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LeFebvre > B14. TOS And Cervical > Flashcards

B14. TOS And Cervical Flashcards

1
Q

What are the mechanisms of injury that cause traumatic brachiplexopathy?

A
  • hyperabduction of the arm causes traction of the brachial plexus
  • lateral compression causes traction of the brachial plexus and NR, but plexus more at risk
  • slow postural load that traction the brachial plexus
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2
Q

What is the prognosis for brachial plexus injuries?

A
  • usually resolve on their own but recurrent injuries can lead to muscle weakness
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3
Q

How would you differentiate between nerve root lesion and brachial plexus injury

A

EMG and nerve conduction study

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4
Q

What muscles are weak/paralyzes with an upper trunk (C5-C6) brachioplexopathy?

A
  • shoulder abductors
  • elbow flexors
  • infraspinatus

NOTE: waiter’s tip posture

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5
Q

What muscles are weak/paralyzes with a middle (C7) trunk brachioplexopathy?

A
  • extensors of the forearm, wrist and fingers
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6
Q

What muscles are weak/paralyzes with a lower trunk (C8-T1) brachioplexopathy?

A
  • wrist and finger flexors
  • intrinsic muscle of the hand

NOTE: causes claw hand

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7
Q

What are the sympathetic changes that can accompany a lower trunk brachioplexopathy?

A
  • Edema and trophic changes in the forearm and hand

- Horner’s syndrome

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8
Q

What are the sympathetic changes that can accompany a upper trunk brachioplexopathy?

A

Horner’s syndrome

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9
Q

What are stingers/burners?

A

Injuries to nerves in the arm/neck, usually fro contact sports, that cause intense pains that occur when the nerves that run from the neck to the arm are stretched or compressed

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10
Q

What is neurapraxia?

A

a type of peripheral nerve injury (known as the mildest form of nerve injury) that is classified as a transient conduction block of motor or sensory function without nerve degeneration. It occurs with stingers/burners

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11
Q

What is TOS?

A

A group of conditions creating arm and sometimes neck symptoms due to entrapment of the neurovascular bundle within the thoracic outlet

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12
Q

What are the common causes of TOS?

A
  • postural
  • over use
  • trauma
  • congenital anomalies
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13
Q

What structures in the thoracic outlet can become entrapped in TOS?`

A
  • brachial plexus
  • subclavian artery
  • subclavian vein
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14
Q

What are the bony margins of the thoracic inlet/“outlet”?

A
  • T1 vertebrae posteriorly
  • Rib 1 laterally
  • manubrium and 1st costal cartilage anteriorly
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15
Q

What muscles are doing the compressing in TOS?

A
  • anterior scalene
  • pectoralis minor
  • subclavian
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16
Q

There are three areas of compromise possible in TOS. What are they? What structures are involved?

A
  • supraclavicular (compression occurs at the interscalene triangle due to anterior scalene and/or cervical rib)
  • costoclavicular (compression occurs between first rib and clavicle doe to subclavian muscle, broken clavicle, etc.)
  • infraclavicular (compression occurs between the coracoid process and tendon of pec minor usually form hyperabduction injury)
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17
Q

What postural things can contribute to TOS?

A
  • “drooping” shoulder girdle posture
  • forward head carriage
  • tight pectoralis major
  • upper cross syndrome
  • poor work ergonomics
  • long periods of hyperabduction (sleep posture, recreation, work)
  • carrying heavy weights on back or shoulder
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18
Q

What are the three types of TOS?

A
  • non specific
  • true neurogenic
  • vascular
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19
Q

How common is arterial or venous compression with TOS?

A

Rare

  • 1-2% of TOS have venous compression
  • 1-5% of TOS have arterial compression
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20
Q

How is the diagnosis of vascular TOS made?

A

Constellation of prominent vascular signs and symptoms, NOT loss of pulse during classic TOS orthopedic tests

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21
Q

Which are more valuable indicators of vascular TOS, symptoms or signs?

A

Signs from the physical are more robust

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22
Q

What are the signs of venous compromise in TOS?

A
  • non-pitting edem
  • cyanosis
  • ecchymosis
  • distended engorgement of superficial veins in infra clavicular area, upper extremity and chest
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23
Q

What are the signs of arterial compromise in TOS?

A
  • pallor in fingertips
  • asymmetrical radial pulses
  • asymmetrical bilateral blood pressure
  • subclavian bruit
  • splinter hemorrhages
24
Q

How common in true neurogenic TOS?

A

Rare

25
Q

Who more commonly get true neurogenic TOS?

A

Young, thin females, possibly with cervical rib

26
Q

To qualify as true neurogenic TOS, one of two findings must be present. What are they?

A
  • reproducible neurological deficit on physical exam

- positive EMG-NCV study demonstrating plexus damage

27
Q

What are some of the neurological signs that would be seen in true neurogenic TOS?

A
  • little, no or intermittent pain
  • sensory paresthesia or dysesthesia
  • symptoms restricted to ulnar aspect of the hand and forearm
  • symptoms aggravated by overhead/abducted arm activities
28
Q

What is Gilliatt-sumner hand?

