 1999. Downloaded from malformations 17 of the patients had an imperforate hymen.' The authors of the paper estimated the incidence of vaginal agenesis to be one in 10 500 births and vaginal agenesis was 10 times more common than imperforate hymen in their series. Thus it can be seen that imperforate hymen is certainly uncommon. The incidence of associated acute retention of urine has been stated to be rare.2 Alterna- tively in a series of 26 cases of imperforate hymen reported by Calvin and Nichamin, 12 cases of the 26 (46%) presented with acute uri- nary retention.3 Urinary retention may occur when the retained menstrual products in the vagina compress the urethra and there is angu- lation of the urethra caused by pressure on the posterior wall of the bladder, again by retained A~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~menstrual products. This condition is not usu- ally associated with other abnormalities.4 Figure 1 Ultrasonography showing dilated uterine cavity. Other causes of acute urinary retention in children include constipation, urinary infec- tion, postoperative causes, pelvic abscess, On catheterisation of the bladder, however, trauma, neurogenic bladder, urethral valves, the external genitalia were noted to be and tumours.5 markedly abnormal. There was no vaginal ori- This condition has not been described fice and the hymen was intact and bulging. before in the UK A&E literature. It is reported Secondary sexual characteristics were normal. here to emphasise the importance of assess- The patient reported that she had not yet ment of the cause of acute urinary retention in experienced a menstrual period. patients whose age and sex make the diagnosis After catheterisation 1000 ml of urine was unusual. drained. Subsequent pelvic ultrasonography revealed a massively dilated uterine cavity (fig 1 Evans TM, Polano ML, Boving RL. Vaginal malformations. 1), to the level of the umbilicus, with a dilated AmJ Obstet Gynecol 1981;141:910-20. 2 Lazarus J. Two cases of urinary retention from vaginal vagina extending to within 1 cm of the perineal occlusion. N YStateMed3' 1932;32:339-40. surface. 3 Calvin JK, Nichamin SJ. Haematocolpos due to imperforate hymen. Am 7 Dis Child 1936;51:832-46. At operation the hymen was incised and 4 Little KH, Crawford BD, Meister K. Haematocolpos: 1500 ml of old blood drained. The patient diagnosis made by ultrasound. J Clin Ultrasound 1978;11: 340-2. http://emj.bmj.com/ went on to make a full and uneventful 5 Peter JR, Steinhardt GF. Acute urinary retention in recovery. children. Pediatr Emerg Care 1993;9:205-7. Axillary vein thrombosis mimicking muscular strain on September 27, 2021 by guest. Protected copyright. J Louis Abstract climbing two weeks previously. While climbing Axillary vein thrombosis may occur on he had reached above his head for a handhold strenuous activity with a clinical picture and, on pulling himself up, experienced a sud- similar to a simple strain. It carries signifi- den sharp pain in his axilla. He had treated cant morbidity but a good outcome is pos- himself for a muscular strain with rest and Accident and sible with early treatment. The aetiology, non-steroidal anti-inflammatory drugs but his Emergency investigation, and treatment are discussed. symptoms had progressively worsened. Department, (J Accid Emerg Med 1999;16:233-234) The arm was diffusely swollen with a 2 cm x Southmead Hospital, 1 cm bruise in the axilla. The patient had Bristol Keywords: axillary vein thrombosis; upper limb injury; prominent superficial veins bilaterally but thrombolysis; vascular injury Correspondence to: those on the right failed to empty on elevation. Mr Jason Louis, Emergency There was no tenderness and shoulder move- Department, Frenchay Case report ments were normal. Hospital, Bristol BS 16 1LE. A 23 year old man presented with history of Axillary vein thrombosis was suspected and Accepted 11 February 1999 aching and tightness in his right arm since rock venography was performed showing complete 234 Louis curs in 5% to 14% of patients6 and is more common after primary thrombosis. Venous obstruction may cause persistent swelling and J Accid Emerg Med: first published as 10.1136/emj.16.3.233 on 1 May 1999. Downloaded from pain and, although these symptoms are less common than after lower limb deep venous thrombosis, 27% of patients remain sympto- matic six months after presentation despite treatment.7 Anticoagulation is the commonest form of