0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Special Feature |

Picture of the Month—Diagnosis FREE

[+] Author Affiliations

Section Editor: Samir S. Shah, MD

More Author Information
Arch Pediatr Adolesc Med. 2009;163(3):276. doi:10.1001/archpediatrics.2009.19-b.
Text Size: A A A
Published online

DENOUEMENT AND DISCUSSION: DIAGNOSIS: PARSONAGE-TURNER SYNDROME

The image depicts a left-winged scapula resulting from shoulder girdle weakness. After plain radiographs showed no abnormalities, magnetic resonance imaging of the cervical spine and shoulder revealed high T2 signal intensity of the long thoracic, suprascapular, and axillary nerves and fatty atrophy of the muscles, confirming the diagnosis of Parsonage-Turner syndrome (PTS) (otherwise known as brachial neuritis, neuralgic amyotrophy, and idiopathic brachial neuritis).1,2

Parsonage-Turner syndrome is a condition that was first described in 1948 in a case series of 136 patients.3,4Typically, PTS presents with abrupt onset of moderate shoulder pain followed by variable weakness of the shoulder girdle. Patients with PTS usually describe a sharp onset of pain that subsides in days to weeks and is slowly replaced with a dull ache. Weakness develops after the resolution of the initial pain, and there is usually normal sensation.1,2Involved muscles are those innervated by the brachial plexus (C5-C8), most commonly the long thoracic, suprascapular, and axillary nerves.1,5In our patient, a winged scapula was present because of paralysis of the serratus anterior muscle, which is innervated by the long thoracic nerve. Any component of the brachial plexus can be involved, with the lower trunk affected in up to 15% of cases.6Case series have been reported of adult men presenting with phrenic nerve involvement, leading to dyspnea from diaphragmatic paralysis.6,7

The incidence of PTS is estimated at 1.64 per 100 000 in the general population and is highest in the third through seventh decades of life; rare reports have occurred in children as young as 3 months.8There is a male predominance, with reported male to female ratios of 2:1 to 11.5:1.3,5,911Although the cause of PTS is undetermined, it has been linked to vaccine administration and viral illnesses in 15% to 25% of cases.5,7,12,13Specific cases after tetanus toxoid immunization and outbreaks in specific clusters have led most to believe that an immune-mediated process is the common pathway in this disease. Most cases are not preceded by trauma.2,7,13Eighty percent of cases spontaneously resolve within 2 years, and patients with severe symptoms at onset may have a more protracted course of weakness.1,13Management is focused on analgesia and physical therapy, with no need for surgery reported in the literature.1,5,14

Return to Quiz Case.

Correspondence:Sujit Iyer, MD, MS, Children's Hospital of Philadelphia, 34th St and Civic Center Blvd, Philadelphia, PA 19104 (iyers@email.chop.edu).

Accepted for Publication:September 15, 2008.

Author Contributions:Study concept and design: Mistry and Iyer. Acquisition of data: Mistry and Iyer. Analysis and interpretation of data: Iyer. Drafting of the manuscript: Mistry and Iyer. Critical revision of the manuscript for important intellectual content: Mistry and Iyer. Administrative, technical, and material support: Mistry and Iyer. Study supervision: Mistry and Iyer.

Financial Disclosure:None reported.

