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 Table of Contents  
CME IN IMAGES
Year : 2017  |  Volume : 15  |  Issue : 1  |  Page : 70-72

Pain in the arm


1 Department of Surgery, Christian Medical College, Vellore, Tamil Nadu, India
2 Department of Continuing Medical Education, Christian Medical College, Vellore, Tamil Nadu, India

Date of Web Publication17-Feb-2017

Correspondence Address:
Rajat Raghunath
Department of Surgery, Christian Medical College, Vellore - 632 004, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_6_17

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How to cite this article:
Raghunath R, Thomas TA. Pain in the arm. Curr Med Issues 2017;15:70-2

How to cite this URL:
Raghunath R, Thomas TA. Pain in the arm. Curr Med Issues [serial online] 2017 [cited 2019 Jul 16];15:70-2. Available from: http://www.cmijournal.org/text.asp?2017/15/1/70/200312


  Case Scenario Top


A 45-year-old female was seen in the clinic with complaints of progressively worsening ill-defined aching pain in her left shoulder radiating to the right upper arm for 6 months. The pain increased after carrying weights (like a bag of groceries from the market) and improved with rest. There was occasional tingling paresthesia in the arm with no dermatomal pattern. Clinical examination was unremarkable except for a positive Adson's test. The X-ray of the cervical spine is shown in [Figure 1].
Figure 1: X-ray of cervical spine and shoulder.

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  Questions Top


  1. What abnormality is seen in the X-ray that may indicate a cause for the symptoms?
  2. What is the syndrome caused by the X-ray abnormality?
  3. What differential diagnoses will you consider for the clinical syndrome?



  Answers Top


1. Cervical rib

A cervical rib is an anomalous rib that arises from the seventh cervical vertebra [Figure 2]. It is said to occur in 0.6%–0.8% of the population. Although usually asymptomatic (only about 10% show symptoms), it is the most common cause of thoracic outlet syndrome (TOS).[1],[2],[3],[4]
Figure 2: Arrows point to the cervical rib.

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There are four main varieties of cervical ribs - type I: a complete cervical rib articulates with the first rib or manubrium of sternum; type II: incomplete cervical ribs with a free end expanded to form a bulbous tip; type III: an incomplete rib that is continued by a fibrous band; and type IV: a rib that appears as a short bar of bone with a length of a few millimeters beyond the C7 transverse process. Additionally, an elongated C7 transverse process can produce neurovascular compression.[1]

Diagnosis

The diagnosis can be made by imaging such as an X-ray or computed tomography scan. Clinical tests such as Adson's test help in making the clinical diagnosis.

Adson's test

With the patient in the seated position, radial pulse is palpated. The patient is instructed to rotate his head and elevate his chin to the tested side. If there is a decrease or absence of pulse, the test is positive showing that vascular component of neurovascular bundle is compressed by scalenus anterior muscle or cervical rib.

Treatment

The treatment of neurogenic TOS is usually physiotherapy with strengthening of shoulder muscles and improvement of posture to decrease the pressure on the neurovascular structure.

Surgical decompression is usually reserved for patients with vascular TOS or neurogenic TOS which has failed physical therapy. For cervical rib, the excision can be performed through the transaxillary or the supraclavicular approach, and the cervical rib with the first rib is excised.[1],[2],][3]

2. Thoracic outlet syndrome

TOS refers to the symptoms and signs resulting from the compression of the brachial plexus elements or subclavian vessels as they pass from the cervical area, through the “thoracic outlet” into the axilla and proximal arm.

Anatomy

The “thoracic outlet” is made up of three compartments: Interscalene triangle, costoclavicular triangle, or subcoracoid space. The interscalene triangle is bordered by the anterior scalene muscle anteriorly, the middle scalene muscle posteriorly, and the medial surface of the first rib inferiorly [Figure 3]. Symptoms are usually due to compression of the trunks of the brachial plexus seen in the interscalene triangle.[5] Compression in this region may occur as a result bony abnormalities (supernumerary ribs, abnormal first rib, and malunion of clavicle) or soft tissue abnormalities (fibrous bands and muscle anomalies).
Figure 3: Anatomy of the Thoracic outlet (a) Middle scalene, (b) Anterior scalene, (c) First rib, (d)Clavicle, (e) Subclavian vein, (f) Subclavian artery, (g) Brachial plexus, (h) Pectoralis minor, (i) Coracoid process.

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Patients with TOS usually have aching type pain radiating from their scapula down the upper extremity. The pain is often exacerbated by lifting the arm or carrying heavy objects. There may be associated numbness, tingling, weakness, swelling, coolness, and discoloration of the arm. TOS is more common in women, especially in the 20–50 years age group.[6]

TOS can be divided into three main types

  1. Neurogenic TOS – symptoms of neurogenic TOS can be dysesthesia, numbness, and weakness of the arm not localized to specific nerve distribution. The symptoms are exaggerated and duplicated by certain movements such as head rotation, neck tilting, and abduction of the arm. 95% of TOS present with neurogenic symptoms
  2. Venous TOS – symptoms caused by venous compression account for 4% TOS. The symptoms range from swelling and edema of the upper limb to spontaneous upper extremity venous thrombosis (Paget–Schroetter syndrome)
  3. Arterial TOS – It is rare and accounts for about 1% of all TOS but is almost always associated with cervical ribs. Symptoms usually are of upper limb ischemia such as pain, pallor, and paresthesia and can even present as digital gangrene.


There is some controversy regarding TOS due to the lack of clear defining criteria and definite pathological correlation.

Diagnosis may be challenging because of the varied presentations of this condition. However, in most cases, a careful history and clinical examination can lead to a diagnosis which may be confirmed with radiological imaging.

3. Differential diagnosis of thoracic outlet syndrome

The diagnosis of TOS is often daunting as there are several conditions that may present with pain in the arm. However, careful clinical examination, clinical provocative tests, and appropriate imaging should rule out the possible differential diagnoses [6],[7] [Table 1].
Table 1: Differential diagnosis of thoracic outlet syndrome

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Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Samarasam I, Sadhu D, Agarwal S, Nayak S. Surgical management of thoracic outlet syndrome: A 10-year experience. ANZ J Surg 2004;74:450-4.  Back to cited text no. 1
    
2.
Wood VE, Twito R, Verska JM. Thoracic outlet syndrome. The results of first rib resection in 100 patients. Orthop Clin North Am 1988;19:131-46.   Back to cited text no. 2
    
3.
Huang JH, Zager EL. Thoracic outlet syndrome. Neurosurgery 2004;55:897-902.   Back to cited text no. 3
    
4.
Sheth RN, Belzberg AJ. Diagnosis and treatment of thoracic outlet syndrome. Neurosurg Clin N Am 2001;12:295-309.  Back to cited text no. 4
    
5.
Demondion X, Herbinet P, Van Sint Jan S, Boutry N, Chantelot C, Cotten A. Imaging assessment of thoracic outlet syndrome. Radiographics 2006;26:1735-50.  Back to cited text no. 5
    
6.
Köknel Talu G. Thoracic outlet syndrome. Agri 2005;17:5-9.  Back to cited text no. 6
    
7.
BMJ Best Practice. Thoracic Outlet Syndrome. Available from: http://www.bestpractice.bmj.com/best-practice/monograph/592/diagnosis/ differential.html. [Last accessed on 2017 Jan 25].  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]



 

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