Gilliatt-Sumner Hand review

Gilliatt-Sumner Hand is a distinctive clinical entity observed in patients with neurogenic thoracic outlet syndrome (nTOS), characterized by progressive atrophy of the intrinsic hand muscles. This phenomenon reflects chronic compression of the lower trunk of the brachial plexus, leading to motor denervation and subsequent wasting of the thenar, interosseous, and hypothenar muscle groups. In the context of an orthopedic symposium, an in‐depth discussion of its clinical presentation, diagnostic workup, and treatment modalities is warranted.

Clinical Signs (8 Key Features)

1. Thenar Atrophy – Marked wasting of the abductor pollicis brevis is a hallmark, often manifesting as a flattened thenar eminence.
2. Interosseous Muscle Atrophy – Loss of bulk in the dorsal and palmar interosseous muscles compromises fine motor function.
3. Abductor Digiti Minimi Wasting – Notable atrophy in the hypothenar region further corroborates the diagnosis.
4. Diminished Grip Strength – Patients frequently exhibit a reduced grip force due to compromised intrinsic hand musculature.
5. Sensory Disturbances – Paresthesias and dysesthesias in a distribution corresponding to the lower brachial plexus (often affecting ulnar and median nerve territories) are common.
6. Pain in the Upper Extremity – Deep, aching pain may extend from the shoulder girdle down to the hand, reflecting neural irritation.
7. Positive Tinel’s Sign – Percussion over the lower trunk of the brachial plexus or the infraclavicular region can elicit tingling, supporting the presence of nerve compression.
8. Provocative Maneuver Positivity – Exacerbation of symptoms during maneuvers such as the elevated arm stress test (EAST) confirms dynamic compression.

Essential Diagnostic Studies

A multimodal diagnostic approach is essential for accurate evaluation:

1. Electrodiagnostic Studies (EMG and Nerve Conduction Studies) – Demonstrate denervation potentials, reduced recruitment patterns, and diminished sensory nerve action potentials in the affected distribution.
2. High-Resolution Ultrasound (HRUS) – Provides real-time visualization of the brachial plexus and may reveal focal nerve swelling or the “wedge-sickle sign” indicative of lower trunk compression.
3. Magnetic Resonance Imaging/Neurography (MRI/MRN) – Affords detailed assessment of soft tissue and neural structures, excluding alternative etiologies such as mass lesions or cervical radiculopathy.
4. Computed Tomography (CT) Scan – Can delineate bony anomalies (e.g., cervical ribs or anomalous first ribs) contributing to the compression.
5. Provocative Testing – Clinical maneuvers, including the EAST and Roos test, help reproduce symptoms and support the diagnosis of dynamic neurovascular compression.

Best Treatment Options

Initial management emphasizes conservative modalities:

• Physical Therapy: Postural correction, scapulothoracic stabilization, and nerve gliding exercises.
• Pharmacologic Interventions: NSAIDs and neuropathic pain agents (e.g., gabapentinoids).
• Interventional Strategies (in refractory cases):
  • Ultrasound-guided perineural corticosteroid injections
  • Nerve hydrodissection

Surgical Intervention
For progressive motor deficits:

• Thoracic Outlet Decompression (TOD) Surgery via transaxillary or supraclavicular approach.
• Goal: Halt muscular atrophy and permit partial recovery.
• Postoperative Rehab: Essential to restore strength and dexterity.

Summary

Gilliatt-Sumner Hand represents a severe manifestation of neurogenic TOS. Early recognition and timely intervention—ranging from conservative management to surgical decompression—are critical to preventing irreversible motor deficits and optimizing patient outcomes.