Diagnosing Thoracic Outlet Syndrome: Current Approaches and Future Directions.

The diagnosis of thoracic outlet syndrome (TOS) has long been a controversial and challenging one. Despite common presentations with pain in the neck and upper extremity, there are a host of presenting patterns that can vary within and between the subdivisions of neurogenic, venous, and arterial TOS. Furthermore, there is a plethora of differential diagnoses, from peripheral compressive neuropathies, to intrinsic shoulder pathologies, to pathologies at the cervical spine. Depending on the subdivision of TOS suspected, diagnostic investigations are currently of varying importance, necessitating high dependence on good history taking and clinical examination. Investigations may add weight to a diagnosis suspected on clinical grounds and suggest an optimal management strategy, but in this changing field new developments may alter the role that diagnostic investigations play. In this article, we set out to summarise the diagnostic approach in cases of suspected TOS, including the importance of history taking, clinical examination, and the role of investigations at present, and highlight the developments in this field with respect to all subtypes. In the future, we hope that novel diagnostics may be able to stratify patients according to the exact compressive mechanism and thereby suggest more specific treatments and interventions.

Low-intensity pulsed ultrasound treatment as an alternative to vascular bone graft surgery for a 5-year-long ulnar non-union in a patient with haemochromatosis.

We present the case of a 75-year-old woman with haemochromatosis who developed a 5-year-long right ulnar non-union after a shortening osteotomy to correct a malunited Colles' fracture. Standard surgical treatment for ulnar non-unions was attempted on 19 March 2008 and again on 20 April 2009, but the non-union persisted on 8 May 2012, as confirmed by CT scan. Vascular bone grafting and refixation was then considered, but the patient declined this extensive operation, instead choosing to try non-invasive low-intensity pulsed ultrasound treatment with an Exogen device. Just 4 months later, complete union as confirmed by CT scan was achieved. This is the first case demonstrating the efficacy of ultrasound treatment for long-standing non-unions resistant to surgery in patients with haemochromatosis, a disorder where iron deposition can provide suboptimal circumstances for bone healing. Our finding suggests that low-intensity pulsed ultrasound devices could be used as a first-line treatment for stable non-unions instead of revision surgery.

Treatment for thoracic outlet syndrome.

BACKGROUND: Thoracic outlet syndrome (TOS) is one of the most controversial diagnoses in clinical medicine. Despite many reports of operative and non-operative interventions, rigorous scientific investigation of this syndrome leading to evidence-based management is lacking. This is the first update of a review first published in 2010. OBJECTIVES: To evaluate the beneficial and adverse effects of the available operative and non-operative interventions for the treatment of TOS a minimum of six months after the intervention. SEARCH METHODS: On 23 June 2014 we searched the Cochrane Neuromuscular Disease Group Trials Specialized Register, CENTRAL, The Database of Abstracts of Reviews of Effects (DARE), MEDLINE, EMBASE, CINAHL Plus and AMED. We also searched reference lists of the identified trials. SELECTION CRITERIA: We selected randomized or quasi-randomized studies involving participants with the diagnosis of TOS of any type (neurogenic, vascular, and 'disputed'), without limitations as to language of publication.We accepted studies that examined any intervention aimed at treating TOS.The primary outcome measure was change in pain rating, measured on a validated visual analog or similar scale at least six months after the intervention.The secondary outcomes were change in muscle strength, disability, experiences of paresthesias (numbness and tingling sensations), and adverse effects of the interventions. DATA COLLECTION AND ANALYSIS: Three authors independently selected the trials to be included and extracted data. Authors rated included studies for risk of bias, according to the methods recommended in the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS: This review was complicated by a lack of generally accepted criteria for the diagnosis of TOS and had to rely exclusively on the diagnosis of TOS by the investigators in the reviewed studies. We identified one study comparing natural progression with an active intervention. We found three randomized controlled trials (RCTs), but only two of them had a follow-up of six months or more, which was the minimum required follow-up for inclusion in the review. The first trial that met our requirements involved 55 participants with the 'disputed type' of TOS and compared transaxillary first rib resection (TFRR) with supraclavicular neuroplasty of the brachial plexus (SNBP). The trial had a high risk of bias. TFRR decreased pain more than SNBP. There were no adverse effects in either group. The second trial that met these requirements analyzed 37 people with TOS of any type, comparing treatment with a botulinum toxin (BTX) injection into the scalene muscles with a saline placebo injection. This trial had a low risk of bias. There was no significant effect of treatment with the BTX injection over placebo in terms of pain relief or improvements in disability, but it did significantly improve paresthesias at six months' follow-up. There were no adverse events of the BTX treatment above saline injection. AUTHORS' CONCLUSIONS: This review was complicated by a lack of generally accepted diagnostic criteria for the diagnosis of TOS. There was very low quality evidence that transaxillary first rib resection decreased pain more than supraclavicular neuroplasty, but no randomized evidence that either is better than no treatment. There is moderate evidence to suggest that treatment with BTX injections yielded no great improvements over placebo injections of saline. There is no evidence from RCTs for the use of other currently used treatments. There is a need for an agreed definition for the diagnosis of TOS, especially the disputed form, agreed outcome measures, and high quality randomized trials that compare the outcome of interventions with no treatment and with each other.

