SHOULDER PAIN AND ARM SWELLING - VOLLEYBALL

Abstract

HISTORY A previously healthy right-handed 15 year-old female high school volleyball player presented to the emergency room with acute right arm swelling and discoloration. She had a two-week history of intermittent right shoulder pain that only hurt her after spiking balls during practice. The pain was relieved by icing her shoulder after practice and taking ibuprofen. One week prior to presentation, a physician diagnosed her with a right scapular/shoulder strain and prescribed physical therapy. There were no labs or radiographs taken at that time. When she awoke on the morning of presentation, she noticed diffuse swelling and a purple discoloration of her entire right arm and hand. Because of these symptoms, her parents took her to the hospital. She denied any trauma, pain, or paresthesias. PHYSICAL EXAMINATION The patient was a well-developed female in no distress. Temperature 97.4, heart rate 74, respiratory rate 18, blood pressure 115/49, pulse oximetry revealed an oxygen saturation of 100% on room air. Weight was 64.3 kg, height 170 cm. HEENT exam was normal. Neck was supple, no lymphadenopathy. Chest was clear to auscultation, normal heart sounds without murmur, rub, or gallop. Abdomen was soft, nontender, and nondistended with no organomegaly. Examination of her extremities revealed diffuse swelling and erythema of her right arm, hand, and fingers. There was increased warmth of the arm without discrete or point tenderness or palpable cords. Distal pulses were present, and sensation was intact. There was diffuse shoulder tenderness and decreased range of motion of the shoulder in all directions secondary to pain. Her other extremities were normal without erythema or edema. There was no rash, and neurologic exam was normal. DIFFERENTIAL DIAGNOSIS Infection of the soft tissue of the shoulder and arm Deep venous thrombosis of the upper extremity Superficial thrombophlebitis Extrinsic compression of the venous drainage by tumor or enlarged lymph nodes Muscle strain with reflex sympathetic dystrophy Fracture TESTS AND RESULTS Ultrasound with Doppler of the upper extremity – revealed an obstructing deep venous thrombosis in the upper brachial vein, axillary vein, and subclavian vein to the area of the first rib Chest radiograph – normal Laboratory data – CBC, blood chemistries, PT, PTT all normal FINAL/WORKING DIAGNOSIS Paget-Schroetter syndrome (spontaneous upper extremity venous thrombosis) TREATMENT AND OUTCOMES 1. Hospitalization and anticoagulation with enoxaparin. 2. Work-up for a hypercoagulable state was normal and included the following: Factor V Leidin, Protein C and S, antithrombin III, plasma homocysteine, antiphospholipid antibodies, prothrombin gene mutation 20210. 3. Her symptoms improved, and after five days of therapy a repeat Doppler ultrasound revealed only a small thrombus in the right subclavian vein at the level of the first rib with good venous flow through collateral vessels. 4. Venogram performed at the time of the repeat Doppler confirmed the results of the ultrasound, but proof of a compressive phenomenon of the subclavian vein at the level of the first rib could not be established. 5. The patient was discharged home after the venogram revealed her DVT was resolving and her symptoms were improving. She is being restricted from all sports and is continuing her enoxaparin as an outpatient. The duration of her anticoagulation therapy will be about three months. 6. The patient was asymptomatic at a one-month follow-up, and repeat Doppler showed almost complete resolution of the thrombus. 7. After completion of her anticoagulation period, she will undergo further imaging (venogram, MRI) to help determine if surgical intervention (removal of first rib) may help to prevent future deep venous thrombosis and allow her to return to volleyball.