This document summarizes a presentation on a rare case of upper limb ischemia. It describes a 32-year-old male patient who presented with pain in his right little finger that progressed to discoloration. Investigations showed narrowing of arteries in the right arm. The patient underwent a scalenectomy procedure to decompress the thoracic outlet. Post-operatively, the patient's symptoms resolved and Doppler studies showed improved blood flow in the right arm arteries. The presentation discusses the anatomy of the thoracic outlet and the suprasclavicular surgical approach for treating thoracic outlet syndrome.

1. A RARE CASE OF UPPER LIMB
ISCHAEMIA
PRESENTER: DR. SIDDHARTH MULKI
POST GRADUATE, DEPT. OF SURGERY
SURGERY 1ST UNIT
A J INSTITUTE OF MEDICAL SCIENCES
Moderator: Dr. Ashok Hegde
Dean and Prof.
Dept. of Surgery.
AJIMS
Dr. Anand I.P
Assoc. Prof.
Dept. of Surgery.
AJIMS.

2. Sequence of slides of the talk
 INTRODUCTION
 CASE PROFILE
 INVESTIGATIONS
 OPERATIVE PROCEDURES
 DISCUSSION
 CONCLUSION

3. Introduction
 IT IS A RARE UNCOMMON ENTITY COMPARED TO LOWER LIMB ISCHAEMIA
 INCIDENCE IS 5% DUE TO ABUNDANT COLLATERALS.
 SYMPTOMS ARE USUALLY DELAYED.
 Causes are acute and chronic.
Acute – Embolus (30%) , trauma, post AV fistula,
Chronic- Raynaud’s disease, Buerger’s disease, Atherosclerosis ,TOS, autoimmune or
connective tissue diseases such as
 scleroderma,
 rheumatoid arthritis,
 systemic lupus.

4. Case profile
 A 32year old male patient who is a mason by occupation came to emergency
 c/o pain in the right little finger since 3 months
 blackish discoloration of the right little finger since 1 month.
History of presenting illness
 Pain initially started in the tip of the right little finger which then gradually progressed
proximally.
 Pain which is non radiating, burning type of pain which is present through out the day.
 Pain increased on daily activities and raising the arms above the shoulders and reduced on
keeping the limb in dependent position.

5.  Patient has to get up in the night due to increased pain.
 There was no change on exposure to cold.
 Later he developed blackish discoloration of the tip of the rt little finger and then
later progressed proximally.
 No H/O any complaints in the opposite limb.
 No h/o tingling or numbness .
 No h/o trauma or use of vibrating tools.
 No h/o syncope or visual disturbances or chest pain.
 No h/o fever.
 He is not on any medications.

6. Past history
 Pt gives h/o similar complaints 3years back in the right index finger and middle finger
for which he under went disarticulation in Shimoga hospital.
 Pt is not a known case of DM/HTN/TB/Cardiac disease.
Personal history
 Pt smokes beedi 7 to 10 beedis /day since the last 5 years.
 Smoking index will be 50 (>300 significant).
Family history
No body in the family has similar complaints.
Treatment history
 Used to take tablet diclo 50mg for the pain.

7. General physical examination.
Pt was conscious and oriented to time, place and person.
There was no pallor, icterus, cyanosis, clubbing, pedal edema.
Head to toe examination :WNL
Right upper limb
 Radial pulse absent
 Ulnar absent
 Brachial pulse felt
 Axillary artery felt
 Sub-clavian artery felt
Left upper limb
 All the pulses felt.
B/L lower limb pulses felt and normal.

8.  BP- right upper limb -140/90mm of Hg
-left upper limb -140/80mm of Hg
-right lower limb -150/90mm of Hg
-left lower limb -150/90mm of Hg
Local examination:
 Distal phalange of right index and middle finger missing.
 Blackish discoloration noted at the tip of the right little finger extending to the
base of the metacarpo phalangeal joint.
 No discharge or ulcer noted.

9.  Muscle wasting noted that is the thenar and hypo thenar muscles.
 Opposite limb normal.
Palpation:
 Cold has compared to opposite limb.
 Tenderness present.
 Elevated arm stress test is positive (2min).
 Roos test was positive
 Costoclavicular compression manoeuvre was positive.