Steroid injection for shoulder pain causes prolonged increased glucose level in type 1 diabetics.

Shoulder pain is very common in diabetic patients and often treated with steroid injections, with subsequent increases in blood glucose levels or the need for additional insulin being questioned. We report a case of significant and prolonged elevation of blood glucose levels and resultant insulin requirement in a type 1 diabetic man after a single 40 mg injection of triamcinolone for shoulder pain. Within 48 h, the shoulder pain as assessed by a visual analogue scale (0-10) was reduced to zero, but the elevated insulin requirements continued for 4 weeks after the injection. This finding suggests that steroid injections for shoulder pain in diabetics may not always be as safe as previously thought. We propose that medical practitioners advise their patients to monitor their glucose levels more carefully after such injections and that caution is exercised when considering administrating these injections to those who have poorly controlled blood glucose levels preinjection to avoid ketoacidosis.

What is the better treatment for single digit dupuytren's contracture: surgical release or collagenase clostridium histolyticum (Xiapex) injection?

UNLABELLED: The purpose of this study was to compare the initial and final outcome range of motion in the MCP-J and PIP-J of single digit Dupuytren's Contracture treated with either open surgical excision or manipulation after collagenase clostridium histolyticum (CCH; Xiapex) injection. MATERIAL: Ten patients in either group. The range of motion measurements were statistically compared using the student t-test with a p-value of 0.05. There was no statistical difference in the pre-treatment status of the total active range of movement (TAM) between the two groups. RESULTS: Open surgical release achieved a statistically better initial outcome in combined total passive range of movement than the xiapex group (p = 0.0047), but at the final outcome the better TAM measurement at the MCP-J after surgery was not statistically significant. However, the total active range of movement was statistically better at the PIP-J level in the xiapex group (p = 0.01) and the MCP-J and PIP-J combined total active range of movement was statistically better in the xiapex group (p = 0.0258). CONCLUSION: Surgery achieved better initial outcome at both MCP-J and PIP-J levels, and at discharge, only extension in the MCP-J level was statistically better after open excision. However the final outcome was statistically better at the PIP-J level in extension (p = 0.006) and total active movement (TAM) (p = 0.008) after treatment with collagenase clostridium histolyticum. Further studies are required to assess the long-term differences between the two groups and to investigate the outcomes for patients with multi-digit involvement.

Resource utilisation associated with single digit Dupuytren's contracture treated with either surgery or injection of collagenase Clostridium histolyticum.

