Pulmonary embolism after zone 5 flexor tendons, ulnar artery, and ulnar nerve repair

Pulmonary embolism (PE) following upper extremity trauma is rare, and PE following injuries of the zone 5 flexor tendon injuries have not been reported. We experienced one case of acute pulmonary embolism after the surgery. The purpose of our report is to raise awareness about this rare but serious complication of pulmonary embolism following upper extremity trauma surgery. It’s important to promptly manage to prevent potentially life-threatening consequences and ensure the best possible outcome for the patient.

Case presentation 

A 41-year-old Thai man, who had no report of previously underlying disease, had a cut wound at his right distal forearm. On physical examination revealed active pulsatile bleeding from the wound at the ulnar side of the right distal forearm. He couldn’t actively flex his right little and ring fingers and also had numbness on the distal ulnar nerve distribution. We performed the urgent systematic debridement and wound exploration and rupture of the ring and little FDPs, FDSs, and FCU tendons along with the ulnar artery and nerve were injured. The tendons, artery and nerve were repaired immediately. After the operation, he complained of dyspnea and his oxygen saturation dropped to 90%. He had good perfusion on his right hand and no sign of deep venous thrombosis in four extremities. 12-lead EKG showed normal sinus rhythm with a heart rate of 82 beats per minute and an S1Q3T3 pattern. Chest X-ray showed a small linear atelectasis at the left lower lung. The urgent CT-PA revealed a concentric intraluminal filling defect within dilated branches of the pulmonary artery to lobar branches of the right and left upper lung. 

He was diagnosed with acute pulmonary embolism and the oxygen cannula 5 L/min. was applied. Also, a subcutaneous injection of 90 mg of Enoxaparin was administered immediately and given twice daily during the admission. He was firstly diagnosed with essential hypertension and manidipine 20 mg was prescribed once daily. Protein C, protein S and antithrombin III activity were unremarkable, Anti-cardiolipin immunoglobulins, Beta-2 glycoprotein immunoglobulins and Lupus anticoagulant were negative. Ten days after the operation, he was completely recovered and discharged from the hospital and was prescribed rivaroxaban 20 mg was used once daily instead of Enoxaparin. His range of motion of the wrist and fingers was full at 4 months after surgery.

Keywords: Pulmonary embolism, Zone 5 flexor tendon injury, ulnar nerve, ulnar artery