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
  • Anterior shoulder dislocation
  • Posterior shoulder dislocation
  • Inferior shoulder dislocation
• Clavicle fracture
• Humerus fracture
• Scapula fracture
• Acromioclavicular 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

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

References

UpToDate

Authors

Jonathan Osgood, Neil Young, Ross Donaldson, Daniel Ostermayer