treatment. This will not recanalise the vessel but is aimed at preventing propagation of the W~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~.......... thrombus and embolisation. Although no data specific to upper limb thrombosis are available, it would theoretically be possible to start anticoagulation with a low molecular weight heparin on an outpatient basis. Surgery is usually reserved for the correction Figure 1 Venogram showing occlusion ofaxillary vein. of anatomical abnormalities if symptoms per- occlusion of the axillary vein (fig 1). The typi- sist after a period of anticoagulation.3 There cal "tramline" appearance of contrast flowing have been no large trials of either acute around a thrombus was not seen, so computed thrombectomy or later balloon venoplasty and tomography was performed to exclude an their roles remain controversial. extrinsic lesion compressing the vein; this was Thrombolysis has been shown to produce normal. patency of the affected vessel in 88% of cases.6 Blood was taken for proteins S and C, Only 15% of patients treated this way experi- antithrombin III, and lupus anticoagulant con- ence persistent symptoms compared with 36% centrations, all of which were normal. Antico- of those receiving anticoagulation only and agulation was then started with intravenous 64% of those left untreated. The mean follow heparin and continued with warfarin. Three up period of these patients was 1.9 years.7 It months after discharge the patient has some has become the treatment of choice in patients residual\welling but good function. He will presenting within five days of thrombus forma- resume rock climbing when anticoagulation tion and is most likely to be successful if has been discontinued. administered by local infusion, through a long venous catheter. Unfortunately our patient Discussion presented too late for thrombolysis to have Axillary vein thrombosis is associated with been effective. various aetiological factors. It may occur as a primary event due to vigorous upper limb SUMMARY activity or extrinsic venous compression, but is Axillary vein thrombosis is an uncommon con- more commonly secondary to central venous dition that may be associated with a history of http://emj.bmj.com/ catheterisation or systemic illness causing a injury and so remain unrecognised. If diag- hypercoagulable state. Overhead positioning of nosed early prognosis can be improved by the arm, as in climbing, may cause stretching thrombolytic treatment, otherwise anticoagula- and intimal tears of the subclavian vein' or tion alone is the treatment of choice. Surgery venous compression in the costoclavicular should be considered for patients who have space,' both predisposing to thrombus forma- anatomical abnormalities and exhibit persist- tion. It accounts for approximately 4% of all ent symptoms. on September 27, 2021 by guest. Protected copyright. deep venous thrombosis and the incidence is increasing with greater use of central venous catheters.3 Conflict of interest: none. Patients present with swelling (74%), discol- Funding: none. oration (68%), or aching (26%) of the affected 1 Schulte KR, Warner JIP. Uncommon causes of shoulder limb.4 Other findings may include venous pain in the athlete. Orthop Clin North Am 1995;26:505-28. 2 Medler RG, McQueen DA. Effort thrombosis in a young distension and tenderness. Venography is the wrestler. J Bone joint SurgAm 1 993;75: 1071-3. investigation of choice and will reveal the posi- 3 Rochester JR, Beard JD. Acute management of subclavian vein thrombosis. BrJ Surg 1995;82:433-4. tion and extent of the thrombus. Doppler 4 Horattas MC, Wright DJ, Fenton AH, et al. Changing con- ultrasound examination may produce false cepts of deep venous thrombosis of the upper extremity- report of a series and review of the literature. Surgery 1988; negative results if large collateral vessels are 104:561-7. present,5 however it is non-invasive and a posi- 5 Whelan TR. Management of vascular disease of the upper extremity. Surg Clin North Am 1982;62:373-89. tive result obviates the need for venography. 6 Hicken GJ, Ameli FM. Management of subclavian-axillary Morbidity after axillary vein thrombosis is vein thrombosis: a review. Can J Surg 1998;41:13-25. 7 Becker DM, Philbrick JT, Walker FB. Axillary and due to pulmonary embolism and chronic subclavian venous thrombosis. Prognosis and treatment. venous obstruction. Pulmonary embolism oc- Arch Intern Med 1991;151:1934-43..