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Thoracic Outlet Syndrome

- See: Vascular Problems of the Upper Extremity:

- Discussion:
    - thoracic outlet space is created by the clavicle, first rib, subclavius muscle, costoclavicular ligament, and anterior scalene muscle;
    - most often affects subclavian artery, vein, and lower trunk (C8 & T1) of brachial plexus;
            - both the subclavian artery and the brachial plexus traverse between the anterior and middle scalene muscles;
    - most symptoms arise from neural compression;
    - compression may occur at the junction of the lower trunk and 1st rib;
    - in some cases, thoracic outlet syndrome will be accentuated by recurrent anterior shoulder instability, and may be the cause of the "dead arm syndrome;"
    - diff dx:
          - Axillopectoral Muscle:
                  - Symptomatic Axillopectoral Muscle in a Swimmer: A Case Report Am J Sports Med June 2013 41 1400-1403; published online before print April 30, 2013,

- Exam:
    - neuro exam:
            - compression of the inferior trunk (C8, T1) is seen most often;
                  - anterior division of inferior cord forms medial cord which gives rise to the median & ulnar nerves;
            - sensory changes in the ring and little finger;
            - intrinsic weakness;
            - can mimic symptoms of cubital tunnel syndrome;
    - upper extremity edema: may indicate effort thrombosis of axillary vein;
    - extinction of pulses:
            - radial pulse obliteration is not by itself specific, but loss of pulse with reproduction of symptoms is a positive test;
            - decreases interscalene space by tensing anterior and middle scalenes;
            - arm of the affected side placed on the sitting patients thigh with forearm supinated;
            - turn head to the affected side;
            - extend neck and hold breath;
            - positive test is obliteration of the radial pulse;
            - hyperabduction maneuver:
                 - tests for compression against axillary pulley which consists of pectoralis minor tendon, coracoid, and humeral head;
                 - components of axillary vessels and plexus bent 90 deg at the junction of the glenoid and humeral head;
                 - place extremity in full abduction and reach back as far possible;
                 - creation of a bruit in the supraclavicular area is further evidence;
                 - alternatively, the patient turns head toward side of compression, inhales, raises arm, and patient shrugs shoulders;
            - "at attention" test:
                 - narrows the costoclavicular space between the clavicle & 1st rib;
                 - pt thrust shoulders down and back as when stading at attention or carrying a backpack
                 - positive test is radial pulse obliteration;

- Radiographs:
    - evaluate for cervical ribs;
    - CXR to rule out pancoast tumor;

- Surgical Management:
    - first rib resection;
    - references:
          - The results of supraclavicular brachial plexus neurolysis (without first rib resection) in management of post-traumatic "thoracic outlet syndrome" 
          - Arterial complications of the thoracic outlet syndrome: fifty-five operative cases.
          - Thoracic outlet syndrome surgery causing severe brachial plexopathy.   
          - Surgery for thoracic outlet syndrome may be hazardous to your health.  
          - First Rib Resection in Thoracic Outlet Syndrome.

Evaluation of patients with thoracic outlet syndrome.

The relationship between dead arm syndrome and thoracic outlet syndrome.

A rare cause of thoracic outlet syndrome

Arterial and Venous Injuries in Athletes.  Findings and Their Effect on Diagnosis and Treatment

Comprehensive surgical management of the competitive athlete with effort thrombosis of the subclavian vein (Paget-Schroetter syndrome).