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Postgrad Med J: first published as 10.1136/pgmj.35.405.397 on 1 July 1959. Downloaded from 397

NEUROVASCULAR SYNDROMES OF THE GIRDLE AND UPPER EXTREMITY: THE COMPRESSION DISORDERS AND THE SHOULDER- 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 and upper of anomalous structures. In some, however, the extremity. , , 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 hooks up and The interpretation and differentiation of the over the first , 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 process and then into the this paper is to summarize present knowledge of . The subclavian 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 . The 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 must be visualized in these present, these include the , 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 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 , gross deformities due to kyphoscoliosis, symptoms only when there is prolonged main- thoracoplasty and , 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 . 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 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

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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 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 Shoulder-hand syndrome Herpes zoster Circumscribed reflex dystrophy (Sudeck's atrophy, Nocturnal dysthesias causalgia, etc.) Brachalgia paresthetica Acroparesthesias syndrome Vascular Disorders, Predominantly Systemic Diseases with Local Features Arterial Diffuse vasculitis Acute arterial occlusion Relapsing nodular panniculitis Chronic occlusive arterial disease Rheumatoid Aneurism Osteoarthritis of the cervical spine and shoulder Erythromelalgia Raynaud's disease Scleroderma Arteriovenous fistula Other Disorders Venous Fibromyalgias of the 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 , 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 ad- They may be either sensory or motor, or both. ducted and with the and 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 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 . 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 ; 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, and asleep, the patient is apt to be awakened by the 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 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 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 or without duction that, in the presence of a normal shoulder occlusion of the vessel.1' girdle, the scalenus anticus muscle compresses In an affected extremity, the is more easily the neurovascular bundle against the first rib and a obliterated than in the normal person, by various normal scalenus medius through a process of manoeuvres to be discussed. An arterial bruit may spastic irritability and hypertrophy. Their theory be heard in the supraclavicular space.4 Cervical holds that the scalenus anticus is irritated in some ribs, if present, can often be palpated in this region. fashion, so bringing about its spasticity, whereby Sometimes the blood pressure will be found to be it compresses the brachial plexus. This compres- lower on the affected side. sion reflexly increases the spasm of the scalenus anticus. These reactions are believed to produce The Compression Syndromes of the Shoulder a vicious circle. The corollary, in the thesis of the Cervical Rib, Scalenus Anticus and First Rib originators, is breaking the circle by sectioning the Syndrome scalenus anticus muscle. Historically, the first of these to be described Diagnosis of a scalenus anticus syndrome was was the cervical rib syndrome. Cervical ribs based on evidence of a tender scalenus anterior, occur as anomalous appendages in approximately the dampening of the pulse of the affected extre- o to o.o5 per cent. of individuals, with more than mity by certain manoeuvres, especially the Adson half being bilateral. They are two to three times routine* and the partial relief of symptoms by more common in women. Usually they are in- procaine injection of the scalenus anticus muscle.'0 cidental findings, with only some io per cent. of This clinical formulation was followed by a cycle of them causing any difficulty. The size, shape favourable reports on the resection of the anterior and insertion of the rib will frequently be the scalene muscle. In time, however, subsequent determining factors in the production of symptoms. observers indicated frequent failures. These led Often there is arterial compression, with post- to further critical evaluation, with the elucidation stenotic dilatation and incipient thrombosis. The of other mechanisms of the compression. The scalenus muscles may or may not be important in initial concept has been challenged on several the activation of symptoms. Their participation, grounds by many