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A 64-year old woman with right hand swelling and paresthesia

  • Or Kalchiem-Dekel
    Correspondence
    Corresponding author at: Department of Medicine B, Soroka University Medical Center, POB 151, Beer-Sheva 8410101, Israel. Tel.: +972 8 640 0622; fax: +972 8 640 3534.
    Affiliations
    Department of Medicine B, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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  • Sharon Davidesko
    Affiliations
    Department of Medicine B, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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  • Nimrod Maimon
    Affiliations
    Department of Medicine B, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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      Keywords

      1. Indication

      A 64-year old woman presented to the emergency department with a 6-month history of right lateral cervical pain and a 2-week history of erythema and swelling of her right hand and wrist, accompanied by a tingling sensation along her right forearm. The patient denied recent occurrence of fever, recent trauma, or strenuous exercise. She appeared comfortable. Her temperature was 36.2 °C, blood pressure was 132/70 mm Hg, pulse was 89 beats/minute and O2 saturation was 98% in ambient room air. Physical examination of the right upper limb revealed mild erythema and non-pitting edema of the hand and wrist as well as decreased sensation to light touch and pain along the C8–T1 dermatomes. Motor strength in all muscle groups and deep tendon reflexes remained intact. Loss of the radial pulse during inspiration was noted upon ipsilateral rotation of the head during neck extension. Examination of the rest of the neck, left arm and lower limbs was normal. Laboratory work-up including complete blood count, erythrocyte sedimentation rate, and C-reactive protein was within the normal limits. A posterior–anterior chest roentgenogram was obtained (Fig. 1).
      Figure thumbnail gr1
      Fig. 1A posterior–anterior chest roentgenogram revealing a long right and short left cervical rib.
      What is the diagnosis?

      2. Diagnosis

      The constellation of signs and symptoms presented by this patient was highly suspicious for thoracic outlet syndrome. Loss of the radial pulse during inspiration upon ipsilateral rotation of the head during neck extension is known as Adson's sign. The diagnosis was confirmed by chest roentgenogram revealing a long right and short left cervical rib and additional confirmation of the diagnosis was provided by computed tomography (CT) of the cervical spine. Doppler ultrasonography did not show evidence of deep vein thrombosis in the right upper limb. A right anterior scalene muscle block with lidocaine was performed and the patient received additional treatment including physical therapy and non-steroidal anti-inflammatory agents generating a good response.
      Thoracic outlet syndrome (TOS) involves compression of the subclavian vessels and/or the lower roots of the brachial plexus, causing a myriad of vascular and neurologic symptoms. Several etiologic agents can cause the syndrome, most common among them is a cervical rib. While the prevalence of cervical ribs constitutes <1-6% of the general population, the occurrence is greater among patients with TOS, constituting 10% of patients in this group [
      • Brewin J.
      • Hill M.
      • Ellis H.
      The prevalence of cervical ribs in a London population.
      ]. Several maneuvers in physical examination were developed to aid in the diagnosis of TOS, including Adson's or scalene test, Wright's hyperabduction maneuver, Halstead's maneuver, and Roos' test, although none of these maneuvers was found to be sensitive or specific [

      Bm ANW, Officer I. Thoracic outlet compression syndrome: the reliability of its clinical assessment. 1987;69.

      ]. Therefore, further evaluation with plain radiography, CT or magnetic resonance imaging of patients with suspected TOS is warranted. Treatment modalities for the management of TOS include conservative measures such as physical therapy and analgesics, or interventional methods such as muscle blocks with local anesthetics or botulinum toxin, and decompressive surgery [
      • Klaassen Z.
      • Sorenson E.
      • Tubbs R.S.
      • Arya R.
      • Meloy P.
      • Shah R.
      • et al.
      Thoracic outlet syndrome: a neurological and vascular disorder.
      ].

      Author contributions

      OKD performed the literature research and devised the final manuscript.
      SD helped draft the final manuscript.
      NM conceived the idea and helped draft the final manuscript.

      References

        • Brewin J.
        • Hill M.
        • Ellis H.
        The prevalence of cervical ribs in a London population.
        Clin Anat. 2009; 22: 331-336
      1. Bm ANW, Officer I. Thoracic outlet compression syndrome: the reliability of its clinical assessment. 1987;69.

        • Klaassen Z.
        • Sorenson E.
        • Tubbs R.S.
        • Arya R.
        • Meloy P.
        • Shah R.
        • et al.
        Thoracic outlet syndrome: a neurological and vascular disorder.
        Clin Anat. 2014; 27: 724-732