10.  Adsons test was done using the brachial pulse which was positive.
 Allens test could not be done.
 Cold and warm water test was negative.
 Right mid arm circumference 23 cm and left 24cm
right forearm was 19.5cm and left was 20cm.
 Power and tone –WNL
 Reflexes - WNL
 Supraclavicular fossae no mass felt.
 On auscultation no bruit was heard.

11.  Cardiovascular system: heart sounds heard and no added sounds heard.
 Rest of the system was normal.

13. Investigations
 CBC –WNL
 ESR-10 mm/first hour
 Lipid profile-WNL
 RFT-WNL
 BT-2.30 min
 CT- 4 min
 INR-1.13

14. X-ray
CERVICAL
REGION

16. Duplex Doppler
 B/L carotid and vertebral arteries normal with no evidence of stenosis.
 Subclavian,axillary ,brachial artery are triphasic with narrowing of the distal
segment of right radial artery with compromised flow beyond it.
 FLOW VELOCITY : Subclavian artery – 85.3cm/sec
axillary artery -82.5cm/sec
brachial artery – 67cm/sec
ulnar artery – 56.7cm/sec
radial artery – 111cm/sec

17. CT angiogram
 Indentation with resulting smooth narrowing of distal subclavian artery by the
scalenius muscle . Diffusely narrowed mid and distal radial arteries and distal ulnar
artery with collateral circulation.

22.  Later patient developed oedema and compartment syndrome of the hand. And we
had to go head with the faceotomy .

23. Operative procedure
 Pt is placed supine with head end of the table elevated by 15’ to reduce venous
congestion and head is tilted to opposite side, arms placed by the side of the pt.
 Incision is made 1.5cm above the clavicle from anterior border of the
sternocleidomastoid muscle extending laterally upto anterior border of the
trapezius.
 Incision is deepened and platysma is incised. EJV is divided with ligatures.the
clavicular head is divided .IJV is preserved.
 Inferior belly of omohoid is divided.phrenic nerve is identified and retracted
medially .scalenus anterior muscle is cut layer by layer.
 Suction drain placed and closed in layers.

26. Post op day 5
• Pt is symptom free, able work
with the limb and no pain on
rising the limb above head
• The hand became warm .
• Feeble radial pulse was felt.
• Pain disappeared.

27. POST OP DAY 7 – DOPPLER STUDY
 Subclavian artery –85cm/sec
 Axillary artery – 68cm/sec
 Brachial artery – 66cm/sec
 Ulnar artery – 53cm/sec
 Radial artery – 43cm/sec
Pre op FLOW VELOCITY
 Subclavian artery – 85.3cm/sec
 Axillary artery -82.5cm/sec
 Brachial artery – 67cm/sec.
 Ulnar artery-56.7cm/sec
 Radial artery – 111cm/sec

28. Discussion
Boundaries of TO
 posteriorly: T1 vertebral body
 laterally: first rib and costal cartilage
 anteriorly: manubrium sterni

29. ANATOMY
 Interscalene triangle
 Inferiorly : 1st rib
 Ant : scaleneus anterior
 Post : scaleneus medius.
Costoclavicular space
Ant : clavicle, subclavius muscle
Post medial: 1st rib
Post lateral: superior border of
scapula.

32. Interscalene triangle

33. Costoclavicular space

34. Subcoracoid area

35. CONCLUSION
 DIAGNOSIS AND TREATMENT OF TOS IS DEMANDING ,CLINICALLY AND
TECHNICALLY CHALLENGING .
 SUPRACLAVICULAR APPROACH IS THE EASIEST AND PRODUCES LESS PAIN WITH
FEWER COMPLICATION THAT OCCUR RARELY.
 RESULTS ARE EXCELLENT.

36. Acknowledgement
 Dr. ASHOK HEGDE .DEAN AND PROF. DEPARTMENT OF SURGERY, AJIMS.
 DR. ANAND I.P . ASSOC. PROF. DEPARTMENT OF SURGERY, AJIMS.
 RADIOLOGY DEPARTMENT –DR .PRAVEEN JOHN AND DR . GURURAJ SHARMA.
 DEPARTMENT OF ANAESTHESIA –DR. ABIN .
 FINALLY MY COLLEAGUES.