Upper Extremity Pain and Swelling ??? Volleyball

Abstract

0742 HISTORY: A right-handed 21-year-old female college volleyball player presented with a four-day history of right upper extremity discomfort. She described aching and occasional tingling from the shoulder down to the hand. There was diffuse swelling and redness of the arm that worsened with activity. Her symptoms initially began after riding a stationary bicycle, and they worsened over the next few days. She denied any recent trauma or vigorous activities; she had no history of similar symptoms. Past medical history was not significant except for the use of oral contraceptives. PHYSICAL EXAMINATION: The patient was in no acute distress, and vital signs were stable. The chest was clear to auscultation, and heart sounds were normal. Examination of the right upper extremity revealed diffuse swelling and a ruddy discoloration. There was mild tenderness of the medial arm but no palpable cord. Upper extremity range of motion was full, although abduction and forward flexion of the right shoulder were painful. Motor and sensation testing, reflexes, and pulses were normal. Adson's maneuver and Roos test were negative. DIFFERENTIAL DIAGNOSIS: Thoracic outlet syndrome Cellulitis Upper extremity deep venous thrombosis Stress fracture of the humerus Muscle strain Rotator cuff injury TESTS AND RESULTS: CBC, chemistries, PT, PTT, INR: normal. Chest radiograph: normal. Ultrasound with Doppler of right upper extremity: occlusive thrombus in the right subclavian vein extending to the axillary vein. Venogram of right upper extremity: complete occlusion of the right axillary and subclavian veins. FINAL/WORKING DIAGNOSIS: Right axillary and subclavian vein thrombosis secondary to thoracic outlet syndrome and primary thrombosis (Paget-Schroetter syndrome). TREATMENT AND OUTCOMES: Hospitalization and anticoagulation with heparin. Catheter-directed thrombolysis using tissue plasminogen activator and transluminal balloon angioplasty were repeated a total of three times. Residual high-grade stenosis, due to external compression, was noted despite thrombus resolution. Right transaxillary first rib resection and subtotal scalenectomy. Post-hospital anticoagulation with enoxaparin. Laboratory work-up for a hypercoagulable state later revealed the athlete was heterozygous for clotting factor V R506Q (factor V-Leiden). Other test results are pending. She is currently two weeks post-operative and will be unable to return to volleyball this season.