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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imagining rib injuries: CT…really?…not

Wednesday, August 17, 2016

The availability of medical technology in the 21st century has a tendency for patients to demand its use, regardless of whether the information it can reveal actually matters. Nothing better highlights this issue than the overuse of radiology by pro sports. This week’s prime example is Carson Wentz, Philadelphia’s first round rookie quarterback, and leader of the future. Towards the end of the game against Tampa Bay, Wentz is hit on the right side and has pain in his right ribs.

ESPN.com quoted Eagle coach, Doug Pederson: “Carson felt some discomfort and soreness as we began this morning’s practice. We decided to limit him throughout the remainder of practice and, as a precaution, sent him for a CT scan after practice. The scan revealed a hairline fracture in his ribs.We do not know an exact timetable for his return, but we hope to have him back before the end of the preseason.”

FYI: fracture, broken, cracked all mean the same thing

Perhaps the CT seems like a reasonable care plan, with the coach and the team worried about their player, but in reality, this is not the standard of care that most people would receive. In the real world, people who hurt their ribs are often examined and may or may not get a simple chest x-ray. CT is definitely not routine.

Here is the thinking. The chest wall, rib cage and muscles have a couple of important jobs. The first is to protect the contents of the chest cavity (thorax) including the heart, lungs and great vessels (aorta, vena cava among others), as well as organs in the upper abdomen like the spleen and liver. The second, is the muscles of the chest wall and the diaphragm that are responsible for the work of breathing. When taking a deep breath, the ribs swing out, the diaphragm pushes down and air is sucked into the lungs like a bellows.

If the rib cage is injured, pain may prevent that process from working well. Deep breaths don’t occur and a multi-step process ends up in the complication of pneumonia. It doesn’t matter whether ribs are bruised or broken, it’s a matter of the pain that causes the problem:

  • Pain decreases the ability to take a deep breath
  • Without that deep breath, the alveoli, small sacs at the end of the bronchial tree, where oxygen gets transferred to the blood stream, can’t pop open. This is called atelectasis
  • With atelectasis, the lungs can’t clear normal secretions and debris and the gunk is left to accumulate in the warm, dark environment. This increases the risk of lung infection
  • A lung infection is called pneumonia and the symptoms include, fever, cough and shortness of breath.
  • Pneumonia associated with chest injury is not a good combination because it becomes that much tougher to take a deep breath to help clear the infection. This failure of pulmonary toilet increases the risk of complications.

While rib injuries hurt, the bigger concern is not the pain but whether damage occurred beneath the injured ribs. If that suspicion is low and physical exam does not point to disaster, then the test of choice is a simple chest x-ray, looking for a collapsed lung (pneumothorax) or a bruised lung (pulmonary contusion). Specific rib x-rays aren’t needed and a CT of the chest to look for rib fractures is definitely overkill.

chest ct rib fx

Black arrow points to rib fracture. White arrows show collapsed lung. Plain X-ray might miss the fracture but not the pneumothorax.

Regardless of whether the rib cage is bruised or a rib is broken, the treatment is the same: pain control and deep breaths to prevent atelectasis and pneumonia and the healing time is 4 to 6 weeks. Just like any other broken bone or torn muscle, it takes that long to get better. Chest injuries may take longer, since the area that is damaged is not allowed to rest and heal. A sore arm can be put into a sling to rest, but a sore chest is asked to work every few seconds, mandating a deep breath to prevent pneumonia.

While NFL coaches can’t order CT scans, team doctors can sign off on that request, and the rationale is presumably to make certain nothing terrible was hiding inside Mr. Wentz’ chest. Aside from increasing his lifetime accumulation of radiation exposure, there would be little risk for the test but also very little reward. Perhaps the major issue will occur later, when fans who see an NFL player gets a CT scan for a chest wall injury, will demand their share of high tech medicine, when low tech might do just as well.

It’s the part of the doctor’s job to explain what tests are needed, and what the next steps are once those results are back. In this regard, doctors and patients can learn from an NFL coach. There always needs to be a game plan for whatever situation might arise on the field. Similarly, there needs to be a game plan based on the history, physical exam and whatever the test results might show. And while Coach/Dr. Pederson may order a CT as a precaution, that shouldn’t necessarily fit into most people’s game plans. Just because there is a test that can be done, doesn’t mean that it is the right thing to do.

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