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Presentation transcript:

A Hand Surgeon's Further Experience With Thoracic Outlet Compression Syndrome Erdoğan Atasoy, MD Journal of Hand Surgery Volume 35, Issue 9, Pages 1528-1538 (September 2010) DOI: 10.1016/j.jhsa.2010.06.025 Copyright © 2010 Terms and Conditions

FIGURE 1 Three anatomical spaces in the thoracic outlet region can be responsible for TOCS. Printed with permission from The Christine M. Kleinert Institute for Hand and Microsurgery, Inc. Journal of Hand Surgery 2010 35, 1528-1538DOI: (10.1016/j.jhsa.2010.06.025) Copyright © 2010 Terms and Conditions

FIGURE 2 A A quite prominent tip of the right cervical rib on the right side of neck. B An x-ray of the same patient showing the cervical rib fused with the first rib. Printed with permission from The Christine M. Kleinert Institute for Hand and Microsurgery, Inc. Journal of Hand Surgery 2010 35, 1528-1538DOI: (10.1016/j.jhsa.2010.06.025) Copyright © 2010 Terms and Conditions

FIGURE 3 Tests used for diagnosis of TOCS. A Adson's, reverse Adson's. B Neck tilting (tilting the neck to the opposite side of the symptomatic extremity). C Costoclavicular compression test. D Wright's test (hyperabduction). E The Roos elevated arm stress test (abduction with exercise, up to 3 minutes). Printed with permission from The Christine M. Kleinert Institute for Hand and Microsurgery, Inc. Journal of Hand Surgery 2010 35, 1528-1538DOI: (10.1016/j.jhsa.2010.06.025) Copyright © 2010 Terms and Conditions

FIGURE 4 Transaxillary first rib resection; marking of incision, just below the hairline, holding the arm in wrist lock position. Printed with permission from The Christine M. Kleinert Institute for Hand and Microsurgery, Inc. Journal of Hand Surgery 2010 35, 1528-1538DOI: (10.1016/j.jhsa.2010.06.025) Copyright © 2010 Terms and Conditions

FIGURE 5 Exposure of scalene muscles, subclavian vessels, lower trunk, and T1. T1, 1st thoracic root of brachial plexus; a, artery; v, vein; mm, muscle. Printed with permission from The Christine M. Kleinert Institute for Hand and Microsurgery, Inc. Journal of Hand Surgery 2010 35, 1528-1538DOI: (10.1016/j.jhsa.2010.06.025) Copyright © 2010 Terms and Conditions

FIGURE 6 Incising scalene muscles and costoclavicular ligament (costocoracoid ligament), freeing of the first rib. Printed with permission from The Christine M. Kleinert Institute for Hand and Microsurgery, Inc. Journal of Hand Surgery 2010 35, 1528-1538DOI: (10.1016/j.jhsa.2010.06.025) Copyright © 2010 Terms and Conditions

FIGURE 7 Cutting the first rib near its middle area. Printed with permission from The Christine M. Kleinert Institute for Hand and Microsurgery, Inc. Journal of Hand Surgery 2010 35, 1528-1538DOI: (10.1016/j.jhsa.2010.06.025) Copyright © 2010 Terms and Conditions

FIGURE 8 Removal of the posterior part of the first rib. Printed with permission from The Christine M. Kleinert Institute for Hand and Microsurgery, Inc. Journal of Hand Surgery 2010 35, 1528-1538DOI: (10.1016/j.jhsa.2010.06.025) Copyright © 2010 Terms and Conditions

FIGURE 9 Removal of the posterior part of the first rib. The remaining posterior portion of the first rib is removed by using a first rib rongeur. Normally, no more than 1 cm of the first rib should remain. Printed with permission from The Christine M. Kleinert Institute for Hand and Microsurgery, Inc. Journal of Hand Surgery 2010 35, 1528-1538DOI: (10.1016/j.jhsa.2010.06.025) Copyright © 2010 Terms and Conditions

FIGURE 10 View following about 90% resection of the right first rib. T1, 1st thoracic root of brachial plexus; a, artery; v, vein; m, muscle; C8, 8th cervical root of brachial plexus. Printed with permission from The Christine M. Kleinert Institute for Hand and Microsurgery, Inc. Journal of Hand Surgery 2010 35, 1528-1538DOI: (10.1016/j.jhsa.2010.06.025) Copyright © 2010 Terms and Conditions

FIGURE 11 Major instruments used during a first rib resection. Printed with permission from The Christine M. Kleinert Institute for Hand and Microsurgery, Inc. Journal of Hand Surgery 2010 35, 1528-1538DOI: (10.1016/j.jhsa.2010.06.025) Copyright © 2010 Terms and Conditions

FIGURE 12 Transcervical anterior and middle scalenectomy: marking of incision and superficial anatomy. Inset shows incision mark. v, vein; m, muscle. Printed with permission from The Christine M. Kleinert Institute for Hand and Microsurgery, Inc. Journal of Hand Surgery 2010 35, 1528-1538DOI: (10.1016/j.jhsa.2010.06.025) Copyright © 2010 Terms and Conditions

FIGURE 13 Division of most of the clavicular head of the sternocleidomastoid muscle, mobilization of the phrenic nerve, and removal of the anterior scalene muscle. m, muscle; n, nerve; a, artery. Printed with permission from The Christine M. Kleinert Institute for Hand and Microsurgery, Inc. Journal of Hand Surgery 2010 35, 1528-1538DOI: (10.1016/j.jhsa.2010.06.025) Copyright © 2010 Terms and Conditions

FIGURE 14 Completion of scalenectomy; 80% to 90% of the anterior and about 50% of the middle scalene muscles (distal half) have been removed. C5, C6, C7, C8, cervical roots of the brachial plexus; T1, 1st thoracic root of the brachial plexus; n, nerve; a, artery. Printed with permission from The Christine M. Kleinert Institute for Hand and Microsurgery, Inc. Journal of Hand Surgery 2010 35, 1528-1538DOI: (10.1016/j.jhsa.2010.06.025) Copyright © 2010 Terms and Conditions

FIGURE 15 Suturing prescalene fat and covering the brachial plexus. int, internal; ext, external; v, vein; m, muscle. Printed with permission from The Christine M. Kleinert Institute for Hand and Microsurgery, Inc. Journal of Hand Surgery 2010 35, 1528-1538DOI: (10.1016/j.jhsa.2010.06.025) Copyright © 2010 Terms and Conditions