clinicians. Walshe26 feels thatcopyright. however, frequently cannot be determined with most of these disorders really are instances of first certainty preoperatively. The approach to these rib syndrome. Others hold that the size of the problems, in the more severe cases, has been surgi- scalenus is variable, that infiltration with procaine cal removal of the rib, initiated by Coste in i861.25 frequently spills over and produces a sympathetic This procedure, although surgically sound, too block of the stellate ganglion with a Horner's often was attended by va'rious complications which syndrome, or that the solution may even flow over resulted in equally severe symptoms, sometimes to the brachial plexus with relief ofpain. Dampen- worse. Law25 in I920, and Adson and Coffey' in ing of the pulse is not regarded as specific. The http://pmj.bmj.com/ I927, suggested resection of the scalenus anticus absence of any spasm or change in the similarly muscle as an easier method of decompression. innervated scalenus medius is thought to remain They found in an impressive series that simple unexplained by this theory. Finally, the pos- tenotomy was quite effective. Today, scaleno- sibility has been suggested that the tenderness is tomy is performed, with partial resection of the not definitely indicative of scalenus origin, but rib, if necessary. The precipitating factors in the may arise from underlying structures. The production of symptoms probably are those men- general view of observers today is that the scalenus tioned among the contributory factors, since most anticus syndrome, as postulated in the 1930S, on October 1, 2021 by guest. Protected patients do not present symptoms until they remains unproved and that relief of symptoms by reach the 2o- to 40-year age group. surgical tenotomy is secondary to simple de- Numerous workers during the past 50 years have compression of the neurovascular bundle. This been impressed by the presence of the ' cervical relief, according to present views, arises from the rib syndrome in the absence of cervical rib.' removal of one of a passive vise, or to the Observers during the I9O3-I9I7l3 period attributed simpler fact that the patient receives, together with these cases to stretching of the brachial plexus over the surgery, a period of bed rest and change in the first rib due to dropping of the shoulder usual habits. The more severe symptomatic girdle from an increased lateral diameter of the failures, when restudied, often were found to have chest with age. In 1933 Adson suggested the other mechanisms or sources of compression. possible responsibility of the scalenus anticus muscle and in 1935 the 'scalenus anticus syn- *The Adson manoeuvre is carried out with the patient drome' was given its present formulation by upright and the examiner's fingers on the radial pulse of the tested extremity, which is held at the side of the Naffziger and Grant,'4 as well as Ochsner, Gage subject who takes a deep breath and holds it, then turns and DeBakey.'5 The basic concept is the de- the head to the side tested. 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 401 Costoclavicular Syndrome Raynaud's phenomenon in about 50 per cent. of In 1943, Weddel and Falconer5 described the the patients. In some cases symptoms included costoclavicular syndrome. In restudying three superficial gangrene of the finger tips which healed cases of scalenotomy failure, they found the readily, when the provocation was eliminated.28'2 principal site of compression located between the clavicle and the first rib. They were able to Management of Compression Syndromes demonstrate that backward and downward bracing The management depends upon the cause and of the shoulders, as in the exaggerated military the severity of symptoms, as well as the major posture, would approximate the two bony point of compression. Where postural or exo- structures and compress the neurovascular ele- genous factors play a role, such as pushing, pulling, ments. That this mechanism could occur in a lifting, carrying heavy objects, etc., simple cor- normal shoulder had been appreciated by earlier rections may relieve the symptoms. When workers. It has been reaffirmed by Wright and shoulder drooping is due to poor posture, age and Lordl8 and by Walshe.26 related factors, muscle development may be This syndrome was common during the last indicated. in the form of heat World War, when heavy packs could not be worn and the use of analgesics may help resolve residual by many men owing to the severe pain, pares- soreness of muscles. Structural deformities of thesias, venous congestion and edemawhichwould the bony, muscular or other tissues may require develop, due to direct costoclavicular com- surgical decompression. When surgery is per- pression.5 19 Interestingly, many of these young formed, the current trend is to do a thorough soldiers were able to sustain the packs following exploration in