UNLABELLED: The gold standard treatment for Dupuytren's contracture is surgical excision of the cord. A non-surgical treatment with collagenase clostridium histolyticum injection is available but appears costly. OBJECTIVES: To provide data on resource consumption related to surgical and non-surgical treatment for Dupuytren's contracture. DESIGN AND PARTICIPANTS: Twenty patients with a single digit Dupuytren's contracture, 10 treated with surgical excision, and 10 treated with a single injection of collagenase. MEASUREMENTS: Minutes spent in theatre, number of follow-up appointments, time to skin healing, and patients return to normal activities of daily living. RESULTS: The injection group was significantly better regarding theatre time (p < 0.0001), follow-up appointments (p = 0.048), skin healing time (p < 0.001), and return to normal activities of daily living (p = 0.02) than the operated group. CONCLUSIONS: There are significant personal and health economic differences between the two methods of treatment which may influence local choice.

Acute double flexor tendon ruptures following injection of collagenase clostridium histolyticum (Xiapex) for Dupuytren's contracture.

We report a case of acute (24 h) double flexor tendon rupture of the little finger after a single injection of collagenase clostridium histolyticum into a palmar Dupuytren's contracture cord which caused metacarpophalangeal joint contracture. Tendon surgery was performed 48 h postinjury with primary repair and standard rehabilitation but it resulted in poor active flexion due to adhesions. Previous papers have suggested that a needle inserted into the flexor tendon can be detected prior to the injection of collagenase by asking the patient to actively move the finger, but our test on an awake patient showed that when a 27-gauge needle was inserted into the flexor tendons through a thick palmar cord, the syringe did not move significantly when the patient moved the finger, and therefore this test does not minimise the risk of iatrogenic tendon injury when using collagenase (Xiapex) for Dupuytren's contracture.

Long-term result and patient reported outcome of wrist splint treatment for carpal tunnel syndrome.

Carpal tunnel syndrome (CTS) is the commonest peripheral neuropathy presenting to specialist hand and wrist clinics. This study investigated the long-term outcome of carpal tunnel syndrome treated with isolated night wrist splint and the factors determining the likelihood of success of this intervention. Seventy-five patients referred to a specialist hand clinic with CTS were given night wrist splint treatment for 3 months as per a previous study protocol. Fifty-two patients from this cohort did not wish to have surgery after wrist splint treatment and were followed for a further 33-month period. Baseline pain and numbness levels were recorded on a Visual Analogue Scale (VAS) using a questionnaire upon first presentation. A further questionnaire at 36 months reassessed pain and numbness levels, patients' satisfaction with the treatment, and whether they had subsequent surgical decompression. Of the patients who completed the follow-up questionnaire 33 months after their period of conservative management, 43% were successfully treated with splint treatment alone. There was no difference in the VAS for pain or numbness at the baseline and at 36 months between successful and failed treatment groups. Patients successfully treated with wrist splinting alone reported a higher level of satisfaction with their treatment compared to patients who failed wrist splint treatment or had surgical decompression. The results reinforce the previous recommendation on wrist splinting as a first-line treatment in the Primary Care setting. Referral to specialist hand and wrist clinics should be reserved for patients with symptoms refractory to this initial measure.

Is typing speed proportional to the severity of pain in keyboard workers with work-related upper limb disorder.

OBJECTIVES: To investigate if typing speed is proportional to the severity of pain in keyboard workers with work-related upper limb disorder (WRULD). DESIGN: Standardized functional typing test with participants scoring pain before and after typing; calculation of typing speed. PARTICIPANTS: Fifty-nine patients and six controls. SETTING: Tertiary hospital centre for hand and upper limb pain. MAIN OUTCOME MEASURES: Pain (VAS 0-10) and calculation of typing speed as words per minute. RESULTS: THREE SUBGROUPS OF PATIENTS WERE FOUND BASED ON THEIR TYPING SPEED: fast, slow and intermediate. Two-tailed student T-test with P level at 0.05 was used for evaluation. The typing speeds were significantly different between all three patient groups (P < 0.05). The typing speed was significantly faster in the fastest patient group than in the control group (P = 0.04) and the slow and middle groups (P = < 0.0001). The pain before typing was highest in the 'slow' group, in both hands but this difference was not statistically significant. CONCLUSION: Typing speed is not proportional to the severity of pain in keyboard workers with WRULD. Patients with statistically significant slower or faster typing speeds do not have statistically different levels of pain.

