Upper Extremity Thrombosis Presenting as Medial Elbow Pain after Shoulder Arthroscopy

Deep vein thrombosis of the upper extremity is believed to be an uncommon complication of arthroscopic shoulder surgery. It most commonly presents with significant swelling and pain throughout the upper extremity. However the diagnosis can be easily missed when findings are more subtle and unrelated or the patient asymptomatic. In this study we report on 5 cases of postoperative upper extremity deep vein thrombosis (UEDVT). Each case was performed in the lateral decubitus position with an interscalene block and postoperative sling immobilization. All patients presented with a primary complaint of medial elbow pain and went on to require anticoagulation. Only one patient was found to have a heritable coagulopathy. The true incidence of thromboembolic phenomena after shoulder arthroscopy may be higher than that reported in the current literature. Therefore a high index of suspicion must be maintained when evaluating patients postoperatively to avoid misdiagnosis. Symptoms of medial elbow pain after immobilization in a sling should be considered an indication for duplex ultrasound evaluation. Ultimately, further prospective study is needed to better understand the prevalence, prevention, and management of this entity. 1. Introduction Deep vein thrombosis (DVT) is a well-known complication following orthopaedic surgery. Most cases typically involve the lower extremities; however, 11% percent of all DVT are known to occur in the veins of the arm and forearm [1]. These upper extremity deep vein thromboses (UEDVT) are well described in the literature [2–5]. Almost 20% of primary cases are believed to occur sporadically and are considered idiopathic; the remainder occurs in the setting of Paget-Schroetter syndrome or venous thoracic outlet syndrome. The vast majority of cases, however, are secondary, caused by exogenous or endogenous risk factors including placement of central venous lines, malignancy, trauma, pregnancy, oral contraceptive use, ovarian hyperstimulation, and baseline coagulopathy [1, 2, 4, 5]. Shoulder arthroscopy was first described as a possible cause by Burkhart as early as 1990 [6]. At the time it was suggested there must be another underlying process other than the procedure, however, several subsequent case reports have refuted that claim [7–11]. Recently there has been increasing recognition that upper extremity injury and upper extremity surgery in general are associated with blood clot formation [12–15]. Dattani et al. in a systematic review showed a 0.52% rate of DVT in shoulder replacements, 0.64% in procedures for fractures of the