order to adequately decompress the six to eight weeks of army life and training.'9 In neurovascular canal by combined procedures, the absence of deformities or exogenous factors where necessary-scalenotomy with clavicular this is not a common syndrome. Walshe, how- removal; possibly resection of the first rib or of ever, cites repetitive costoclavicular compression the cervical rib; or section of the pectoralis minor as a frequent contributor to symptoms.26 Telford muscle in some cases. copyright. and Mottershead were unable to demonstrate compression by simple depression of the shoulder, The Shoulder-Hand Syndrome but in their work they do not comment on whether Nature of the Syndrome they retracted the shoulder as well.23 (The pulse The shoulder-hand syndrome is a reflex neuro- can be dampened in some 6o per cent. of people vascular disorder, often termed ' reflex neuro- by an exaggerated military posture.)'9 vascular dystrophy,' characterized by painful disability of the shoulder preceding, accompanying Hyperabduction Syndrome or following painful disability, vasomotor changes,

Wright described the mechanism of the hyper- with swelling, or dystrophic alterations in the later http://pmj.bmj.com/ abduction syndrome in 1945.28 2 In this group of phases, at the hand and fingers. This condition patients with clear-cut neurovascular symptoms, is seen largely in the older age groups, in medical mostly of a vascular nature, the principal points of disorders, arising often from etiologic factors en- compression were found to be under the coracoid countered in the later decades of life. The process and between the clavicle and first rib. symptom-complex develops in most patients so The symptoms were demonstrated to occur by closely after external trauma or internal lesions, laterally circumducting the arms and clasping such as myocardial infarction, that the etiologic the hands over the head. The neurovascular relationship seems obvious. A multiplicity of on October 1, 2021 by guest. Protected bundle becomes taut as it crosses the coracoid designations (Table 2), according to the observers' process and the head of the . It is further viewpoints, have obscured the clinical similarity of compressed by the clavicle and the muscular action the physiologic disturbance and symptoms, of the pectoralis minor. Some reduction of the whether they originate in external trauma or pulse by this manoeuvre has been observed in 6o internal violence to tissue. to 8o per cent. of normal individuals. The original paper reported on eight patients in whom Symptomatology of the Shoulder-Hand Syndrome the principal factor was this persistent posture in The clinical picture has been divided roughly sleep.28 Symptoms were relieved by a change in into three stages (Table 3). In the first phase the the habit. Most individuals affected have been essential features consist of pain and disability of found to maintain a hyperabducted position of the the shoulder, of insidious or sudden onset, which extremity in sleep, recreational activities or in frequently is thought to be a bursitis or peri- certain occupations-ballet dancers, painters, arthritis. Usually, a short time after (sometimes grease pit mechanics and others. Subsequent simultaneously or before) the appearance of the observations also have shown the presence of shoulder symptoms, a sudden or gradual onset of Postgrad Med J: first published as 10.1136/pgmj.35.405.397 on 1 July 1959. Downloaded from 402 POSTGRADUATE MEDICAL JOURNAL July I959 TABLE 2* TERMINOLOGY OF THE VARious R3FLEx NEUROVASCULAR SYNDROMES OFTEN DESCRIBED AS SPECIAL ENTITIES Neurological and Neurosurgical Traumatic and Post-traumatic Peripheral Acute atrophy Causalgia Minor causalgia Phantom Post-traumatic arteriospasm Spinal and Central Lesions Post-traumatic Thalamic syndrome Post-traumatic osteoporosis Cerebrospinal pain syndromes Post-traumatic spreading neuralgia Shoulder-hand syndrome Post-traumatic sympathalgia Post-traumatic trophoneurosis Internal Lesions Post-traumatic vasomotor syndrome Changesinpareticlimbsofhemiplegics Reflex dystrophy Neurotrophic rheumatism Reflex hyperemic deossification Painful disability of the shoulder (and Reflex sympathetic dystrophy hand) after coronary occlusion Sudeck's atrophy Post-infarction sclerodactylia Sympathetic trophoneurosis Swollen atrophic hand with cervical Shoulder-hand syndrome osteoarthritis Shoulder-hand syndrome From the Shoulder-Hand Syndrome: Present Status as a Diagnostic and Therapeutic Entity Medical Ci. N.A., November, 1958.

TABLE 3* CLINICAL EVOLUrION OF THE SHOULDER-HAND SYNDROME

