This document discusses unilateral arm swelling and thoracic outlet syndrome (TOS). TOS is caused by compression of neurovascular structures as they pass through the thoracic outlet and can be categorized as neurogenic TOS (NTOS), arterial TOS (ATOS), or venous TOS (VTOS). NTOS is usually treated conservatively unless an anatomical abnormality is present, while ATOS and VTOS may require urgent thrombolysis, anticoagulation, stenting/venoplasty, or surgical decompression. Evaluation includes provocative testing, imaging like Doppler ultrasound, and x-rays to rule out other potential causes and guide management, which could involve physical therapy, surgery to remove ribs or muscle, or treating underlying

1. Unilateral Arm Swelling
Tim Kubal

2. Venogram

3. ProvocativeVenogram

4. Thoracic Outlet
Syndrome
• Compression of neurovascular structures
as they pass through the thoracic outlet.
• NTOS,ATOS,VTOS (Paget-Schroetter
Syndrome)
• Whiplash, Repetitive activity, rib anomaly,
prior clavicular fx, fibrosis.

5. Anatomy

6. NTOS
• Most common with the majority of these
cases being related to trauma and virtually
impossible to diagnose objectively
• Paresthesias, pain
• Tx conservatively in majority of cases
unless demonstrable anatomical
abnormality then consider surgery

7. VTOS
• Majority of cases related to strenuous or
repetitive overhead activity.
• Acute or subacute swelling, heaviness, pain,
venous distention with visible collaterals.
• Acute: Thrombolytics, stenting/venoplasty,
surgical decompression, anticoagulation.
• Subacute: Conservative vs. Surgery

8. ATOS
• Least common
• Subclavian Artery Compression
• Typically secondary to demonstrable rib
abnormality
• Pain, Paresthesias, Cyanosis, Embolism,
Negative Pulses, Slow capillary refill

9. How do i work this up?
• Provocative testing
• Dopplers (Acutely r/o thrombosis)
• C-Spine films, shoulder films
• CT chest

10. Management
• VTOS: Usually requires urgent
thrombolysis, anticoag, surgical
decompressions
• ATOS: surgical decompression and
restoration of arterial blood flow
• NTOS: PT, surgical decompression.

11. Surgery
• Rib, muscle resection
• Less stuff
• More space

12. What else could it be?
• Brachial plexus injury
• Carpal Tunnel
• CRPS
• Malignancy
• C-Spine or shoulder MSK
• Nothing

13. TOS
• JR Richard (CVA)
• David Cone (Arterial aneurysm)
• Hanson