thoracic outlet syndrome…when a diagnosis hides

Tuesday, September 13, 2016

First rib displacement, not a fracture or a broken bone. Philadelphia Eagle coach, Doug Pederson, talking about an injury sustained by his receiver, Zach Ertz. The trainer thought he had strained a shoulder, but later decided that it was a first rib issue. Sometimes it’s difficult to appreciate the type of injury based on a medical report relayed by a coach, but it is helpful to understand that the source of pain is not always where the pain is felt.

The body is sometimes evil in trying to trick patients and doctors by having a diagnosis made that misinterprets symptoms.

  • In the back of every doctor’s mind is the fact that a leaking abdominal aortic aneurysm is masquerading as renal colic, an awful waxing and waning pain from kidney stones. Not treating a kidney stone leaves you with a very unhappy and painful patient, but missing a leaking aneurysm leaves a very dead patient.
  • Indigestion can be just that, an irritated stomach and esophagus, uncomfortable because of acid buildup. But woe is the patient and doctor who forgets that indigestion is also a common symptom of angina or pain due to narrowing of blood vessels to heart muscle. Inferior myocardial; infarction, a heart attack that affects the bottom part of the heart is notorious for causing GI complaints.
  • Bell’s Palsy looks frightening; one side of a patient’s face stops working and droops. It’s due to inflammation of a peripheral nerve (the 7th cranial nerve) and is not due to a stroke. The way that the face muscles are wired, in Bell’s, the patient cannot wrinkle their forehead on the affected side but in the midst of a stroke, the patient’s forehead can wrinkle and move, but the lower two thirds of the face may be weak or paralyzed.

Thoracic Outlet Syndrome

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In the case of thoracic outlet syndrome, shoulder and arm pain may be due to narrowing of the space between the collarbone and the first rib. That space is filled with the brachial plexus, (the bundle of nerves that allow the arm, wrist and hand to feel and move), the subclavian artery that sends blood to the arm and the subclavian vein that returns blood to the heart. If the space narrows enough, symptoms of numbness tingling, pain, and weakness in the neck, shoulder, arm and hand may develop; but the cause of the symptoms isn’t where they are felt but instead are due to not having enough real estate around the first rib. Sometimes, surgery is needed to remove the first rib and allow enough room for that important stuff to live peacefully. Matt Harvey of the New York Mets and Kyle Zimmer of the Kansas City Royals both had surgery to fix thoracic outlet syndrome this summer.

The injury suffered by Zach Ertz may potentially cause his first rib to narrow the thoracic outlet space.

Differential Diagnosis

In the world outside of the NFL, the patient complaint allows the doctor and patient to develop the differential diagnosis, a list of ailments that might be the cause of the symptoms. Sometimes, that list is short; imagine an ankle injury where the list might include an ankle sprain or fracture. Sometimes the list is long; an infant who is colicky. Common things are common and colic would be good bet, but other potential diagnoses might include issues within the abdomen like a hernia, intussusception or testicular torsion. Colic doesn’t have to come from the abdomen and children can be irritable because of a corneal abrasion, pneumonia, meningitis or food intolerance. Not every diagnosis is evident and it sometimes takes work to sort things out.

For that reason, the trainer is allowed to miss the diagnosis on the first patient touch, examining the player in full pads on the field, in front of 70,000 fans and with too many television cameras zooming on the scene. As the game progressed, Mr. Zach likely was repeatedly evaluated and the diagnosis came to light. The medical lesson to be learned is that the body is a complicated machine and one needs to be wary of the tricks it can play on unsuspecting patients and doctors.

 

 

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