Stage I Stage 2 Stage 3 copyright. Shoulder Pain Pain and disability resolving or Residual pain infrequently Disability in all ranges persisting Tenderness, diffuse (localized Possible atrophy of muscles Disability sometimes early) Osteoporosis, patchy at humeral Osteoporosis, patchy then ground- Ground-glass, diffuse osteoporosis head sometimes glass Hand and Fingers Pain Symptoms resolving or continuing Persistent pain, rarely http://pmj.bmj.com/ with earlv dystrophic changes Tenderness, diffuse Residual dystrophy and Cutaneous hyperesthesia Disability Massive dorsal swelling Often induration of cutis and subcutis Digital Changes swelling, diffuse Firm induration with obliteration Rarely increased Dermal on October 1, 2021 by guest. Protected of dorsal skin creases Sometimes early, shiny cutis and Shiny, trophic skin surface Dull, diffuse atrophy of skin and trophic changes as in next stage Trophic changes initiated subcutis sometimes Marked occasionally Dorsal hypertrichosis sometimes Increased sometimes Incomplete, painful digital flexion Resolving or impending digital Residual contractures and dis- atrophy and contractures tortions Vasomotor Changes Vasodilatation or vasospasm Vasospasm often with hyper- Vasomotor imbalance occasionally hidrosis Colour changes Usually absent with dystrophic Hyperhidrosis at palms changes Roentgenographic Spotty osteoporosis of humeral More marked Ground-glass diffuse osteoporosis of head, humeral head, wrist and fingers *From the Shoulder-Hand Syndrome: Present Status as a Diagnostic and Therapeutic Entity. Medical Cl. N.A., November, 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 403 painful disability of the hand and fingers develops, symptoms in the presence of injury has not been marked by swelling of the latter, pain on passive explained. motion of hand , loss of skin wrinkles, in- Both varieties of these neurovascular complexes, ability to flex the fingers, and often spotty osteo- the compressive and reflex, may be disabling. porosis of the carpus in films. The first stage may The shoulder-hand syndrome tends to become a last up to three to six months. It may gradually more serious disorder, because its progression resolve, spontaneously, but may progress to the to a disabled or even a useless extremnity may be second stage. The pain in the shoulder gradually rapid, and the time for successful intervention subsides, the swelling of the hand decreases, short. The average case of any of the com- possibly with increasingly painful and limited pression disorders is apt to be symptomatic over mobility; sometimes with a Dupuytren-like the course of many years and, in the absence of thickening at the palm, often with coldness of the severe injury to vessels leading to thrombosis or hand and some degree of dystrophic skin changes. embolism, generally does not lead to serious This phase may gradually merge into the final consequencies. stage with the production of a ' fibrosed,' distorted hand with contracted fingers, a ' frozen shoulder ' Management of the Shoulder-Hand Syndrome and an impaired extremity. The process may Most of the treatment employed until recently stop anywhere along this line of progression, was ineffectual. X-ray therapy to the cervico- spontaneously or as a result of treatment. thoracic ganglia or to the shoulder and hand, physical modalities, ganglionic blocking agents Etiology and Mechanism of the Shoulder-Hand and local infiltration of trigger points have been Syndrome reported to be helpful in early cases. Graded The etiology remains obscure in some 30 per exercises within the limits of tolerance un- cent. of our carefully studied cases in which it must doubtedly should be initiated at all stages as an be classified as ' idiopathic.' Severe or minor adjunct to any form of therapy. Effective early trauma to limbs, myocardial infarction, peri- treatment is provided by serial stellate ganglion copyright. carditis, hemiplegia, cervical osteoarthritis and blocks, especially in the first and second stages disc changes, brain tumours and many internal often with complete or satisfactory remissons (and lesions, with neural or segmental connections to occasional relapses). With the advent of the the upper extremity, have been implicated. corticosteroids, comparable results have been However, the sequence of events in the many obtained with these compounds. A completely conditions with which there is a frequent associa- reliable form of treatment still is needed. tion suggests a common pathway of production of Prevention symptoms. The concept most widely held today http://pmj.bmj.com/ is that of a traumatic focus, internal or external, An important consideration is the prevention of with a channelling of stimulating impulses to the reflex phenomena, when possible. In conditions cervico-thoracic spinal cord. known to provoke reflex symptoms, such as ex- According to this widely regarded theory, the ternal trauma, myocardial infarction, osteo- normal physiology of the ' internuncial pool ' of arthritic neuropathy, hemiplegia, and others, it neurons at the level of local injury is disturbed. may be useful to introduce mobilizing exercises at From the site of the lesion through the inter- the extremity as soon as practical, also