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musculoskeletal imaging
FIGURE 1. Long-axis view of color Doppler ultrasonography demonstrating a right distal subclavian vein thrombosis, characterized by a filling defect and absence of color flow (arrow).
]
FIGURE 2. Short-axis view of color Doppler ultrasonography demonstrating a right axillary vein thrombosis, characterized by absence of color flow and noncompressibility of the vein (arrow).
Upper Extremity Deep Venous Thrombosis CHARLES E. RAINEY, PT, DSc, DPT, OCS, FAAOMPT, Naval Special Warfare Group ONE, San Diego, CA. DANIELLE A. TAYSOM, MD, Department of Radiology, Naval Medical Center, San Diego, CA. MICHAEL D. ROSENTHAL, PT, DSc, SCS, ECS, ATC, Department of Physical and Occupational Therapy, Naval Medical Center, San Diego, CA.
T
he patient was a 34-year-old man currently serving in the military who was referred to a physical therapist by his primary care physician for a chief complaint of worsening right shoulder pain and paresthesias of the first, second, and third digits of his right hand, as well as right upper extremity swelling. His symptoms began 4 days prior and were insidious in onset. The patient denied any previous history of right upper extremity pain or paresthesias, recent injury, or a recent change in activity involving his right upper extremity. Physical examination revealed marked swelling with pitting edema and cyanosis
of the right upper extremity, as well as localized pain with palpation of the right upper extremity. Due to concern for an upper extremity deep venous thrombosis, the patient was referred back to his primary care physician.1,2 Doppler ultrasonography was performed, and the presence of an occlusive thrombus in the right distal subclavian (FIGURE 1) and axillary veins (FIGURE 2) was revealed. The patient underwent a catheter-directed thrombolysis, and anticoagulation therapy was initiated.2 Though venography revealed near-complete resolution of the thrombus, residual irregular stenosis of the vessel was noted at the
costoclavicular junction, which was concerning for thoracic outlet syndrome. The patient subsequently underwent balloon angioplasty to dilate the stenotic region, as well as a right first-rib resection.2,3 After surgery, the patient’s right upper extremity pain, paresthesias, and swelling resolved. Following 6 weeks of physical therapist intervention, which included range-of-motion and progressive strengthening activities, the patient returned to full military duty without limitations. t J Orthop Sports Phys Ther 2014;44(4):313. doi:10.2519/jospt.2014.0405
References 1. Constans J, Salmi LR, Sevestre-Pietri MA, et al. A clinical prediction score for upper extremity deep venous thrombosis. Thromb Haemost. 2008;99:202-207. http://dx.doi. org/10.1160/TH07-08-0485 2. Engelberger RP, Kucher N. Management of deep vein thrombosis of the upper extremity. Circulation. 2012;126:768-773. http://dx.doi.org/10.1161/CIRCULATIONAHA.111.051276 3. Samarasam I, Sadhu D, Agarwal S, Nayak S. Surgical management of thoracic outlet syndrome: a 10-year experience. ANZ J Surg. 2004;74:450-454. http://dx.doi. org/10.1111/j.1445-2197.2004.03016.x The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the US Department of the Navy or US Department of Defense.
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[
musculoskeletal imaging
FIGURE 1. Long-axis view of color Doppler ultrasonography demonstrating a right distal subclavian vein thrombosis, characterized by a filling defect and absence of color flow (arrow).
]
FIGURE 2. Short-axis view of color Doppler ultrasonography demonstrating a right axillary vein thrombosis, characterized by absence of color flow and noncompressibility of the vein (arrow).
Upper Extremity Deep Venous Thrombosis CHARLES E. RAINEY, PT, DSc, DPT, OCS, FAAOMPT, Naval Special Warfare Group ONE, San Diego, CA. DANIELLE A. TAYSOM, MD, Department of Radiology, Naval Medical Center, San Diego, CA. MICHAEL D. ROSENTHAL, PT, DSc, SCS, ECS, ATC, Department of Physical and Occupational Therapy, Naval Medical Center, San Diego, CA.
T
he patient was a 34-year-old man currently serving in the military who was referred to a physical therapist by his primary care physician for a chief complaint of worsening right shoulder pain and paresthesias of the first, second, and third digits of his right hand, as well as right upper extremity swelling. His symptoms began 4 days prior and were insidious in onset. The patient denied any previous history of right upper extremity pain or paresthesias, recent injury, or a recent change in activity involving his right upper extremity. Physical examination revealed marked swelling with pitting edema and cyanosis
of the right upper extremity, as well as localized pain with palpation of the right upper extremity. Due to concern for an upper extremity deep venous thrombosis, the patient was referred back to his primary care physician.1,2 Doppler ultrasonography was performed, and the presence of an occlusive thrombus in the right distal subclavian (FIGURE 1) and axillary veins (FIGURE 2) was revealed. The patient underwent a catheter-directed thrombolysis, and anticoagulation therapy was initiated.2 Though venography revealed near-complete resolution of the thrombus, residual irregular stenosis of the vessel was noted at the
costoclavicular junction, which was concerning for thoracic outlet syndrome. The patient subsequently underwent balloon angioplasty to dilate the stenotic region, as well as a right first-rib resection.2,3 After surgery, the patient’s right upper extremity pain, paresthesias, and swelling resolved. Following 6 weeks of physical therapist intervention, which included range-of-motion and progressive strengthening activities, the patient returned to full military duty without limitations. t J Orthop Sports Phys Ther 2014;44(4):313. doi:10.2519/jospt.2014.0405
References 1. Constans J, Salmi LR, Sevestre-Pietri MA, et al. A clinical prediction score for upper extremity deep venous thrombosis. Thromb Haemost. 2008;99:202-207. http://dx.doi. org/10.1160/TH07-08-0485 2. Engelberger RP, Kucher N. Management of deep vein thrombosis of the upper extremity. Circulation. 2012;126:768-773. http://dx.doi.org/10.1161/CIRCULATIONAHA.111.051276 3. Samarasam I, Sadhu D, Agarwal S, Nayak S. Surgical management of thoracic outlet syndrome: a 10-year experience. ANZ J Surg. 2004;74:450-454. http://dx.doi. org/10.1111/j.1445-2197.2004.03016.x The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the US Department of the Navy or US Department of Defense.
journal of orthopaedic & sports physical therapy | volume 44 | number 4 | april 2014 |
44-04 Imaging-Rainey.indd 1
313
3/19/2014 5:42:03 PM