Physical rehabilitation with ergonomic intervention of currently working keyboard operators with nonspecific/type II work-related upper limb disorder: a prospective study.

OBJECTIVE: To evaluate the effect of a physical training program in combination with ergonomic changes in a group of keyboard operators with nonspecific/type II work-related upper limb disorder (WRULD). DESIGN: Prospective study. SETTING: Hospital department. PARTICIPANTS: Pain-free controls (n=6) and currently working patients with WRULD (n=17) were included. INTERVENTIONS: Participants were taught how to self-rehabilitate according to a previously published physical exercise program, in addition the patients requested maximal ergonomic assistance from their employer according to British law. MAIN OUTCOMES MEASURES: Pain at rest and after a standardized functional typing test, before and after rehabilitation, with recording of endurance and calculation of typing speed during the tests. Statistical evaluation: Student t test, paired, and 2-tailed. RESULTS: After the rehabilitation program, the patients as a group had significantly less pain both at rest (P=.009) and after the typing test (P<.001). The typing endurance improved significantly (P=.027) and became similar to the healthy control group (P =.09). The typing speed improved significantly in the patient group after rehabilitation (P=.032) and became similar to the normal control group (P=.058). CONCLUSIONS: Currently working keyboard operators with nonspecific/type II WRULD can benefit significantly from a combination of an individualized self-administered physical rehabilitation program and ergonomic work place improvements. Randomized control studies are needed to further investigate the long-term effect of this encouraging finding.

Low typing endurance in keyboard workers with work-related upper limb disorder.

OBJECTIVE: To compare results of typing endurance and pain before and after a standardized functional test. DESIGN: A standardized previously published typing test on a standard QWERTY keyboard. SETTING: An outpatient hospital environment. PARTICIPANTS: Sixty-one keyboard and mouse operating patients with WRULD and six normal controls. MAIN OUTCOME MEASURE: Pain severity before and after the test, typing endurance and speed were recorded. RESULTS: Thirty-two patients could not complete the test before pain reached VAS 5 and this group only typed a mean of 11 minutes. The control group and the remaining group of 29 patients completed the test. Two-tailed student T test was used for evaluation. The endurance was significantly shorter in the patient group that could not complete the test (P < 0.00001) and the pain levels were also higher in this group both before (P = 0.01) and after the test (P = 0.0003). Both patient groups had more pain in the right than the left hand, both before and after typing. CONCLUSIONS: Low typing endurance correlates statistically with more resting pain in keyboard and mouse operators with work-related upper limb disorder and statistically more pain after a standardized typing test. As the right hands had higher pain levels, typing alone may not be the cause of the pain as the left hand on a QWERTY keyboard does relative more keystrokes than the right hand.

High incidence of absent nerve conduction in older patients with bilateral carpal tunnel syndrome.

INTRODUCTION: Carpal tunnel syndrome has been reported by some to have a less satisfactory outcome in older patients following surgery. However, this impression is not supported by other investigators but no objective explanation has been suggested for these differences. In our department, such patients are routinely treated with night wrist splints and, if this is unsatisfactory, they are investigated with nerve conduction studies prior to surgery. PATIENTS AND METHODS: This paper reports the neurophysiological outcome in a young (< 40 years of age) and an older (> 60 years of age) group of patients with clinical bilateral carpal tunnel syndrome who did not benefit from splints. RESULTS: The results showed that both the motor and sensory conduction speeds are significantly lower in the older age group. More importantly in the older group, half had one or more hands where the sensory conduction was absent. In four out of these 10 patients this finding was bilateral and three patients had unilateral absent motor conduction. In the younger group, no patient had absent conduction. CONCLUSIONS: Poor surgical outcome in some older patients may be because of irreversibly damaged nerves prior to surgery and pre-operative neurophysiology is, therefore, recommended both for clinical and medicolegal reasons.

