Thoracic outlet syndrome
Background
- Symptoms from compression of neurovascular bundle at thoracic outlet
- Neuro complications most common (95%), then venous compression (3%), and then arterial (1%)
- Scalene triangle most often involved area: borders are anterior scalene, middle scalene and first rib
Clinical Features
- Pain, numbness or weakness in upper extremity aggravated by elevating hands
- Neck rotation, arm abduction or UE external rotation may elicit symptoms
- Sensory deficits common along T1 distribution
- Swelling, claudication pain & cyanosis with activity if venous compression
- Hand ischemia (pain, pallor, paresthesia, cold) if arterial compression
- Almost always has cervical/anomalous rib
- May have tender scalene muscles
- Thrombus may develop from vascular compression
Differential Diagnosis
Shoulder and Upper Arm Diagnoses
Traumatic/Acute:
- Shoulder Dislocation
- Clavicle fracture
- Humerus fracture
- Scapula fracture
- Acromioclavicular joint injury
- Glenohumeral instability
- Rotator cuff tear
- Biceps tendon rupture
- Triceps tendon rupture
- Septic joint
Nontraumatic/Chronic:
- Rotator cuff tear
- Impingement syndrome
- Calcific tendinitis
- Adhesive capsulitis
- Biceps tendinitis
- Subacromial bursitis
- Cervical radiculopathy
Refered pain & non-orthopedic causes:
- Referred pain from
- Neck
- Diaphragm (e.g. gallbladder disease)
- Brachial plexus injury
- Axillary artery thrombosis
- Thoracic outlet syndrome
- Subclavian steal syndrome
- Pancoast tumor
- Myocardial infarction
- Pneumonia
- Pulmonary embolism
Evaluation
- CXR
- Consider duplex ultrasound if venous/arterial compression suspected
Management
- Physical therapy as outpatient
- Treat embolus if present
- Consider interscalene injection
Disposition
- Home
See Also
References
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