Unilateral Arm Swelling

Tim Kubal

Venogram

Provocative Venogram

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.

Anatomy

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