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Key Features

Essentials of Diagnosis

  • Compression of neurovascular structures supplying upper extremity

General Considerations

  • Intermittent or continuous pressure on elements of the brachial plexus and the subclavian or axillary vessels by anatomic structures of the shoulder girdle region results in symptoms and signs

  • The neurovascular bundle can be compressed between the anterior or middle scalene muscles and a normal first thoracic rib or a cervical rib

  • Predisposing factors

    • Scarred scalene neck muscle secondary to neck trauma

    • Sagging of the shoulder girdle, resulting from aging, obesity, or pendulous breasts

    • Faulty posture

    • Occupation

    • Thoracic muscle hypertrophy from physical activity (eg, weight-lifting, baseball pitching)

  • Predominant symptoms depend on whether obstruction affects neural or vascular structures

Clinical Findings

Symptoms and Signs

  • Onset usually gradual but can be sudden

  • Pain

  • Numbness

  • Weakness

  • Swelling

  • Vascular symptoms consist of arterial ischemia, characterized by

    • Pallor of fingers on elevation of extremity

    • Sensitivity to cold

    • Gangrene of digits (rare)

    • Venous obstruction marked by edema, cyanosis, and engorgement (also rare)

Differential Diagnosis

  • Osteoarthritis of cervical spine

  • Tumors of the superior pulmonary sulcus, cervical spinal cord, or nerve roots

  • Periarthritis of the shoulder

Diagnosis

Imaging Studies

  • Chest radiography identifies presence of cervical rib

  • MRI with arms held in different positions useful in identifying sites of impaired blood flow

  • Angiography confirms intra-arterial or venous obstruction

Diagnostic Procedures

  • Reflexes not usually altered

  • Symptoms can be provoked within 60 seconds over 90% of the time by having a patient elevate the arms in a "stick-em-up" position (ie, abducted 90 degrees in external rotation)

  • Obliteration of the radial pulse with certain maneuvers of the arm or neck, once considered a highly sensitive sign of thoracic outlet obstruction, does not occur in most cases

Treatment

Surgery

  • Required by < 5% of patients

  • More likely to relieve neurologic rather than vascular component that causes symptoms

Therapeutic Procedures

  • Conservative measures (eg, physical therapy) to relieve compression of neurovascular bundle

  • Some women will benefit from support bra

Outcome

Complications

  • Gangrene of the digits or venous obstruction if there is vascular obstruction

Prognosis

  • Greater than 95% of patients can be treated successfully with conservative therapy, consisting of physical therapy and avoiding postures or activities that compress the neurovascular bundle

Prevention

  • Avoid faulty posture or physical activities (eg, weight-lifting, baseball pitching) that compress neurovascular bundle

When to Refer

  • Persistent symptoms despite conservative therapy

References

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Buller  LT,  et al. Thoracic ...

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