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Upper Limb Deep Vein Thrombosis and Portable Computer Games
CLINICAL COMMUNICATION TO THE EDITOR
Upper Limb Deep Vein Thrombosis and Portable Computer Games To the Editor: A 33-year-old man presented with progressive right arm swelling that had started 2 weeks before admission. He had never experienced similar symptoms. His past medical history was unremarkable for trauma to the shoulder or arm, venous catheter insertion, radiotherapy, or intravenous drug usage. On examination he was afebrile, and there was increased girth of the right arm compared with the left. Tenderness and increased warmth were absent, and the brachial and radial pulses were of normal volume. Neurological examination was unremarkable. A color Doppler and duplex ultrasound scan of the right upper limb showed acute deep vein thrombosis involving the right axillary and subclavian veins. Chest radiographs including apical lordotic views did not reveal any cervical ribs. A thrombophilia screen, which included tests for protein C and S, antithrombin, factor V Leiden mutation, lupus anticoagulant, and anticardiolipin antibodies, did not demonstrate any abnormalities. On further questioning, the patient gave a history of playing a recently acquired portable computer gaming console daily, at continuous stretches of 2-3 hours. He would do this in a supine position in bed, holding the console at eye level directly above his head and would stop when numbness developed in his hands. Having excluded other possible predisposing factors for upper limb deep vein thrombosis, prolonged playing of his gaming console in an unusual position was thought to be the primary cause for thrombosis. He was treated with anticoagulation therapy and advised to refrain from assuming similar positions and to take regular breaks while playing his portable device. The upper limb is an uncommon site for deep vein thrombosis. Primary axillary-subclavian vein thrombosis is, however, well described and is also called “Paget-Schroetter syndrome.”1 It is largely due to chronic compression of these vessels at the level of the costoclavicular space from repetitive muscular activity or trauma, ultimately leading to intimal damage and clot formation. Arm elevation, as in our case, narrows the costoclavicular space and causes compression of the axillary and subclavian veins. In two thirds of Requests for reprints should be addressed to Colin Phipps, MBBChBAO, MRCP (UK), Department of Hematology, Singapore General Hospital, Outram Road, Singapore 169608, Singapore. E-mail address: [email protected]
0002-9343/$ -see front matter © 2008 Elsevier Inc. All rights reserved.
cases, the right side is involved,2 probably from the fact that the angle where the right subclavian vein joins the right internal jugular vein is more acute than on the left side. This syndrome is usually ascribed to athletic activity in young adults.3 Despite being a sedentary activity, our opinion is that portable computer gaming can potentially produce the same degree of repetitive muscular activity and associated trauma and compression needed to cause venous thrombosis. Both distal and proximal muscle groups in the arm are likely to be used during rapid and repetitive operation of the console buttons for durations that are likely longer than most athletic pursuits. New interactive games playable on portable consoles are increasingly engaging, with players achieving high excitement levels that may translate to similarly intense muscular efforts on the upper limbs. The portability of the device also allows it to be used in unusual and ergonomically unfavorable positions, which can further accentuate the repetitive strain on proximal muscle groups and cause various degrees of deep vein compression. Venous thromboembolism has also been described with prolonged use of computer terminals,4 but this is likely to be precipitated by stasis from immobility, without the element of vascular injury as seen in portable computer gaming. In conclusion, portable computer gaming might confer a potential risk for upper limb thrombosis if used in an unconventional fashion, and portable video game enthusiasts should be advised to assume appropriate ergonomic playing positions and avoid prolonged use of the console without changing positions or taking breaks. Colin Phipps, MBBChBAO, MRCP (UK) Heng Joo Ng, MBBS, MRCP (UK) Department of Hematology Singapore General Hospital Singapore
doi:10.1016/j.amjmed.2008.01.034
References 1. Hughes ES. Venous obstruction in the upper extremity. Br J Surg. 1948;36:155-163. 2. Sanders RJ, Haug C. Subclavian vein obstruction and thoracic outlet syndrome: a review of etiology and management. Ann Vasc Surg. 1990;4:397-410. 3. Chaudhry MA, Hajarnavis J. Primary subclavian-axillary vein thrombosis in sport activities (Case Reports). Clin J Sports Med. 2003;13: 269-271. 4. Beasley R, Raymond N, Hill S, et al. eThrombosis: the 21st century variant of venous thromboembolism associated with immobility. Eur Respir J. 2003;21:374-376.
