Arm Pain, Dysesthesias, And Pallor In A High School Soccer Athlete

HISTORY: The patient is a 15-year-old female soccer athlete status-post open reduction and internal fixation (ORIF) with plate and screws of the left clavicle after she sustained a displaced, comminuted mid-shaft clavicle fracture during a fall in a soccer game. The patient recovered well and was symptom-free until ten months later when she developed intermittent tingling of the left hand and shooting pain from the shoulder to the hand. These symptoms progressively worsened over two months (now one-year post-ORIF), and she developed decreased sensation of her left upper extremity (LUE) especially with overhead movement. Then, one night while combing her hair, she had acute worsening of her symptoms with pallor of her left hand which prompted a visit to an emergency department where symptoms resolved spontaneously. The patient was subsequently referred to the Sports Medicine clinic for further evaluation and point-of-care (POC) ultrasound examination. PHYSICAL EXAMINATION: On exam, she had full shoulder and cervical spine range of motion. There was diminished sensation to light touch of C4-T2 dermatomes on the left. The left radial pulse was palpable but markedly weaker compared to the right side with loss of palpable radial pulse with overhead motion which subsequently reproduced pallor of the left index finger. She had 4 second capillary refill time of the left fingertips. Adson's, Roos, and Wright’s tests were positive. DIFFERENTIAL DIAGNOSIS: 1. Vascular Thoracic Outlet Syndrome (TOS) 2. Neurogenic TOS 3. Paget-Schroetter syndrome TEST AND RESULTS: POC ultrasound revealed decreased peak systolic velocities of the left subclavian and brachial arteries compared to right. The visualized left brachial plexus was normal with and without dynamic scanning. A duplex angiogram was performed which revealed occlusion of the left axillary and brachial arteries with two major collateralizations reconstituting the left radial and ulnar arteries. FINAL WORKING DIAGNOSIS: Arterial TOS TREATMENT AND OUTCOMES: The patient was taken to the OR for left 1st rib resection, left pectoralis minor release, and left subclavian to axillary artery bypass graft, and clavicle hardware explant. The patient tolerated the procedure well. She is to have her first postoperative follow-up with Vascular Surgery in the coming weeks.