analgesic nuncial communications, along the pathways of infiltration of trigger points. Violent procedures on October 1, 2021 by guest. Protected the autonomic and motor systems, the symptom- to extremities presenting any suggestive symptoms producing neurovascular impulses reach the peri- are to be avoided. Alertness to early reflex phery of the upper extremity. Once the syn- neurovascular symptoms in underlying conditions drome has been produced by the injury or lesion, predisposing to them should lead to early treat- a self-perpetuating mechanism or ' feedback ' is ment which appears to prevent more severe set up via the afferent, sensory fibers to the inter- developments. nuncial pool with short and long reverberating 'closed loop ' relays of neurological impulses in Differential Diagnosis of Neurovascular the 'pool,' which are thought to keep the process Disorders of the Shoulder going until it runs its course. This is one of Diagnostic evaluation requires a careful history several, different, helpful working concepts. and physical examination to investigate the There are, nevertheless, many unknown facets of characteristic pressure points and their features, this group of disorders leaving great room for given under the various headings. Apart from further clarifying observations. Why only a small standard physical examination, these include in- group of subjects should develop these reflex spection, palpation and postural tests for local Postgrad Med J: first published as 10.1136/pgmj.35.405.397 on 1 July 1959. Downloaded from 404 POSTGRADUATE MEDICAL JOURNAL July 1959

TABLE 4 DIAGNOSTIC FEATUREs OF COMPRESSION AND REFLEs NEuRovAscuLAR SYNDROMES OF TH SHOULDER GIRDLE History Pulse Neurologic Signs Diagnostic Test Therapeutic Response Costoclavicular Symptoms associated Reduced in abnormal Usually except with Forced abnormal po- Elimination of postu- Syndrome with shoulders forc- shoulder position deformities sition of shoulder ral defects giving re- ed downward and reproduces signs lief backward for long and symptoms periods Hyperabduction Hyperabduction in Reducedinhyperabd. Often Hyperabduction re- Correction of sleeping Syndrome (Costo- sleep or at work for (also B.P. and oscil- production of signs or working position clavicular Syndrome) long periods lometry) and symptoms giving relief Scalenus Anticus No special postural Reduced in resting Reflexes occasionally Adsonmanoeuvremay Correct injection of Syndrome and Cer- features position or brought reduced on affected reproduce musculo- procaine into ant. vical Rib on by Adson man- side; noted weak- skeletal, neuritic and scalenus may give re- oeuvre ness in same vascular signs. Ten- lief scalenotomy derpoint at scalenus often effective area Shoulder-Hand Trauma, intrathor- Sometimes reduced Increased or de- Stellate ganglion Repeated blocks or Syndrome (Reflex acic disease or idio- creased reflexes of block produces tran- corticosteroids sym- Dystrophy) pathic, no special part sometimes sient or prolonged pathectomy e#tective postural features relief in earlier stages

Symptoms common to some or all in each disorder: pain of shoulder, arm and/or hand; numbness, paresthesias of fingers; swelling of hand(s), fingers; discoloration of hand(s); Raynaud's phenomenon; weakness of hand(s); supraclavicular bruit possible in compression disorders. compression, cervical ribs, thoracic deformities, embolism. Occasionally, severe vascular or neural bulges or distortions in the supraclavicular area, compression may provoke superimposed reflex evidence of vascular disturbance or disease; symptoms at the hand or possibly a shoulder-hand X-ray films of the cervical spine (with oblique syndrome, creating a complex situation for an views), and of the shoulder and hand, if necessary, observer who has not followed the evolution of the as well as special tests where bizarre compression clinical picture. When musculoskeletal or neuro-copyright. may arise from tumour, enlarged lymph nodes, muscular symptoms predominate, intrinsic dis- etc. The main differential points are summarized orders of the shoulder or neuropathy must be in Table 4. differentiated, most frequently cervical disco- The compression neurovascular disorders are genetic or osteoarthritic pathology. the most easily understood from the mechanical The reflex neurovascular disorders, as ex- standpoint. In all of them the production of emplified by the shoulder-hand syndrome, symptoms is secondary to direct mechanical generally differ characteristically from the com- compression, of one anatomical variety or another, http://pmj.bmj.com/ of the neurovascular bundle somewhere along the pression syndromes in causation, manifestations course of the cervico-axillary canal at the thoracic and therapy. The reflex clinical picture usually is outlet, leading to distinctive forms of ' thoracic secondary to initial injury, by either internal or outlet syndromes.' The