Image Quiz
Subclavian Vein Thrombosis, Brachial Plexopathy, and Sternoclavicular Pain and Popping in a Sixteen-Year-Old Boy1
A sixteen-year-old male high-school student
who worked part-time as a butcher presented to a vascular surgeon with a six-week
history of insidious swelling in the left, nondominant arm. The patient also
complained of diffuse brachial plexus paresthesias. He smoked one pack of cigarettes
per year but was otherwise healthy. A laboratory evaluation for thrombophilia revealed
normal findings. The family history was negative for hereditary bone tumors and
thromboembolism. A venogram revealed complete occlusion of the left subclavian vein
along with adjacent partial obstruction of the axillary vein. Increased collateral
venous drainage was present, suggesting external compression. This finding was consistent
with a primary subclavian thrombosis resulting from thoracic outlet syndrome, also
known as Paget-Schroetter syndrome. Routine radiographs of the chest were initially
interpreted as normal, although a later retrospective review ultimately revealed
the lesion. Magnetic resonance images of the shoulder revealed no obvious extrinsic
masses compressing the lateral aspects of the subclavian vessels or brachial plexus,
although the medial aspects of these structures were not scanned. However, possible
anterior scalene hypertrophy was noted, suggesting a specific type of thoracic outlet
syndrome, namely, scalenus anticus syndrome. Thoracic outlet exploration was considered
but was not performed given the absence of a definite extrinsic compression etiology.
Interventional thrombolysis of the subclavian vein failed because of a technical
inability to access the occluded vein. Anticoagulation therapy with Coumadin (warfarin)
was instituted for one year, without any change in symptoms; it was stopped thereafter
because of its inconvenience to the patient.
Three years after the onset of thrombosis, the patient was working
full-time as a butcher and presented to his chiropractor because of new sternoclavicular
pain and popping, which worsened with butchering duties that required ballistic
overhead movements and heavy lifting. A plain anteroposterior radiograph of the
shoulder and a sagittal computed tomogram of the medial part of the left side of
the chest were made.
Fig. 1 |
Fig. 2 |
For larger view, click on image |
The radiograph of the shoulder revealed a conspicuous sessile
osteolytic bone lesion on the medial part of the clavicle, adjacent to the sternoclavicular
joint (Fig. 1). A retrospective review of an initial chest radiograph that had been
made three years earlier also revealed this same lesion. There had been no obvious
radiographic changes during the three-year interval. The patient was referred to
the orthopaedic tumor service for further evaluation.
Physical examination revealed engorged veins throughout the proximal
aspect of the arm. The range of motion of the shoulder was full. The sternoclavicular
joint was tender, without a palpable mass. Forward flexion of the shoulder and adduction
of the arm generated an audible and palpable pop over the sternoclavicular joint.
The patient had full motor strength, a bounding radial pulse,
and diffuse altered sensation throughout the hand and forearm. Adson's test
was positive.
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