Outcome of late presentation of injuries of the volar plate of the proximal interphalangeal joint.

Early recognition and treatment of volar plate injuries within two weeks is reported to give a good outcome, but there is no published information about the consequences of delayed presentation. We present a series of 14 patients with 16 injuries, who presented more than two weeks after the initial injury. All patients were referred to a specialist hand trauma clinic over a 10 months period and were evaluated prospectively and treated with immediate mobilisation by a specialist hand therapist. Mean time to presentation was 27 days (range 14-79) and mean improvement in range of movement was 25 degrees (range 2-52) with mean residual extension lag 10 degrees (range -4-56). All patients returned to their previous levels of function by the time of discharge. We conclude that it is possible to achieve good outcome without surgical intervention even when the presentation time is four weeks if experienced hand therapists manage the rehabilitation.

Treatment for thoracic outlet syndrome.

BACKGROUND: Thoracic outlet syndrome (TOS) is one of the most controversial clinical entities in medicine. Despite many reports of operative and non-operative interventions, rigorous scientific investigation of this syndrome leading to evidence based management is lacking. OBJECTIVES: To evaluate the beneficial and adverse effects of the available operative and non-operative interventions for the treatment of thoracic outlet syndrome. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group Trials Specialized Register (July 2009), The Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2009), MEDLINE (January 1966 to June 2009), EMBASE (January 1980 to June 2009), CINAHL (January 1981 to June 2009 ), AMED (January 1985 to June 2009 ) and reference lists of articles. SELECTION CRITERIA: We selected randomized or quasi-randomized studies in any language of participants with the diagnosis of any type of thoracic outlet syndrome (neurogenic, vascular, and 'disputed'). The primary outcome measure was change in pain rating on a validated visual analog or similar scale at least six months after the intervention. The secondary outcomes were change in muscle strength and adverse effects of the interventions. DATA COLLECTION AND ANALYSIS: Four authors independently selected the trials to be included and extracted data. The one included study was rated for risk of bias according to the methods recommended in the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS: This review was complicated by a lack of generally accepted criteria for the diagnosis of TOS and had to rely exclusively on the diagnosis of TOS by the investigators in the reviewed studies. There were no studies comparing natural progression with any active intervention. In one trial with a high risk of bias involving 55 participants transaxillary first rib resection decreased pain more than supraclavicular neuroplasty of the brachial plexus. There were no adverse effects in either group. AUTHORS' CONCLUSIONS: This review was complicated by a lack of generally accepted diagnostic criteria for the diagnosis of TOS. There was very low quality evidence that transaxillary first rib resection decreased pain more than supraclavicular neuroplasty but no randomized evidence that either is better than no treatment. There is no randomized evidence to support the use of other currently used treatments. There is a need for an agreed definition for the diagnosis of TOS, especially the disputed form, agreed outcome measures and high quality randomized trials that compare the outcome of interventions with no treatment and with each other.

Managing type II work-related upper limb disorders in keyboard and mouse users who remain at work: a case series report.

Work-related upper limb disorders (WRULDs) are difficult to diagnose due to the limited availability of recognized objective assessment methods. This case series report demonstrates the use of the "typing capacity cycle" test and standardized clinical tests as outcome measures to assess work capacity in four high-intensity keyboard and mouse users who remain at work before and after the implementation of a six-month treatment program. Pain intensity, the duration of pain before treatment, the duration of treatment, type of work, and the location of the pain were recorded for each patient. Function was assessed before and after treatment using the Functional Grading Scale. The assessment results were analyzed to determine any improvements made after rehabilitation. The outcomes indicate that all patients improved their resting pain and work capacity with the three-phase rehabilitation program.