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Thoracic outlet syndrome

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Thoracic outlet syndrome

  1. 1. THORACIC OUTLET SYNDROME
  2. 2.  Thoracic outlet syndrome (TOS)- a collection of symptoms brought about by abnormal compression of the neurovascular bundle by bony, ligamentous or muscular obstacles in the narrow space between clavicle and 1 st rib – the thoracic outlet.
  3. 3. ANATOMY  interscalene triangle  Costoclavicular space − Med : 1st rib − Med : 1st rib − Ant : clavicle, scaleneus anterior − Ant : clavicle − Post : scaleneus medius − Lat : costoclavicular ligament, subclavius muscle − Post : scaleneus medius
  4. 4. contents  Brachial plexus  Subclavian artery  Subclavian vein
  5. 5. Causes  Cervical rib  Long C7 transverse process  Anomalous insertion of scalene muscles  Scalene muscle hypertrophy  scaleneus minimus  Abnormal bands, ligaments  Fracture clavicle/ 1st rib  Exostosis  Tumours  Brachial plexus trauma / diseases
  6. 6. Cervical rib
  7. 7. Clinical features  Most commonly seen in middle aged women  Usually due to neural compromise. Interscalene triangle Artery , Nerves Costoclavicular space Vein Subcoracoid area Artery, Vein , Nerves
  8. 8. Interscalene triangle
  9. 9. Costoclavicular space
  10. 10. Subcoracoid area
  11. 11. Arterial compromise  Fatigue  Weakness  Coldness  Upper limb claudication  Thrombosis  Paraesthesia  Raynaud's phenomenon due to thrombosis with distal embolisation
  12. 12. Venous compromise  Edema  Venous distension  Collateral formation  Cyanosis  Paget-Schroetter syndrome – effort thrombosis − "Effort" axillary-subclavian vein thrombosis (PagetSchroetter syndrome) is an uncommon deep venous thrombosis due to repetitive activity of the upper limbs.
  13. 13. Neural compromise  Paraesthesia  Pain in shoulder, arm, forearm and fingers   Occipital headache – referred from tight scalene muscles Weakness of forearm, hand.
  14. 14. Clinical tests
  15. 15. Roos Test   Hold both arms in surrendering position (90°overhead with shoulders in external rotation) – reproduction of symptoms within 1 minute . Arm collapses if continued. modified Roos test / Extended Arm Stress Test(EAST)– same as above. Symptoms precipitated by opening and closing fists continuously.
  16. 16. Elevated arms stress test
  17. 17. Adson's (Scalene) Test   Radial pulse diminishes and disappears on turning chin to same side. Decreases space between scaleneus anterior and medius .
  18. 18. Adsons test
  19. 19. Halsted's costoclavicular compression test  45° abduction and extension of arm with downward pressure on shoulders –neck turned to opposite side- reproduce symptoms
  20. 20. Exaggerated military position  Patient shrugs shoulders with deep inhalation while drawing the shoulders backward in an exaggerated military position – radial pulse diminishes.
  21. 21. Military position
  22. 22. Wright's hyperabduction test   Arm hyperabducted to 180°-diminishing radial pulse. Neurovascular structures compressed in subcoracoid region by pectoralis minor tendon, head of humerus or coracoid process.
  23. 23. Wright's hyperabdution test
  24. 24.   Tinel sign – in supra and infraclavicular region Phalens sign – in carpel tunnel syndrome (CTS)
  25. 25. Differential diagnoses  Carpel tunnel syndrome  Spinal canal tumors  Shoulder myositis  Angina pectoris  Raynaud's disease  Ulnar nerve compression - epicondylitis
  26. 26. investigations  Chest x ray, cervical spine x ray  MRI, cervical myelography −  Doppler , vascular imaging(angiogram/venogram) −  r/o narrowing of intrevertebral foramen, disc compression. r/o aneurism, thrombosis Nerve conduction study, electromyography − confirm neurogenic TOS, localise the area of compression- r/o CTS
  27. 27.  Double crush syndrome – TOS with other peripheral sites of nerve compression(CTS)
  28. 28. Treatment
  29. 29. Non operative treatment  Posture improving exercises.  Breathing exercises.  Avoid aggravating activities.  Avoid repetitive upper extremity mechanical work and muscular trauma.  Analgesics,muscle relaxants, antidepressants.  Physiotherapy .
  30. 30. Surgical treatment Indications:  Symptoms persists with non operative treatment.  Associated vascular compression.  Progression of neurological symptoms.  Nerve conduction velocity < 60m/s
  31. 31.   Trans cervical or trans axillary(Roos) resection of 1st rib often with release of scalene muscles. Cervical rib excision.
  32. 32. Roos approach
  33. 33. Thank you....

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