symptoms may arise external trauma, with a reflex neurovascular from neural compression (usually the lower cords reaction mediated by a complicated spinal cord of the brachial plexus containing fibers from roots reflex. The tissue disturbance tends to be localized of C8-Ti) with the production of pain, pares- at the shoulder and hand. It is reflected in various thesias, hypalgesia or hyperesthesia and atrophy degrees and combinations of pain, disability, on October 1, 2021 by guest. Protected of muscles. Involvement of the vascular com- vasomotor fluctuations, swelling, edema, spotty ponents may cause vasospastic phenomena with osteoporosis and deforming trophic changes. classical Raynaud's manifestations, ulceration, The shoulder-hand syndrome is more likely to blanching of the skin, boring pain; in arterial simulate some form of rheumatic disorder, such as compression, diminution of the pulse, difference in , bursitis, or scleroderma. blood pressure, swelling, discoloration, even When it is in mild form, or when neuritic symp- gangrene; with venous impingement, venous dis- toms are impressive, and especially when there tention and edema. Thrombosis may occur at are localized reflex neurovascular symptoms, as in any time. In most instances removal of the circumscribed hand involvement, the question of compression results in eliminating the neuro- excluding compressive neurovascular disorders is vascular symptoms, except where obviously per- more apt to arise. manent changes have occurred, as in thrombosis or For references see page 412 Postgrad Med J: first published as 10.1136/pgmj.35.405.397 on 1 July 1959. Downloaded from

412 POSTGRADUATE MEDICAL JOURNAL July 1959 The Shoulder-Hand Syndrome by the eighth cervical to the fourth thoracic spinal The shoulder-hand syndrome consists of pain, segments. stiffness and limitation of movement of the shoulder, hand and fingers, and trophic changes in Treatment the skin and other tissues of the hand, following No special treatment is needed for the pain of acute cardiac infarction. The complete picture is acute infarction referred to the arm. The mild uncommon, occurring in less than 5 per cent. of varieties of the shoulder-hand syndrome usually infarctions. Some degree of stiffness of one or yield to passive and active shoulder and arm both shoulders develops in about io per cent. of exercises. The more severe degrees are often patients within a month or six weeks of an long-lasting and resistant to treatment. If the acute infarction. infarction heals satisfactorily and pain does not In the mildest form of the syndrome, the patient recur, the shoulder stiffness may subside spon- complains of slight pain or stiffness on moving the taneously in a few months. Sometimes it may arm. Severe limitation of movement with pain still cause trouble after a year. In addition to shooting down the arm, upwards to the neck and physiotherapy the various measures used i-nclude down the side of the on abduction and procaine infiltration around the , lateral rotation is known as a ' frozen shoulder.' steroid therapy, upper thoracic sympathetic block In some cases the hand is warm and the fingers with procaine and stellate ganglionectomy. These pulsate, reflecting vaso-dilation. These changes points are considered fully in other parts of this may be the forerunners of severe, if uncommon symposium. trophic changes, namely swelling of the fingers and hand, stretching of the skin with red-purple discoloration, trophic ulceration of the fingers or Summary hand, and thickening and ofthe palmar The typical chest pain of ischaemic heart aponeurosis. The condition in any degree of disease (angina pectoris and cardiac infarction) is often transmitted to one severity except the slightest, may be very resistant or both shoulders andcopyright. to treatment and sometimes the results of months arms. Occasionally, it is felt first in the forearm of painstaking physiotherapy may be disappoint- or arm and spreads upwards to the shoulder and ing. Occasionally, all stiffness and pain may across the chest. Rarely, it may be confined to the disappear spontaneously within a few weeks. arms. The correct diagnosis may be missed when The shoulder-hand syndrome has not been the pain is dominantly in the arms or shoulders. satisfactorily explained. The changes show a The shoulder-hand syndrome is an uncommon tendency to appear in joints which have been the sequela of acute cardiac infarction. It consists of seat of arthritis or peri-arthritis. The left arm is stiffness of the shoulder, and in its severe form, of the more often affected but the right arm is in- great pain on moving the arm and trophic changes http://pmj.bmj.com/ volved when the ischaemic pain was right-sided. in the hand. The condition may respond only Protective disuse of the limb is responsible to slowly to treatment, and may be troublesome for some extent, but other factors are involved, too. many months after an acute infarction. One of these is a neurovascular reflex mechanism. Pain impulses arising from the heart, reflexly pro- duce muscular spasm and neuro-vascular reac- BIBLIOGRAPHY tions in the , muscles and HEBERDEN, W. (1772), Med. Trans. Roy. CoU. Phys., 2, 59. skin, innervated HERRICK, J. B. (I9I2), Y. Amer. med. Ass., 59, 2015. on October 1, 2021 by guest. Protected

