1. THORACIC OUTLET SYNDROME

3. 
Thoracic outlet syndrome (TOS)- a collection
of symptoms brought about by abnormal
compression of the neurovascular bundle by
bony, ligamentous or muscular obstacles in the
narrow space between clavicle and 1 st rib – the
thoracic outlet.

4. ANATOMY

interscalene triangle

Costoclavicular space
−
Med : 1st rib
−
Med : 1st rib
−
Ant : clavicle,
scaleneus anterior
−
Ant : clavicle
−
Post : scaleneus
medius
−
Lat : costoclavicular
ligament, subclavius
muscle
−
Post : scaleneus
medius

7. contents

Brachial plexus

Subclavian artery

Subclavian vein

8. Causes

Cervical rib

Long C7 transverse process

Anomalous insertion of scalene muscles

Scalene muscle hypertrophy

scaleneus minimus

Abnormal bands, ligaments

Fracture clavicle/ 1st rib

Exostosis

Tumours

Brachial plexus trauma / diseases

9. Cervical rib

10. Clinical features

Most commonly seen in middle aged women

Usually due to neural compromise.
Interscalene triangle
Artery , Nerves
Costoclavicular space
Vein
Subcoracoid area
Artery, Vein , Nerves

11. Interscalene triangle

12. Costoclavicular space

13. Subcoracoid area

14. Arterial compromise

Fatigue

Weakness

Coldness

Upper limb claudication

Thrombosis

Paraesthesia

Raynaud's phenomenon due to thrombosis with
distal embolisation

15. Venous compromise

Edema

Venous distension

Collateral formation

Cyanosis

Paget-Schroetter syndrome – effort thrombosis
−
"Effort" axillary-subclavian vein thrombosis (PagetSchroetter syndrome) is an uncommon deep
venous thrombosis due to repetitive activity of the
upper limbs.

16. Neural compromise

Paraesthesia

Pain in shoulder, arm, forearm and fingers


Occipital headache – referred from tight
scalene muscles
Weakness of forearm, hand.

17. Clinical tests

18. Roos Test


Hold both arms in surrendering position
(90°overhead with shoulders in external
rotation) – reproduction of symptoms within 1
minute . Arm collapses if continued.
modified Roos test / Extended Arm Stress
Test(EAST)– same as above. Symptoms
precipitated by opening and closing fists
continuously.

19. Elevated arms stress test

20. Adson's (Scalene) Test


Radial pulse diminishes and disappears on
turning chin to same side.
Decreases space between scaleneus anterior
and medius .

21. Adsons test

22. Halsted's costoclavicular
compression test

45° abduction and extension of arm with
downward pressure on shoulders –neck turned
to opposite side- reproduce symptoms

23. Exaggerated military position

Patient shrugs shoulders with deep inhalation
while drawing the shoulders backward in an
exaggerated military position – radial pulse
diminishes.

24. Military position

25. Wright's hyperabduction test


Arm hyperabducted
to 180°-diminishing
radial pulse.
Neurovascular
structures
compressed in
subcoracoid region by
pectoralis minor
tendon, head of
humerus or coracoid
process.

26. Wright's hyperabdution test

27. 

Tinel sign – in supra and infraclavicular region
Phalens sign – in carpel tunnel syndrome
(CTS)

28. Differential diagnoses

Carpel tunnel syndrome

Spinal canal tumors

Shoulder myositis

Angina pectoris

Raynaud's disease

Ulnar nerve compression - epicondylitis

29. investigations

Chest x ray, cervical spine x ray

MRI, cervical myelography
−

Doppler , vascular
imaging(angiogram/venogram)
−

r/o narrowing of intrevertebral foramen, disc
compression.
r/o aneurism, thrombosis
Nerve conduction study, electromyography
−
confirm neurogenic TOS, localise the area of
compression- r/o CTS

30. 
Double crush syndrome – TOS with other
peripheral sites of nerve compression(CTS)

31. Treatment

32. Non operative treatment

Posture improving exercises.

Breathing exercises.

Avoid aggravating activities.

Avoid repetitive upper extremity mechanical
work and muscular trauma.

Analgesics,muscle relaxants, antidepressants.

Physiotherapy .

33. Surgical treatment
Indications:

Symptoms persists with non operative
treatment.

Associated vascular compression.

Progression of neurological symptoms.

Nerve conduction velocity < 60m/s

34. 

Trans cervical or trans axillary(Roos) resection
of 1st rib often with release of scalene muscles.
Cervical rib excision.

35. Roos approach

36. Thank you....