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SHOULDER GIRDLE and UPPER EXTREMITY: the COMPRESSION DISORDERS and the SHOULDER-HAND SYNDROME by H

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SHOULDER GIRDLE and UPPER EXTREMITY: the COMPRESSION DISORDERS and the SHOULDER-HAND SYNDROME by H Postgrad Med J: first published as 10.1136/pgmj.35.405.397 on 1 July 1959. Downloaded from 397 NEUROVASCULAR SYNDROMES OF THE SHOULDER GIRDLE AND UPPER EXTREMITY: THE COMPRESSION DISORDERS AND THE SHOULDER-HAND SYNDROME By H. HAROLD FRIEDMAN, M.D., THOMAS G. ARGYROS, M.D., AND OTTO STEINBROCKER, M.D.* Introduction anatomic constitutents already mentioned. In Some of the most perplexing and difficult the vast majority of people this short distance is musculoskeletal disorders are included among traversed without difficulty, even in the presence those affecting the shoulder girdle and upper of anomalous structures. In some, however, the extremity. Pain, paresthesias, hyperesthesia and bundle is impinged upon, in one way or another, vasomotor disturbances may occur in any of them, to produce the symptoms underlying the syn- but these symptoms in combination are character- dromes under discussion. istic of few, chiefly the neurovascular syndromes. Normally, the subclavian artery hooks up and The interpretation and differentiation of the over the first rib, lying between the insertions of clinical features may embrace a large number of the scalenus anterior and medius muscles, passes diseases and disorders (Table I). The purpose of down under the coracoid process and then into the this paper is to summarize present knowledge of axilla. The subclavian vein runs a parallel route, two groups of these conditions-the reflex neuro- except that it proceeds between the scalenus copyright. vascular disorders, as fully exemplified by the anterior and the clavicle. The brachial plexus shoulder-hand syndrome, and the compression in this region tends to course along the artery neurovascular syndromes (' thoracic outlet syn- and is represented primarily by fibers from C8-Ti. dromes '). Since anatomic factors are of basic The prominent points of compression have given importance in the genesis of these disturbances, their names to the syndromes they provoke. At the pertinent anatomy must be visualized in these present, these include the cervical rib, scalenus problems (Fig. i). anticus, first rib and costoclavicular syndromes. The hyperabduction syndrome might be regarded, http://pmj.bmj.com/ Anatomy accordingly, as the ' coracoid pectoralis minor The anatomy is complex, so only its main clavicle syndrome.' features will be mentioned here. The normal components of this area include the first rib, the Contributory or Provocative Factors scalene muscles (anterior, medial, occasionally Contributing factors in the production of inferior), clavicle and subclavius, the coracoid symptoms include the great mobility of the process and pectoralis minor muscle. Added to shoulder which, even in normal structures, permits these at times may be encountered bony de- compression of the neurovascular bundle in certain on October 1, 2021 by guest. Protected formities of the first rib and the clavicle, cervical positions. Generally, these are responsible for ribs, gross deformities due to kyphoscoliosis, symptoms only when there is prolonged main- thoracoplasty and injury, bizarre insertions of the tenance of bizarre positions, as in work, sleep, scalene muscles and assorted congenital fibrous recreation, etc. As people age there is a tendency bands, vascular anomalies, lymph node enlarge- toward a reduction in muscle mass and a loss of ments, tumours, etc.11 The key to the whole tone with a drooping of the shoulders. Anomalies problem consists of the size and the adaptability of and trauma play an obvious role. Arteriosclerosis the thoroughfare, the thoracic outlet and its con- with loss of pliability is a frequent predisposing tiguous space, through which the neurovascular factor to vascular complication from compression bundle must pass in close relationship to the in the older age groups. *From General Rose Memorial Hospital and the Symptomatology of the Compression University of Colorado Medical Center, Denver Syndromes Colorado (Dr. Friedman) and the Rheumatology Department, Hospital for Joint Diseases and Lenox The clinical manifestations of these syndromes Hill Hospital, N.Y.C. (Drs. Argyros and Steinbrocker). are dependent upon compression of the brachial Postgrad Med J: first published as 10.1136/pgmj.35.405.397 on 1 July 1959. Downloaded from 398 POSTGRADUATE MEDICAL JOURNAL JUIy 1959 C..RA....D..P..OCESS ......C..O...ON. P..TORAL.S.MINOR A....L..ARY.ARTERY. AND. ..V.. CLAVICLE SUCAiANATR FIRSTRIB8 SIJBCAVIAVEI SCALENE MU..CL...MI.D.EANTER.R.B.AC....PLEX. copyright. MANEUVER..FOR DIAGNSISRO C..ST.CLAV.CU... S..NDROME. http://pmj.bmj.com/ on October 1, 2021 by guest. Protected FIG. i.