References from page 404 - H. Harold Friedman, M.D., Thomas G. Argyros, M.D., and Otto Steinbrocker. M.D. REFERENCES 7. FISKE, L. G. (I952): ' Brachial plexus irritation due to hyper- I. ADSON, A. W., and COFFEY, J. R. (1927): 'Cervical rib, trophied ,' J.A.M.A., I49, 758. method of anterior approach for relief of symptoms by 8. GAMBLE, S. G. (1gsi): 'Costoclavicular syndrome,' Arch. division of scalenus anticus,' Ann. Surg., 85, 839. phys. Med., August, 5x6-522. 2. BEYER, J. A., and WRIGHT, I. S. (I95I): 'The hyper- 9. HAGGERT, G. E. (Igg8): 'Value of conservative management abduction syndrome with special reference to its relationship in cervicobrachial pain,' J.A.M.A., 137, So8-513. to Raynaud's syndrome,' Circulation (N. Y.), 4, No. 2. so. JUDOVICH, B., BATES, W., and DRAYTON, W., Jr. 3. EDEN, K. C. (1939): 'The vascular complications of cervical (1944): 'Pain in the shoulder and upper extremity due to ribs and first thoracic rib abnormalities,' Bnt. _. Surg., scalenus anticus syndrome,' Amer. J. Surg., 63, No. 3, 27, III. March. 4. EDWARDS, E. A., and LEVINE, H. D. (1942): 'Auscultation i I. LORD, J. W., Jr., and ROSATI, L. M. (5958): ' Neurovascular in the diagnosis of compression of the subclavian artery,' compression syndromes of the upper extremity,' Clin. Symp., New Eng. J. Med., 247, 79. 10, NO. 2, March-April. 5. FALCONER, M. A., and WEDDELL, G. (1943): 'C08to- 12. MURPHY, J. B. (igos): 'Cervical rib symptoms resembling clavicular compression of the subclavian artery and vein,' subclavian aneurysm,' Ann. Surg., 4x, 399. Lancet, 245, 539. 13. MURPHY, T. (I9I0): 'Brachial neuritis from pressure of the 6. FALCONER, M. A. (1947): 'The costoclavicular syndrome,' first rib,' Aust. med. Y., zI, 582-585. correspondence, Brit. med. J7., July I2. References continued on page 425 Postgrad Med J: first published as 10.1136/pgmj.35.405.397 on 1 July 1959. Downloaded from

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associated with a relaxation in BURNETT, W. E., CASWELL H T, SCHREK, K. M., CAR- aseptic techniques, RINGTON, E. R., LEARNiR, N., STEEL, H. H., TYSON, is responsible for the emergence of and infections R. R., and WRIGHT, W. C. (x958), J. Amer. med. Ass., with, the 'Hospital Staphylococcus': an anti- 566, Ix83. CASWELL, H. T., SCHREK, K. M., BURNETT, W. E. CAR- biotic-resistant , apparently more virulent RINGTON, E R. LEARNER, N., STEEL, H. H., TYSON, R. R., and WRIGHT, W. C. (I958), Surg. Gynec. Obstet., than its predecessors, liable to cause large-scale I06, I. epidemics, extremely well adapted for cross-infec- CLARKE, S., DALGLEISH, P. G., and GILLEPSIE, W. A. tion by its ability to survive the most adverse (1952), Lancet, i, 1132. conditions and liable to CLARKE, S. K. R. (I957), Brit. J7. Surg., 44, 592. particularly produce a DINEEN, P., and PEARCE, C. (I958), Surg. Gynec. Obstet. carrier-state. Its exact mode of spread is still X06, 453. obscure but direct contact plays an important part. Editorial (I958), Brit. med. 7., i, 207. A hospital Editorial (1958), Lancet, i, SiS staphylococcal infection carries the GILLEPSIE, W. A., SIMPSON, K., and TOZER, R. (x9S8), twofold danger of virulence and antibiotic Ibid., ii, I07S. GODFREY, M. E., and SMITH, I. M. (x958), 7. Amer. med. Ass., resistance. For this reason the problem is now I66, 1197. as serious as it was in the pre-antibiotic era, with GOULD, J. C. (I958), Lancet, i, 489. other virulent organisms now replaced by the HlARE, R., and RIDLEY, M. (xg58), Brit. med. 7., i, 69. JEFFREY, J. S., and SKLAROFF, S. A. (I958), Lancet, i, 365. hospital staphylococcus. The problem is largely KINMONTH, J. B., HARE, R., TRACY, G. D., THOMAS, preventable by strict control measures aimed at C. G. A., MARSH, J. D., and JANTET, G. H. (I958), Brit. med. 3'., 2, 407. limiting the use of antibiotics, and a return to LANGMUIR, A. D. (I958), 7. Amer. med. Ass., I66, 1202. strict aseptic and cross-infection precautions. The Leading Article (I958), Lancet, 1, 250. infected 'case must be considered as a real source Leading Article (1958), Ibid., ii, I o6. LOH, W. P., and STREET, R. B. (I957), New Engl. 7. Med., of danger to himself and to others. 256, 177. PETERSDORF, R. G., CURTIN, J. A., HOEPRICK, P. D., PEELER, R. N., and BENNETT, I. L. (I957), Ibid., 257, 1001. Acknowledgment RAVENHOLT, R. T., and LA VECK, G. D. (1956), Amer. -7. I should like to thank Professor J. B. Kinmonth Publ. Hlth, 46, 1287. RAVENHOLT, R. T., WRIGHT, P., and MULHERN, M. for kindly reading this paper and making helpful (I957), New Engl. Y. Med., 257, 789.