Gaskin  CMHelms  CA Parsonage-Turner syndrome: MR imaging findings and clinical information of 27 patients. Radiology 2006;240 (2) 501- 507
PubMed
Helms  CAMartinez  SSpeer  KP Acute brachial neuritis (Parsonage-Turner syndrome): MR imaging appearance–report of three cases. Radiology 1998;207 (1) 255- 259
PubMed
Turner  JWParsonage  MJ Neuralgic amyotrophy (paralytic brachial neuritis); with special reference to prognosis. Lancet 1957;273 (6988) 209- 212
PubMed
Parsonage  MJTurner  JW Neuralgic amyotrophy: the shoulder-girdle syndrome. Lancet 1948;251 (6513) 973- 978
Scalf  REWenger  DEFrick  MAMandrekar  JNAdkins  MC MRI findings of 26 patients with Parsonage-Turner syndrome. AJR Am J Roentgenol 2007;189 (1) W39- W44
PubMed
Tsairis  PDyck  PJMulder  DW Natural history of brachial plexus neuropathy: report on 99 patients. Arch Neurol 1972;27 (2) 109- 117
PubMed
Mulvey  DAAquilina  RJElliott  MWMoxham  JGreen  M Diaphragmatic dysfunction in neuralgic amyotrophy: an electrophysiologic evaluation of 16 patients presenting with dyspnea. Am Rev Respir Dis 1993;147 (1) 66- 71
PubMed
Beghi  EKurland  LTMulder  DWNicolosi  A Brachial plexus neuropathy in the population of Rochester, Minnesota, 1970-1981. Ann Neurol 1985;18 (3) 320- 323
PubMed
Magee  KRDejong  RN Paralytic brachial neuritis: discussion of clinical features with review of 23 cases. JAMA 1960;1741258- 1262
PubMed
Mamula  CJErhard  REPiva  SR Cervical radiculopathy or Parsonage-Turner syndrome: differential diagnosis of a patient with neck and upper extremity symptoms. J Orthop Sports Phys Ther 2005;35 (10) 659- 664
PubMed
Misamore  GWLehman  DE Parsonage-Turner syndrome (acute brachial neuritis). J Bone Joint Surg Am 1996;78 (9) 1405- 1408
PubMed
Suarez  GAGiannini  CBosch  EP  et al.  Immune brachial plexus neuropathy: suggestive evidence for an inflammatory-immune pathogenesis. Neurology 1996;46 (2) 559- 561
PubMed
Augé  WK  IIVelazquez  PA Parsonage-Turner syndrome in the Native American Indian. J Shoulder Elbow Surg 2000;9 (2) 99- 103
PubMed
Nath  RKLyons  ABBietz  G Microneurolysis and decompression of long thoracic nerve injury are effective in reversing scapular winging: long-term results in 50 cases. BMC Musculoskelet Disord 2007;825
PubMed

Figures

Tables

References

Gaskin  CMHelms  CA Parsonage-Turner syndrome: MR imaging findings and clinical information of 27 patients. Radiology 2006;240 (2) 501- 507
PubMed
Helms  CAMartinez  SSpeer  KP Acute brachial neuritis (Parsonage-Turner syndrome): MR imaging appearance–report of three cases. Radiology 1998;207 (1) 255- 259
PubMed
Turner  JWParsonage  MJ Neuralgic amyotrophy (paralytic brachial neuritis); with special reference to prognosis. Lancet 1957;273 (6988) 209- 212
PubMed
Parsonage  MJTurner  JW Neuralgic amyotrophy: the shoulder-girdle syndrome. Lancet 1948;251 (6513) 973- 978
Scalf  REWenger  DEFrick  MAMandrekar  JNAdkins  MC MRI findings of 26 patients with Parsonage-Turner syndrome. AJR Am J Roentgenol 2007;189 (1) W39- W44
PubMed
Tsairis  PDyck  PJMulder  DW Natural history of brachial plexus neuropathy: report on 99 patients. Arch Neurol 1972;27 (2) 109- 117
PubMed
Mulvey  DAAquilina  RJElliott  MWMoxham  JGreen  M Diaphragmatic dysfunction in neuralgic amyotrophy: an electrophysiologic evaluation of 16 patients presenting with dyspnea. Am Rev Respir Dis 1993;147 (1) 66- 71
PubMed
Beghi  EKurland  LTMulder  DWNicolosi  A Brachial plexus neuropathy in the population of Rochester, Minnesota, 1970-1981. Ann Neurol 1985;18 (3) 320- 323
PubMed
Magee  KRDejong  RN Paralytic brachial neuritis: discussion of clinical features with review of 23 cases. JAMA 1960;1741258- 1262
PubMed
Mamula  CJErhard  REPiva  SR Cervical radiculopathy or Parsonage-Turner syndrome: differential diagnosis of a patient with neck and upper extremity symptoms. J Orthop Sports Phys Ther 2005;35 (10) 659- 664
PubMed
Misamore  GWLehman  DE Parsonage-Turner syndrome (acute brachial neuritis). J Bone Joint Surg Am 1996;78 (9) 1405- 1408
PubMed
Suarez  GAGiannini  CBosch  EP  et al.  Immune brachial plexus neuropathy: suggestive evidence for an inflammatory-immune pathogenesis. Neurology 1996;46 (2) 559- 561
PubMed
Augé  WK  IIVelazquez  PA Parsonage-Turner syndrome in the Native American Indian. J Shoulder Elbow Surg 2000;9 (2) 99- 103
PubMed
Nath  RKLyons  ABBietz  G Microneurolysis and decompression of long thoracic nerve injury are effective in reversing scapular winging: long-term results in 50 cases. BMC Musculoskelet Disord 2007;825
PubMed

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
PubMed Articles