Thoracic Outlet Syndrome Flashcards
What does the Thoracic Outlet consist of?
Interscalene Triangle (created by Anterior / Middle Scalene and 1st Rib)
Costoclavicular Space (Subclavius, 1st rib, Anterior Scalene)
Subcoracoid Space (Pec Minor, Ribs 2-4, Coracoid)
Compression of the key structures that run within the Thoracic Outlet result in TOS. What are these structures?
Brachial Plexus
Subclavian Artery / Vein
nTOS (Nerve Involvement)
Incidence / Population Most Commonly Affected / Impingement on Which Structure?
95% of cases (most common)
Women aged teenage to 60 years old
Impingement on Brachial Plexus
vTOS (Venous Involvement)
Incidence / Population Most Commonly Affected / Impingement on Which Structure?
3-5% of all TOS cases (2nd most common)
Men / younger, able-bodied individuals
Impingement on Subclavian Vein
aTOS (Arterial Involvement)
Incidence / Population Most Commonly Affected / Impingement on Which Structure?
1-2% of all TOS cases (least common)
Young adults / affects both genders equally
Impingement on Subclavian Artery
nTOS Symptoms
UE paresthesias (various finger patterns)
Neck / Trapezius / Chest / Supraclavicular / Shoulder and Arm pain
Occipital HA
vTOS Symptoms
Unilateral symptoms
Acute UE swelling
Cyanosis
Heaviness
Pain
aTOS Symptoms
Unilateral symptoms
Turbulent blood flow
Vessel dilation
Potential Arterial Thrombosis
Distal Embolization (Acute distal UE ischemia)
TOS Causes
Trauma (MVA / hemorrhages or fractures can result in compression)
Repetitive motions (resulting in muscle hypertrophy / swelling / fibrosis)
Anatomic variations (Cervical Rib increases risk of nTOS and aTOS / congenital variations in musculature)
Malignancy
There is a high prevalence of Double Crush Injuries with both ___ and TOS.
Carpal Tunnel Syndrome
What are the most common provocative diagnostic tests for TOS?
Adson
Elevated Arm Stress Test
Upper Limb Tension Test
Adson Test
Affected arm abducted 30 degrees while maximally extended
Pt inhales deeply while extending neck and turning head towards ipsilateral shoulder
Result: Decrease or absence of ipsilateral radial pulse
Elevated Arm Stress Test (EAST) or ROOS
Arms in 90 degrees abduction / 90 degrees of elbow flexion / ER
Patient slowly opens and closes hand for 3 minutes
Result: Precipitates pain / paresthesias / heaviness or weakness
Upper Limb Tension Test (ULTT) or Elvey
Position 1: Arms abducted to 90 degrees with elbows flexed
Position 2: Active extension of both wrists
Position 3: Head tilted ear to shoulder in both directions
Result: Positions 1 and 2 elicit ipsi symptoms / Position 3 elicits contra symptoms
C5-C7 Compression (Referred Pain)
Rhomboid area
Anterior clavicle
Deltoid / Trap muscle areas
Down outer aspect of the arm
C8-T1 Compression (Referred Pain)
Posterior anterior shoulder
Radiculopathy down the arm
Paresthesia along Ulnar Nerve distribution
What makes a patient with TOS a candidate for surgery?
Failure with conservative management (4-6 months of PT specifically with nTOS)
nTOS patients with uncontrolled pain / progressively worsening UE weakness
Patients with aTOS or vTOS (initial intervention often surgical)
Transaxillary Surgical Approach
Accesses the 1st rib between the Pec Major and Latissimus Dorsi in the axilla
Supraclavicular Surgical Approach
Requires a scalenectomy of the Middle and Anterior Scalene muscles to expose a small portion of the 1st rib
Infraclavicular Surgical Approach
Allows for reconstruction in patients with vTOS or aTOS
Should be pursued if central venous exposure is required