criticisms. ROBERTSON, H. R. (19S8), Ann. Roy. CoU. Surg., 23, 141. copyright. ROWNTREE, P. M., and FREEMAN, B. M. (I95S), Aust., 2, 157. Medj.J BIBLIOGRAPHY SHOOTER, R. A. (1958), Ann. Roy. CoU. Surg., 23, 312. Annotation (I958), Lancet, if, 1i10. SHOOTER, R. A., SMITH, M. A., GRIFFITHS, J. D., BROWN, Annotation Ibid., i, M. E. A., WILLIAMS, R. E. O., RIPPON, J. E., and (1959), 34. JEVANS, M. M. P. (I958), Brit. med. ., i, 607. BARBER, (i957), in 'Drug Resistance in Micro-organisms, SHOOTER, R. A., TAYLOR, G. W., ELLIS, G., and ROSS, edited by G. W. Wolstenholme and C. M. O'Connor, London. J. P. (I956), Surg. Gynec. Obstet., 503, 257. BRODIE, J., KERR, M. R., and SOMMERVILLE, T. (I956), TIMBURY, M. C., WILSON, T. S., HUTCHISON, J. G. P., Lancet, i, I9. and GOVAN, A. D. T. (I958), Lancet, ii, xo8i. BURNETT, W., McDONALD, S., and TIMBURY, M. C. WISE, R. I. (I958), J. Amer. med. Ass., x66, 1178. (Ig98), Scot. med. 7., 3, 392. VWYSHAM, D. N., and KIRBY, W. M. (I9S7), Ibid., I64, 1733. http://pmj.bmj.com/ on October 1, 2021 by guest. Protected References continued from page 412-H. Harold Friedman, M.D. Thomas G. Argyros, M.D., and Otto Stienbrocker, M.D. 14. NAFFZIGER, H. C., and GRANT, W. T. (1938): 'Neuritis 22. STEINBROCKER, O., NEUSTADT, D., and BOSCH, S. J. of the brachial plexus, mechanical in origin: the scalenus (I955): 'Painful shoulder syndromes; their diagnosis and syndrome,' Surg. Gynec. Obstet., 67, 722. treatment,' Ibid., 39, No. 2, I. J5. OCHSNER, A., GAGE, M., and DEBAKEY, M. (1935): 'Scalenus anticus (Naffziger) 23. TELFORD, E. D., and MOTTERSHEAD, S. 'The syndrome,' Amer. Y. Surg., " costoclavicular syndrome,"' Brit. med. J.,(1947):i, 325-328, 28, 669. March I5. x6. PAULL, R. (1946): 'The neurovascular syndrome as mani- fested in the upper extremities, Amer. Heart Y., 32, 32. 24. THEIS, F. V. (1939): 'Scalenus anticus syndrome and cervical 17. PEET, R., HENRIKSEN, J. D., and ANDERSON, M. G. M. ribs,' Surgery, 6, No. I, I I2-125. (x956): 'Thoracic outlet syndrome: evaluation of a thera- 25. COOTE and LAW, cited in UPMALIS, I. H. (I958): 'The peutic exercise programme,' Staff Meet. Mayo Clin., May 2. scalenus anticus and related syndromes,' Surg. Gynec. Obstet., x8. RAAF, J. (Ig5s): 'Surgery for cervical rib and scalenus with Int. Abstr. Surg., 307, No. 6, December. anticus syndrome,' Y.A.M.A., 157, 219-223. 26. WALSHE, F. M. R. (I95I): 'Nervous and vascular pressure ig. STAMMERS, F. A. R. (ig5o): 'Pain in the from syndromes of the thoracic inlet and cervico-axillary canal.' mechanisms in the costoclavicular space,' Lancet, April I. 'Modem Trends in Neurology,' p. 542. Edited by A. Feiling. 20. STEINBROCKER, O., SPITZER, N., and FRIEDMAN, Butterworth, London. H. H. (x948): 'The shoulder-hand syndrome in reflex 27. WILLSHIRE (I86o): Referred to in clinical records, 'Super- dystrophy of the upper extremity,' Ann. intern. Med., 29, 22. numerary first rib,' Lancet, il, 633. 21. STEINBROCKER, O., and ARGYROS, T. G. (I9S8): 'The 28. WRIGHT, I. S. (I945): 'The neurovascular syndrome pro- shoulder-hand syndrome: Present status as a diagnostic and duced by hyperabduction of the arms,' Amer. Heart J., therapeutic entity,' Med. Clin. N. Amer., November. 29, I.