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Matthew Rennels, DO Ryan Szepiela, MD

Promedica Toledo Hospital Primary Care Sports Medicine Fellowship

! The patient is a 26-year-old male professional baseball pitcher (right-handed) who presented with a 2 week history of pale, cold and painful right index and middle fingers.

! He initially reported his symptoms to be intermittent – as “coldness and mild numbness”. •  It was first noticed with driving. •  Intermittently, with pitching.

! These symptoms progressively worsened and were constant by his initial presentation. •  At this point, he did not feel he was pitching

effectively due to the symptoms.

! ROS: Noncontributory other than noted above.

! Past Medical and Surgical History: UCL reconstruction with ulnar nerve translocation (2008).

! Family Medical History: Noncontributory ! Social History: Prior tobacco use. Social

alcohol use. Denies illicit drug use. ! Medications: None ! Allergies: NKDA

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! Constitutional: Well-developed male in no acute distress.

! HEENT: NCAT, normal appearing sclera and conjunctiva, MMM without erythema or exudates, normal dentition.

! Neck: Supple, trachea midline, no cervical LAD. ! Lungs: CTAB, good respiratory effort with

symmetrical expansion. ! Abdomen: Soft, NT. No palpable masses or

organomegaly. ! Osteopathic: Normal standing structural exam.

No first rib dysfunction.

! CV: RRR, S1 and S2 heard without additional sounds. +2 pulses were palpated and equal bilaterally in the radial, ulnar, DP and PT arteries. Allen’s and Adson’s tests were normal. No peripheral edema.

! Neurologic: CN2-12 intact. Grossly normal balance and sensory examination. Neurologically intact in the bilateral upper extremities.

! Musculoskeletal: Normal muscle strength and tone. Gait normal. Complete shoulder exam normal bilaterally.

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! Integumentary: Normal turgor. Normal color. Callous at the tip of his right middle finger. The index and ring finger were cool to touch with cyanotic discoloration.

! Thoracic Outlet Syndrome

! Arterial Occlusion ! Aneurysm ! Embolus ! Hand Arm Vibration

Syndrome ! Quadrangular

Space Syndrome

! Venous Compression

! Hypothenar Hammer Syndrome

! Raynaud’s ! Scleroderma ! SLE ! Buerger’s Disease

! Laboratory Studies: CBC, CMP, PT/INR, APTT, ANA, CRP all within normal limits.

! Non-Invasive Vascular Testing: There was marked compromise of pulsatile perfusion to the tip of the right index and middle finger. There was normal pulsatile perfusion to the arm, forearm and other fingers of the right hand. This suggests obstruction of the metacarpal or digital arteries of the right index and middle finger.

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!  Arterial Duplex: Normal in the right and left upper extremities.

!  Arteriogram: The was occlusion of the distil arteries of the right index and middle finger with normal perfusion of each additional finger in the right hand. The aortic arch and great vessels were normal. There was no evidence of Thoracic Outlet Compression of the subclavian artery. There was evidence of a dilatation at the origin of the humeral circumflex artery with thrombus. Upon hyperextension and abduction of the right arm, there is occlusion of the first branch of the humeral circumflex. This normalizes when the arm is returned to neutral.

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! Pseudoanerysm of the circumflex humeral artery with thrombus resulting in embolization of the distal arteries of the right index and middle fingers from stretch injury during hyperabduction-hyperextension motions.

! Posterior circumflex humeral aneurysm with embolization to the right hand.

! Anterior and Posterior circumflex humeral aneurysm with embolization to the right hand.

! Initially he was placed on medications to maximize perfusion and prevent further embolization: •  Nifedipine 20mg BID (advanced to TID over 1

week) •  ASA 81mg Daily •  Plavix 75mg Daily •  Pentoxifyline 400mg BID

! It was recommended he discontinue pitching until surgical correction

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! He had corrective surgery: •  Endoaneurysmorrhaphy of the anterior and

posterior circumflex humeral artery aneurysms •  Patch angioplasty of the right axillary artery with

a bovine pericardial patch

! His postoperative course was routine: •  Overnight hospitalization •  Discharged with medications: " ASA 325mg Daily " Plavix 75mg Daily " Norco and Colace

•  Scheduled for 2 week follow-up " No heavy lifting for 2 weeks (>10-15 lbs)

! His progression started with stretching and range of motion at 2 weeks.

! He progressed to strengthening and into a return to thrown program.

! He had no limitations at 6 weeks with ADLs

! After 3 months, there were no limitations with pitching.

! He reported to spring training in February.

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! Questions?