TOS Flashcards
what to Thoracic outlet syndrome
compression or tension event that compromise the neurovascular structures of the cervicoaxillary canal
cervicoaxillary canal
structure where neurovascluar things pass through
cervicoaxillary canal boney
scapula
clavicle
5 ribs
cervicoaxillary canal muscle
scalenes
pectroalis
minor subclavius
what divides cervicoaxillary canal into upper and lower sections
the 1st rib
cervicoaxillary canal (Thoracic outlet) contents
brachial plexus and branches
sunclvain vein and art + branches
place of compression - interscalene triangle TOS
upper section
ant and post scalene and the 1st rib
place of compression - costoclvicular space
upper section
superior scapula , 1st rib, clavicle
place of compression - Thoraco-coraco-pectoral Space
space
lower section
pect minor
ribs 2-4
coracoid process
places of compression - regions
Thoraco-coraco-pectoral Space
interscalene triangle
costoclavicular space
muscle source of compression
subclavius
contributes mostly to VTOS
what is the attachment of the subclavius
Costal Cartilage of 1st Rib to Clavicle
what subclavian thing is not normally part of the subclavian triangle
subclavian vein
the brachial plexus and the scalenes
the brachial plexus normally passes through or pierces the scalenes
pierce the anterior scalene
places of compression all
Thoraco-coraco-pectoral Space
interscalene triangle
costoclavicular space
subclavius
cervical rib - Supernumerary Ribs
clavicle
scar tissue
what are Supernumerary Ribs
also called accessory ribs are an uncommon variant of extra ribs arising most commonly from the cervical or lumbar vertebrae
type 1 - Supernumerary Ribs
Long Rib from C7 with short fibrous attachment to 1st Rib
Type II - Supernumerary Ribs
Short Rib from C7 with long fibrous attachment to 1st Rib
what does the clavicle do as you bring up your arm
it needs to elavate, retract, and spin
what happens when the clavicle movement is compromised
this could compress the tunnel
what could be a cause of clavicle dysfunction
AC SC joints
scar tissue and compression
Soft Tissue Compression
Enlarged (Scar Tissue) Anterior Scalene, especially after MVA (Demodion et al)
Anomalous Fibrous Bands constricting the tunnel (Roos et al)
type od TOS
vascular and neurologic
vascular TOS type
arterial and venous
arterial TOS rate
very rare 1%
vascular TOS rate
3-5%
seen more in athletes
paget-schroetter syndrome
neurologic TOS type
true neuro
disputed neuro
true neuro TOS
confirmed with valid standard diagnostic testing
disputed neuro
no confirmation from standard tests
what is the TOS movement diagram
flexion pattern with radiating features
Double Crush Syndrome
Compression of the axon at one location creates increased susceptibility to effects of compression of the axon at another location (i.e. Carpal Tunnel Syndrome combined with cervical nerve root involvement).
Diagnosis of TOS
diagnosis of exclusion
where do we mostoften see parathesisa with TOS
UE 98%
the arm feel heavy dead an tired
what is the common dermtonal distrubtion of TOS
C8 T1
location of TOS
UE Paresthesia (98%)
Trapezius Pain (92%)
Neck Pain (88%)
Shoulder/Arm (88%)
Supraclavicular Pain (76%)
Occipital HA (76%)
Chest Pain (72%)
Hand Paresthesia (58%)
Arterial compression
Signs & Symptoms
Secondary to repetitive activities leading to claudication
Pain, numbness in non-radicular pattern. Associated fatigue with activity that is relieved at rest
Cramping in the hand with use
Skin cool to touch; increased sensitivity to cold; Reynaud’s phenomenon
Pale discoloration
test for ATOS
Allens
Venous Compression
Signs & Symptoms
Deep pain in chest, shoulder, & entire upper extremity
Distal limb edema with paresthesia in hand & fingers; skin tightness; fatigue; cyanosis discoloration
Venous distension and heaviness of extremity may be observed after activity – should diminish with rest. If not, then possible venous thrombosis - refer to MD
how is VTOS confirmed
Confirmed by special laboratory tests (plethysmography, venography, venous ultrasound studies)
TOS neuro sym
Often associated with previous trauma (MVA or Repetitive stress at work)
Symptoms include: Pain, paresthesia, numbness, and/or weakness.
Cold intolerance (Reynaud phenomenon) due to Sympathetic over activity, not ischemia. Decreased finger dexterity possible.
upper plexus NTOS
Upper Plexus Irritation (C5,6,7) – Occipital headache. Pain and paresthesia in anterior chest, periscapular area, radial aspect of arm to dorsum of hand and index finger. Provoked by head movements or lifting.
lower plexus irrtation NTOS
Lower Plexus Irritation (C8,T1) – Pain & paresthesia in suprascapular area, posterior neck, medial side of arm & forearm and ulnar digits of the hand. Provoked by activities that depress the shoulders (lifting, carrying a brief case)
true neuro tests
- Based on symptoms above & at least 2 (+) provocation tests. EAST test almost always (+).
- Confirmed with (+) neurophysiological testing (EMG, NCV)
Disputed neuro tests
- Based on symptoms above & at least 2 (+) provocation tests. Cyriax Release test often (+).
- No confirmation with objective testing. Negative
- Neurophysiological testing; negative vascular tests; negative imaging.
what do we see more over true or disputed
disputed
- This is what we see most of the time – movement system problem
compressors presentation
Symptoms during the day, especially with overhead activities. Increase in tension or compression of the brachial plexus.
Usually no night pain unless sleep with arm overhead
job - normal have arm over the head
Since compression is intermittent, the blood supply returns when arm is lowered & symptoms are relieved
what is being compressed with compressors presentation
Compression at costoclavicular &/or pectoralis minor spaces
what tests are positive for these pt’s -compressor
EAST (Roos) Test is (+) with these patients
Release Phenomenon
presentation
Brachial plexus under constant tension due to poor posture, weight of the arms during the day
In bed, the tension is released; blood flow returns; axonal flow returns; patient feels paresthesia.
test for release phenom
(+) Cyriax Release Test
what does adons test test
scalene triangle
what is a positive adons
reduced pulse or onset of syms
costoclvicular - military brace is testing
costo-clvicular space
Wright’s (Hyperabduction) testing what space
Retropectoral space (gate).
behind the pecct minor
Upper Limb Tension (ULTT) is testing what
– Neural irritability from nerve roots to peripheral nerve.
what is the most common type of TOS
neuro TOS 95%
