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CONDITION/DISORDER SYNDROME

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  • Neurogenic thoracic outlet syndrome (NTOS)

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ICD-9-CM CODE

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  • 353.0 Brachial plexus lesions

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ICD-10-CM CODE

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  • G54.0 Brachial plexus disorders

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PREFERRED PRACTICE PATTERN

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  • 4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Rang of Motion Associated with Localized Inflammation

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PATIENT PRESENTATION

Patient is a 23-year-old male who is in the army. Patient complains that both of his arms feel heavy. He has a cold sensation in his hands. Patient spent the last 2 weeks in boot camp. He had to hike 5 miles a day while wearing a fully loaded back pack. The heaviness has begun since he started with the hiking. The patient has a positive costoclavicular thoracic outlet test.

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KEY FEATURES

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Description
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  • Entrapment of the neurovascular bundle comprising the brachial plexus, subclavian artery and/or subclavian vein, neurogenic or vascular types (venous and arterial)

  • Symptomatology and management is different depending on the primary structure compressed

    • Compression on the brachial plexus

      • Direct compression can occur at

        • Scalene triangle

        • Cervical rib/first rib

        • Pectoralis minor

        • Costoclavicular space

        • Unstable humeral head in an anterior/inferior position1

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Essentials of Diagnosis
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  • Diagnosis is made by clinical examination and thorough diagnosis of exclusion

  • Most common to least common incidence is brachial plexus, subclavian artery, and subclavian vein compression, respectively2

  • Thoracic outlet syndrome involving the subclavian vein and artery requires immediate medical attention and is often the result of trauma or clot3

  • Worse with repetitive postural habits, pain at rest, night pain4

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General Considerations
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  • Neurological examination and diagnostic imaging is required to rule out the most common differential diagnoses

  • Double crush syndrome is a possibility5

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Demographics
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  • Young and middle-aged adults most commonly affected6

  • Females to males 3:16

  • Can develop spontaneously, gradual onset due to poor posture or post-trauma

  • Teenagers with a cervical rib

  • There is increased incidence with participation in sports

  • Correlated with a high incidence of forward head carriage and rounded shoulders7

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CLINICAL FINDINGS

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SIGNS AND SYMPTOMS

  • Intermittent numbness and tingling in the forearm, wrist and hand

    • Most often in the medial forearm and hand in the distribution of C8/T1 nerve roots but can be whole hand

  • Feeling of weakness and fatigue in the upper extremity (UE) especially with arm overhead

  • Pain in the arm, neck, shoulders, and upper back

  • Aggravated by overhead activities, repetitive activities, and activities that depress the shoulder girdle4

  • Pain is worse at night.4,8

  • Pain can be better with rest

  • Postural examination may reveal low lying shoulder girdle on affected side, forward head carriage, and anteriorly rounded shoulders6

  • Isolated venous type of thoracic outlet syndrome presents with unilateral UP edema, pain, ...

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