-Essential anatomy of the shoulder girdle, especially the costoclavicular space, and diagnostic manoeuvre for costoclavicular syndrome. Courtesy, Jere W. Lord, Yr., M.D., and Louis M. Rosati, M.D., Clinical Symposia, IO, 2, I958. Postgrad Med J: first published as 10.1136/pgmj.35.405.397 on 1 July 1959. Downloaded from July 1959 FRIEDMAN, ARGYROS and STEINBROCKER: Neurovascular Syndromes 399 1TABLE I DisoRDRms WITH NEURAL, VASCULAR AND NEUROVASCULAR FEATURES AT THE SHOULDER AND UPPER ExmRziTY Neurovascular Disorders Neurological Disorders, Predominantly Compression Syndromes Spinal cord trauma Cervical rib, scalenus or first rib syndrome Syringomyelia Costoclavicular syndrome Protruded intervertebral disk Hyperabduction syndrome Neuropathy or tumours of the brachial plexus or Reflex neurovascular syndromes cervicodorsal nerves Shoulder-hand syndrome Herpes zoster Circumscribed reflex dystrophy (Sudeck's atrophy, Nocturnal dysthesias causalgia, etc.) Brachalgia paresthetica Acroparesthesias Carpal tunnel syndrome Vascular Disorders, Predominantly Systemic Diseases with Local Features Arterial Diffuse vasculitis Acute arterial occlusion Relapsing nodular panniculitis Chronic occlusive arterial disease Rheumatoid arthritis Aneurism Osteoarthritis of the cervical spine and shoulder Erythromelalgia Dermatomyositis Raynaud's disease Scleroderma Arteriovenous fistula Other Disorders Venous Fibromyalgias of the neck and shoulder Acute thrombophlebitis Intrinsic lesions of the shoulder Chronic venous insufficiency Bicipital tendovaginitis Lymphatic Calcific tendinitis Acute lymphangitis Periarthritis of the shoulder Chronic lymphedema Psychalgias plexus and/or vascular structures and the radiation swing over the side of the bed. At other times, copyright. or referral of pain from the structures compressed. relief is obtained by elevating the shoulders, as in Vascular symptoms are frequently absent, some- leaning forward on the elbows, or by bending the times prevail, and occasionally are the only ones neck toward the affected side, a position which present. Neurologic symptoms and signs are reduces the drag on the brachial plexus. Some presented more often than those of vascular origin. patients are more comfortable with the arms ad- They may be either sensory or motor, or both. ducted and with the forearm and hands placed Pain at the shoulder or along the extremity may be across the chest. described. Local tenderness may be elicited by The pain is generally aggravated by activities palpation at the sites of complaint. Symptoms, which involve the use of the arms and shoulders http://pmj.bmj.com/ therefore, may be essentially musculoskeletal, such as lifting, reaching or pushing. Activities neurologic, vascular or any combination of them. which depress the shoulder, such as carrying Pain and paresthesias are the predominant suitcases or heavy objects, also are likely to in- symptoms in most cases, but they are variable. tensify symptoms. Deep inspiration and hyper- Pain in the shoulder and deltoid regions with extension of the neck often increase the dis- radiation to the elbow is a not uncommon com- comfort. plaint. Frequent, also, is pain felt in the ulnar There is usually a paucity of objective neuro- aspect of the forearm and hand in the fourth and logical signs. Sensory changes, such as hyper- on October 1, 2021 by guest. Protected fifth fingers. Sometimes the pain spreads to the esthesiae, are infrequent. When present, they radial aspect of the forearm, hand and fingers; tend to occur in the distribution of the median or to the head, neck and face; and to the scapular ulnar nerves. Such motor abnormalities as area or chest. The pain is generally described weakness, atrophy and muscle twitchings, are as being of an aching or shooting nature. likewise found in similar distribution.26 In rare While the pain in these syndromes may occur instances, in the presence of a cervical rib, a during the course of the day's activities it has a Homer's syndrome provides evidence of involve- decided tendency to become worse at night, ment of the cervical sympathetic fibers. particularly when the patient is lying down. The vascular changes which occur in these There often is difficulty in falling asleep and, if syndromes include: (i) coldness, pallor and asleep, the patient is apt to be awakened by the cyanosis of the hand; (2) swelling of the hand(s); discomfort. Whenever pain occurs, the patient (3) dependent rubor; (4) gangrene and ulcera- attempts to find relief by adopting different tions of the finger tips; (5) classical Raynaud's positions. Sometimes the symptoms are allevi- phenomenon2; and (6) complications such as ated by lying prone and permitting the arms to axillary vein or subclavian artery thrombosis and Postgrad Med J: first published as 10.1136/pgmj.35.405.397 on 1 July 1959. Downloaded from 400 POSTGRADUATE MEDICAL JOURNAL July 1959 aneurysm of the subclavian artery with
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