From the Guidelines
Thoracic Outlet Syndrome (TOS) commonly presents in the emergency room with upper extremity pain, numbness, and weakness, often accompanied by paresthesias along the ulnar nerve distribution. The presentation can vary depending on which neurovascular structures are compressed in the thoracic outlet, with symptoms ranging from neck, shoulder, arm, or hand pain to more severe complications like arm swelling, discoloration, or acute thrombosis in vascular TOS 1.
Key Symptoms and Signs
- Upper extremity pain
- Numbness
- Weakness
- Paresthesias, particularly along the ulnar nerve distribution
- Diminished pulses with provocative maneuvers
- Worsening symptoms with overhead activities or heavy object carrying
Diagnosis and Management
Diagnosis in the ER is primarily clinical, supported by vascular studies or imaging when available 1. Initial management includes pain control, positioning to relieve compression, and appropriate referral for follow-up care. Understanding the anatomical basis of TOS, including the costoclavicular triangle, interscalene triangle, and pectoralis minor space, is crucial for diagnosing and managing the condition effectively 1. The current management of TOS is variable, but recognizing the clinical entity and its implications on morbidity, mortality, and quality of life is essential for providing optimal care 1.
From the Research
Common ER Presentation for TOS
- The common ER presentation for Thoracic Outlet Syndrome (TOS) includes symptoms such as arm pain and swelling, arm fatigue, paresthesias, weakness, and discoloration of the hand 2, 3, 4.
- Patients with TOS may also present with pain, numbness, tingling, weakness, and vasomotor changes of the upper extremity 5, 6.
- Vascular complications of TOS, such as thromboembolic phenomena and swelling, are uncommon but can occur 5, 6.
- The clinical presentation of TOS is highly variable, and diagnosis is often based on a physician's judgment after a meticulous history and physical examination 3, 6.
- TOS can be classified as neurogenic, arterial, or venous based on the compressed structure(s), with neurogenic TOS being the most common manifestation 2, 5.