Hot Seat #20 Denouement: Arm Pain and Swelling

By Kaynan Doctor, Children's National
with Jamil Madati on the Hot Seat, Children's National

The Case
This is a case of a 14 year-old boy with several days of progressing, intermittent right arm pain not associated with trauma. For a complete case presentation, click here.

Clinical Pearls
Thank you to Dave and Maybelle for your comments and clinical reasoning on the case and Jamil for a thorough Hot Seat Response. Click here to read them. 

"I think our job as ED docs is to rule out arterial obstruction/claudication, neoplasms, and localized infections." -Dave, Children's National

"My first decision tree is if it's swollen. Because localized swelling in this distribution really makes me think about either venous obstruction or lymphedema... if it's painful and swollen, add in a soft tissue infection (cellulitis, pyomyositis, nec fasc, etc). And an ischemic proces like compartment syndrome." -Dave, Children's National

"Localised pain in the wrist, without significant swelling, could also point to tendinous injury and tunnel syndromes, cubital for example." Maybelle, Inova Fairfax

"Would be odd to have significant cervical impingement minus a motor deficit." -Maybelle, Inova Fairfax

"If a patient keeps returning to an ED with the same complaints, and I’m the 3rd guy seeing him, I generally take a step back and look through everything in the H&P with a fine toothed comb." -Jamil, Children's National

"The swelling (which appears intermittent in nature, since none noted on exam) is also worrisome. On initial thinking, unilateral arm swelling is concerning for DVT or clot somewhere in the upper extremity resulting in venous congestion leading to arm swelling. But patient had dopplers of the RUE that were negative." -Jamil, Children's National

"I suspect that repeating some of the same labs from previous ED visits would be of low utility. The patient’s symptoms would urge me to obtain further imaging of the UE along the lines of MRI/MRA." -Jamil, Children's National

Here's how you answered our questions. 
The most popular answers were repeating labs and getting further plain radiographs. For disposition, there was an almost even split between admitting to the hospitalist, discharging with orthopedic follow-up, and getting a neurology consult in the ER and having disposition depend on that. No one was comfortable with calling this "rubbish" (Kaynan is wonderfully British) and arranging PMD follow-up.

1. Which ONE of the following tests would add the most to your ED diagnostic workup (bearing in mind the prior workup)

Some labs and radiographs come back and they are unremarkable.

2. What do you do next?

The Hot Seat Response
by Jamil Madati, Children's National

Thanks Kaynan for the interesting case. This patient presents with persistent symptoms that point towards both a neurologic (arm pain, numbness and tingling) and possible vascular cause (arm/wrist swelling). He has had a pretty extensive (xrays, labs x2, bone scans, dopplers), and thus far, a negative work up at the previous EDs and now presents to our institution with the same symptoms. If a patient keeps returning to an ED with the same complaints, and I’m the 3rd guy seeing him, I generally take a step back and look through everything in the H&P with a fine toothed comb.

Symptoms started after a bike ride (which from personal experience involves all kinds of aches and pains from being in a specific position for prolonged periods of times) implying that symptoms might be positional in nature. Pain seems to be his most persistent symptom and from the PE appears to extend from his wrist to his shoulder and is exacerbated by light touch (hyperesthesia). If the pain involves the entire arm, one would think that the nerves involved would be at/or proximal from the brachial plexus, however there does not seem to be any specific dermatomal distribution pattern to his pain (sparing the hand, stopping at the shoulder). He has both sensation and strength “intact” which is also reassuring for any focal spinal cord or nerve root lesion. The swelling (which appears intermittent in nature, since none noted on exam) is also worrisome. On initial thinking, unilateral arm swelling is concerning for DVT or clot somewhere in the upper extremity resulting in venous congestion leading to arm swelling. But patient had dopplers of the RUE that were negative. I would have liked to know if the patient had noted any color or temp changes in his upper extremity in relation to his symptoms (pallor or coolness associated with the swelling, pain, numbness/tingling). If it’s not a clot then I wonder if there is some intermittent claudication of the subclavian artery leading to the patient’s symptoms.

Thoracic Outlet Syndrome (TOS) is the diagnosis that comes to mind resulting from changes in neck/arm positions that cause compression of nerves and/or blood vessels leading to the upper extremity symptoms much like the ones our patient exhibits. Common causes in pediatrics are congenital upper rib abnormalities, trauma and repetitive/overuse injuries. The work up for TOS would include EMG studies, musculoskeletal US, MRI/MRA of upper extremity.

The other diagnosis that can present similarly (hyperesthesia, pain, swelling, numbness/tingling) is Reflex Sympathetic Dystropy (complex regional pain syndrome). Not enough space to discuss this in detail, but suffice to say that this is a diagnosis that requires many specialists (Rheumatology, Neurology, Psychiatry, Pain specialists) to assist in making the diagnosis and initiating treatment. Not sure what to make of rash on arm 3 days ago??? Lyme disease shouldn’t cause arm swelling (unless arthritis) or arm numbness. With that said, I suspect that repeating some of the same labs from previous ED visits would be of low utility. The patient’s symptoms would urge me to obtain further imaging of the UE along the lines of MRI/MRA looking for vascular cause of symptoms and/or anatomic compression of nerves and vessels of the brachial plexus. Given that this is his 3rd visit for the same, I would probably admit for further work up and pain management but he is stable, could also work up as an outpatient if PCP is willing to facilitate this.

The Denouement
by Kaynan Doctor, Children's National

The acute and unusual nature of the pain with multiple visits to EDs and clinics prompted us to admit this patient. Initially neurology agreed to accept him on to their service with the assumption that this might be a reflex sympathetic dystrophy presentation. However, they later preferred he be admitted to the general medical team to help rule out possible infectious or rheumatological causes of his arm pain. The following day, patient had an MRI which showed an abnormal bone marrow signal in the proximal to mid R radius without evidence of focal fluid collection or abscess; findings were consistent with osteomyelitis. The following laboratory tests recommended by rheumatology and infectious disease consults to evaluate for possible multifocal chronic osteomyelitis returned as unremarkable – Aldolase, Immunoglobulins, Lyme titers, total complement, rheumatoid factor, HLA-B27, Creatinine Kinase and flow cytometry. Patient was discharged home on IV clindamycin after a PICC line was placed.

The Hot Seat is a recurrent online case series aimed at facilitating asynchronous sharing of PEM knowledge and experience. Faculty are placed on The Hot Seat and publish their opinions without knowing the case or its outcomes. Cases are written by PEM fellows at Children's National in DC, Johns Hopkins in MD, and INOVA Fairfax in VA. Emily Willner is the faculty advisor on case presentations. We welcome your commentary.