Unilateral Arm Swelling • Tim Kubal
Thoracic Outlet Syndrome • Compression of neurovascular structures as they pass through the thoracic outlet. • NTOS, ATOS, VTOS (Paget-Schroetter Syndrome) • Whiplash, Repetitive activity, rib anomaly, prior clavicular fx, fibrosis.
NTOS • Most common with the majority of these cases being related to trauma and virtually impossible to diagnose objectively • Paresthesias, pain • Tx conservatively in majority of cases unless demonstrable anatomical abnormality then consider surgery
VTOS • Majority of cases related to strenuous or repetitive overhead activity. • Acute or subacute swelling, heaviness, pain, venous distention with visible collaterals. • Acute: Thrombolytics, stenting/venoplasty, surgical decompression, anticoagulation. • Subacute: Conservative vs. Surgery
ATOS • Least common • Subclavian Artery Compression • Typically secondary to demonstrable rib abnormality • Pain, Paresthesias, Cyanosis, Embolism, Negative Pulses, Slow capillary refill
How do i work this up? • Provocative testing • Dopplers (Acutely r/o thrombosis) • C-Spine films, shoulder films • CT chest
Management • VTOS: Usually requires urgent thrombolysis, anticoag, surgical decompressions • ATOS: surgical decompression and restoration of arterial blood flow • NTOS: PT, surgical decompression.
Surgery • Rib, muscle resection • Less stuff • More space
What else could it be? • Brachial plexus injury • Carpal Tunnel • CRPS • Malignancy • C-Spine or shoulder MSK • Nothing
TOS • JR Richard (CVA) • David Cone (Arterial aneurysm) • Hanson