Upper Limb Deep Vein Thrombosis and Portable Computer Games To the Editor: A 33-year-old man presented with progressive right arm swelling that had started 2 weeks before admission. He had never experienced similar symptoms. His past medical history was unremarkable for trauma to the shoulder or arm, venous catheter insertion, radiotherapy, or intravenous drug usage. On examination he was afebrile, and there was increased girth of the right arm compared with the left. Tenderness and increased warmth were absent, and the brachial and radial pulses were of normal volume. Neurological examination was unremarkable. A color Doppler and duplex ultrasound scan of the right upper limb showed acute deep vein thrombosis involving the right axillary and subclavian veins. Chest radiographs including apical lordotic views did not reveal any cervical ribs. A thrombophilia screen, which included tests for protein C and S, antithrombin, factor V Leiden mutation, lupus anticoagulant, and anticardiolipin antibodies, did not demonstrate any abnormalities. On further questioning, the patient gave a history of playing a recently acquired portable computer gaming console daily, at continuous stretches of 2-3 hours. He would do this in a supine position in bed, holding the console at eye level directly above his head and would stop when numbness developed in his hands. Having excluded other possible predisposing factors for upper limb deep vein thrombosis, prolonged playing of his gaming console in an unusual position was thought to be the primary cause for thrombosis. He was treated with anticoagulation therapy and advised to refrain from assuming similar positions and to take regular breaks while playing his portable device. The upper limb is an uncommon site for deep vein thrombosis. Primary axillary-subclavian vein thrombosis is, however, well described and is also called “Paget-Schroetter syndrome.”1 It is largely due to chronic compression of these vessels at the level of the costoclavicular space from repetitive muscular activity or trauma, ultimately leading to intimal damage and clot formation. Arm elevation, as in our case, narrows the costoclavicular space and causes compression of the axillary and subclavian veins. In two thirds of Requests for reprints should be addressed to Colin Phipps, MBBChBAO, MRCP (UK), Department of Hematology, Singapore General Hospital, Outram Road, Singapore 169608, Singapore. E-mail address: [email protected]
0002-9343/$ -see front matter © 2008 Elsevier Inc. All rights reserved.
cases, the right side is involved,2 probably from the fact that the angle where the right subclavian vein joins the right internal jugular vein is more acute than on the left side. This syndrome is usually ascribed to athletic activity in young adults.3 Despite being a sedentary activity, our opinion is that portable computer gaming can potentially produce the same degree of repetitive muscular activity and associated trauma and compression needed to cause venous thrombosis. Both distal and proximal muscle groups in the arm are likely to be used during rapid and repetitive operation of the console buttons for durations that are likely longer than most athletic pursuits. New interactive games playable on portable consoles are increasingly engaging, with players achieving high excitement levels that may translate to similarly intense muscular efforts on the upper limbs. The portability of the device also allows it to be used in unusual and ergonomically unfavorable positions, which can further accentuate the repetitive strain on proximal muscle groups and cause various degrees of deep vein compression. Venous thromboembolism has also been described with prolonged use of computer terminals,4 but this is likely to be precipitated by stasis from immobility, without the element of vascular injury as seen in portable computer gaming. In conclusion, portable computer gaming might confer a potential risk for upper limb thrombosis if used in an unconventional fashion, and portable video game enthusiasts should be advised to assume appropriate ergonomic playing positions and avoid prolonged use of the console without changing positions or taking breaks. Colin Phipps, MBBChBAO, MRCP (UK) Heng Joo Ng, MBBS, MRCP (UK) Department of Hematology Singapore General Hospital Singapore
doi:10.1016/j.amjmed.2008.01.034
References 1. Hughes ES. Venous obstruction in the upper extremity. Br J Surg. 1948;36:155-163. 2. Sanders RJ, Haug C. Subclavian vein obstruction and thoracic outlet syndrome: a review of etiology and management. Ann Vasc Surg. 1990;4:397-410. 3. Chaudhry MA, Hajarnavis J. Primary subclavian-axillary vein thrombosis in sport activities (Case Reports). Clin J Sports Med. 2003;13: 269-271. 4. Beasley R, Raymond N, Hill S, et al. eThrombosis: the 21st century variant of venous thromboembolism associated with immobility. Eur Respir J. 2003;21:374-376.