Patient 1 is a 57 year-old man who worked for thirty years as a draftsman and map maker. The patient gradually developed pain in his neck, both shoulders, anterior chest, and interscapular region, with pain, numbness, tingling and severe swelling in both hands. Initially, the swelling would resolve over each weekend, but eventually became permanent.
As his symptoms progressed, the patient was unable to work as a draftsperson. He found that repetitive hand activity, fine motions of his fingers, reaching for objects, or driving would increase his pain and cause pronounced numbness and tingling of all fingers on both hands. He began experiencing intermittent, severe headaches, and the swelling of his hands progressed to the point that he could not make a fist or wear rings.
Physical examination showed scapular winging, decreased two-point discrimination in both hands, rapid fatigue of grip, and strongly positive upper limb neural tension signs, indicative of brachial plexus irritation.
Figures 1 and 2 demonstrate the upper trunk penetrating the anterior scalene muscle on each side, and the remainder of each brachial plexus passing normally between the anterior and middle scalene muscles.
Figure 3 (arms neutral) and Figure 4 (arms elevated) demonstrate the clavicle impinging on the laterally displaced upper trunk when the patient lifts his arms.
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