Picture of the Month—Diagnosis | Neurology | JAMA Pediatrics | JAMA Network
[Skip to Navigation]
Citations 0
Special Feature
March 2, 2009

Picture of the Month—Diagnosis

Arch Pediatr Adolesc Med. 2009;163(3):276. doi:10.1001/archpediatrics.2009.19-b

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 11.5:1.3,5,9-11Although 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- 507PubMedGoogle ScholarCrossref
Helms  CAMartinez  SSpeer  KP Acute brachial neuritis (Parsonage-Turner syndrome): MR imaging appearance–report of three cases.  Radiology 1998;207 (1) 255- 259PubMedGoogle ScholarCrossref
Turner  JWParsonage  MJ Neuralgic amyotrophy (paralytic brachial neuritis); with special reference to prognosis.  Lancet 1957;273 (6988) 209- 212PubMedGoogle ScholarCrossref
Parsonage  MJTurner  JW Neuralgic amyotrophy: the shoulder-girdle syndrome.  Lancet 1948;251 (6513) 973- 978Google ScholarCrossref
Scalf  REWenger  DEFrick  MAMandrekar  JNAdkins  MC MRI findings of 26 patients with Parsonage-Turner syndrome.  AJR Am J Roentgenol 2007;189 (1) W39- W44PubMedGoogle ScholarCrossref
Tsairis  PDyck  PJMulder  DW Natural history of brachial plexus neuropathy: report on 99 patients.  Arch Neurol 1972;27 (2) 109- 117PubMedGoogle ScholarCrossref
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- 71PubMedGoogle ScholarCrossref
Beghi  EKurland  LTMulder  DWNicolosi  A Brachial plexus neuropathy in the population of Rochester, Minnesota, 1970-1981.  Ann Neurol 1985;18 (3) 320- 323PubMedGoogle ScholarCrossref
Magee  KRDejong  RN Paralytic brachial neuritis: discussion of clinical features with review of 23 cases.  JAMA 1960;1741258- 1262PubMedGoogle ScholarCrossref
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- 664PubMedGoogle ScholarCrossref
Misamore  GWLehman  DE Parsonage-Turner syndrome (acute brachial neuritis).  J Bone Joint Surg Am 1996;78 (9) 1405- 1408PubMedGoogle Scholar
Suarez  GAGiannini  CBosch  EP  et al.  Immune brachial plexus neuropathy: suggestive evidence for an inflammatory-immune pathogenesis.  Neurology 1996;46 (2) 559- 561PubMedGoogle ScholarCrossref
Augé  WK  IIVelazquez  PA Parsonage-Turner syndrome in the Native American Indian.  J Shoulder Elbow Surg 2000;9 (2) 99- 103PubMedGoogle ScholarCrossref
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;825PubMedGoogle ScholarCrossref