A

Dramatic degree of atrophy of the abductor pollicis brevis that may be present with true neurogenic TOS

Interossei and hypothenar eminence may also be atrophied

29
Q

What are the primary signs of non-specific TOS?

A

Paresthesia (more common) and pain (less common) in an ulnar distribution (sometimes median) and sometimes in the neck

30
Q

Who more common gets non-specific TOS?

A

Women 20-40

31
Q

What is a physiologic factor that contributes to TOS and occurs with aging?

A

Progressive acromio-clavicular descent, more pronounced in women

32
Q

What are some joint restrictions that contribute to TOS?

A
  • first rib

- lower cervical rotation restrictions

33
Q

What is the recommended group of tests for TOS?

A
  • Adson’s
  • Hyperabduction
  • costoclavicular
  • Roos
  • Tinel’s
34
Q

For 4 out of the 5 recommended orthopedic tests for TOS, a positive test is on a continuum? Describe the continuum.

A
  • strong positive = pain reproduction in upper extremity
  • soft positive = paresthesia reproduction in upper extremity
  • least positive = loss of pulse (most likely to occur in healthy patients)
35
Q

Describe how to perform Adson’s test

A

Patient seated.
Doctor pulls both straight arms back into extension
Patient rotates head away from affected side

Positive test = pain/paresthesia reproduction

36
Q

Describe how to do hyperabduction (AKA Wright’s) test.

A

Patient seated.
Doctor abducts one arm at a time
May need to maintain position for 30-60 seconds

Pain reproduction = TOS
Pain improvement = possible NR

37
Q

Describe the costoclavicular test for TOS.

A

Patient seated
Doctor pulls both straight arms down and back into extension.
Patient pushed chest out

Positive test = pain/paresthesia reproduction

38
Q

Describe Roos test

A

Patient holds arms up
Rapidly opens and closes hands for 3 minutes

Positive sign = arm dropping due to exacerbation of symptoms

39
Q

Describe Tinel’s and deep pressure test for TOS

A 
Patient seated
Doctor taps (Tinel’s) or applies deep pressure just superior to the clavicle

Positive test = pain/paresthesia reproduction

40
Q

How many of the TOS tests should be positive to make the diagnosis of TOS?

A
  • 2 hard positives (pain reproduction)
    OR
  • 3 hard or soft positives (pain or paresthesia reproduction)
41
Q

What three key muscles should be assessed with a TOS diagnosis? How would you assess them?

A
  • scalenes (length test)
  • pec major (length test)
  • pec minor (length test and palpate)
42
Q

Describe where compression occurs in supraclavicular TOS and what structures are involved

A

In the scalene triangle

  • tight/spasming scalene
  • cervical rib
  • joint dysfunction of upper ribs or cervical spine
43
Q

What two orthopedic tests are most likely to be positive with supraclavicular TOS?

A

Adson’s and Roo’s

44
Q

Describe where compression occurs in costoclavicular TOS and what structures are involved

A

The costoclavicular space

  • 1st rib
  • clavicle (SC and/or AC joint may be involved)
45
Q

Which of the orthopedic tests would most likely be positive with costoclavicular TOS?

A

Eden’s test

46
Q

Describe where compression occurs in infraclavicular TOS and what structures are involved

A

The space between the coracopectoral structures and the ribs

  • tight/spasming pec minor
  • AC descent due to aging
47
Q

Which orthopedic tests are most likely to be positive with intraclavicular TOS?

A
  • Hyperabduction (wright’s)

- Roo’s

48
Q

TOS has a high incidence of concurrence with what other two conditions?

A
  • carpal tunnel (30%)

- cubital tunnel (10%)

49
Q

What are your two pain DDX to rule out before diagnosing TOS?

A
  • cervical radicular syndrome

- myofascial pain syndrome (scalene or latissimus dorsi)

50
Q

What 4 postural categories should be assessed when deciding on a management plan for TOS?

A
  • intrinsic posture (ex: forward head carriage, drooping shoulders)
  • extrinsic posture (ex: work station ergonomics, backpacks)
  • breathing patterns
  • upper cross syndrome
51
Q

What joints may benefit from CMT in TOS management?

A
  • R1
  • C spine
  • T spine
  • AC
  • SC
  • GH
  • scapulothoracic
52
Q

How would STM differ for pec major and pec minor in management of TOS?

A
  • pec major would be stretched

- pec minor would do intermittent ischemic compression

53
Q

What home exercises/treatment could be given in the management of TOS?

A
  • home stretches of scalenes and pectorals
  • nerve mobilization
  • Brugger relief posture
  • diaphragmatic breathing
  • endurance exercises for middle/lower traps, external rotators, thoracic extensors, deep cervical flexors
54
Q

Why is it important to address breathing patterns in the management of TOS?

A

Vertical/chest breathing may be associated with overactive and tight scalenes

55
Q

What are some medical interventions for TOS?

A
  • interscalene injection block
  • rib resection
  • vascular decompression
  • sympathetectomy

LeFebvre (29 decks)

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