An 18 y.o. presents with arm pain

What is wrong?

Our patient had venous  thoracic outlet syndrome with a DVT in the upper extremity.  He was a pitcher and noted pain and cyanosis of the arm when he pitched.  Collateral veins can develop around the affected shoulder, neck and chest wall because of the obstruction to venous return. 

The thoracic outlet consists of three areas: the scalene triangle, the space between the first rib and clavicle and the infraclavicular space.  Within these spaces there are three types of compression:  venous , arterial and neurologic. While 8% of the population is affected by thoracic outlet syndrome about 98% are neurologic compression. 

Neurologic thoracic outlet – involves the scalene triangle and often presents with shoulder pain which is worse with overhead movement or exercise. A scalene muscle botox injection may relieve the pain. Since cervical roots 3-5 and the brachial plexus traverse this region; they are injured commonly in whiplash with MVCs.

Venous thoracic outlet syndrome or Paget-Schroetter  involves the costoclavicular space where the subclavian vein can be pinched between the clavicle and first rib causing compression. This was the problem for our patient. Surgery involved in correcting this involves  first rib removal, scalenectomy , removal of the subclavius muscle and vein patch of the stenotic subclavian segment . 

Arterial thoracic outlet syndrome  is  nearly always associated with a cervical rib. Arterial thoracic outlet syndrome is extremely rare  and is usually caused by arterial thromboembolism.  The presenting findings are hand and finger ischemia.  An arterial clot in the subclavian can embolize in a retrograde fashion causing a stroke. 

Our patient underwent surgery for his subclavian thrombosis. He had a complicated course with an extraplural hemothorax requiring reoperation five days out from surgery.  Now three months out he has minimal residual pain and is off anticoagulation.

For the ultrasound inclined, below are images of the thoracic outlet on US. 

Hassan S, Akhtar A, Falah N, et al. A case of subclavian artery thrombosis 2020, Cureus Feb;12(2):e6842.

Hooper T, Denton J, McGalliard M., et al. Thoracic outlet syndrome;a controversial clinical condition. Part 1. Anatomy and clinical examinathion/diagnosis. 2010. Journal of Manual & Manipulative therapy. 18(2):74-83.

Boezaart A, Haller A, Laduzenski S, et al. Neurogenic thoracic outlet syndrome: A case report and review of the literature. Int J Shoulder Surg . 2010 Apr-Jun;4(2):27-35.

Lobato E, Kern K, Bauder-Heit J, et al. Incidence of coronary-subclavian steal syndrome in patients undergoing noncardiac surgery. J Cardiothorac Vasc Anesth 2001 Dec;15(6):689-92.