NMS Exam 3: Thoracic Outlet Syndrome (TOS) Terms & Definitions

Thoracic Outlet Syndrome (TOS) is neuromuscular compression/compromise of _________ and/or ___________ as they exit the thoracic cavity and enter UE

brachial plexus and/or subclavian-axillary vessels

what form of TOS involves the lower trunk of the brachial plexus, is caused by abnormal nerve stretch/compression, and is MC in women with drooping shoulders

neurologic

what form of TOS involves the subclavian artery and vein, may see unilateral arm swelling, and is MC in men

-other s/s include cold hand, pale palm, numbness/tingling (typically multidermatomal)

vascular

what treats the floor for thoracic compression compartment?

1st rib

what are some potential causes of TOS?

clavicle (fx), cervical rib, elongated C7 TVP, hypertrophic scalene/subclavius muscle, bony callous or exostosis, tight pectoralis muscle

classic presentation of TOS

-diffuse arm symptoms (paresthesia, hyperesthesia)

-path down inside of arm to 4th and 5th digits

-weak grip strength

-made worse by overhead activity

-thickness of hands

-weakness/clumsiness of fingers

-normal reflexes

TOS most commonly involves what part of the brachial plexus?

lower: C8-T1

with TOS, ________ precedes any persistent pain

paresthesia (numbness, tingling, burning)

TOS distribution

follows ulnar n. and medial cutaneous n. of the forearm

what is the "later pain" felt with TOS?

aching and poorly localized over the whole arm

-"fingers feel thick"

where does sensory loss occur with TOS?

territories of ulnar and medial cutaneous n.

large nerve that arises from the medial cord of the brachial plexus

medial cutaneous nerve of the forearm

TOS VS ulnar neuropathy: which condition can have proximal and middle portion of the forearm involved?

TOS

what TOS tests may give a false positive?

adson's, eden's, wright's

(check hemodynamics bilaterally)

early vascular symptoms of TOS

coldness, aching in muscles, loss of strength from continued use, hand may be pale or cyanotic with dependency

late vascular symptoms of TOS

gangrene to fingertips, trophic changes in nail/skin

DYNAMIC causative factors of TOS

Arm abduction bends axillary a. across coracoid and head of humerus. Clavicle rotates, and narrows passage

STATIC causative factors of TOS

increase in muscle bulk, sagging shoulders

CONGENITAL causative factors of TOS

cervical rib, bifid rib, clavicle (loss of ant. curvature)

TRAUMATIC causative factors of TOS

fx of clavicle, malunion or nonunion with excessive callus

-subacromial shoulder dislocation may be initiating factor

ARTERIOSCLEROTIC factors causing TOS

unusual vigorous activity may cause thrombosis, further narrowing in a vessel that cause compression

what test is this describing?

-open and close hand repeatedly

-dr occludes radial and ulnar artery at same time

-maintain occlusion for radial and pt opens hand and compares color return with in 5 seconds

-repeat on ulnar artery

allen's test

with Allen's test, if skin color does not return within 5 seconds, the patient has signs of.....

vascular occlusion

what TOS test evaluates for compression of subclavian artery and brachial plexus by anterior scalene and/or cervical rib by:

-palpating radial pulse

-abducting and externally rotating pts arm

-rotating head to side being tested

-extending neck as far as possible

-deep breath and hold for 10 count

adson's test

what TOS test evaluates for compression of subclavian artery and brachial plexus caused by middle scalene or cervical rib by:

-examiner slightly abduct arm and palpate radial pulse

-pt rotates head opposite of affected shoulder

-pt slightly extends neck and examiner externally rotates and extends shoulder slightly

-pt takes a deep breath and hold

modified adson's test

what is a positive modified adson's test?

loss of pulse amplitude

what test is performed by:

-patient seated and place both arms 90 degrees abducted and externally rotated

-pt repeatedly open and closes fists 3 min

roos' test

what considers roos' test positive?

if patients numbness and tingling is reproduced and/or patient cannot keep shoulders abducted to 90 degrees because of pain, numbness or tingling

most reliable test for diagnosis of TOS

roos' test (3-min elevated-arm stress test)

what TOS test evaluates for compromise of axillary artery by pec minor by:

-examiner palpate radial pulse

-examiner passively abducts shoulder to 180 degrees

-examiner notes angle of abduction at which radial pulse diminishes/disappears

-repeats on other side

wrights test (hyperabduction maneuver)

what TOS test evaluates for compression of subclavian artery, vein and brachial plexus between clavicle and 1st rib by:

-examiner bilaterally palpates radial pulse

-examine extends pt shoulder and has pt flex cervical spine (chin to chest)

costoclavicular test (eden's)

what makes the costoclavicular test positive?

amplitude of radial pulse decreases or disappears

what test evaluates for compression of subclavian artery and brachial plexus by middle scalene and cervical rib by:

-examiner palpates radial pulse of unaffected arm

-examiner applies downward traction on affected extremity while pt hyperextends neck

-if pulse does not disappear, test is repeated with pts head rotated on opposite side

Halstead's test

what makes Halstead's test positive?

disappearance or decreased amplitude of pulse

what is often confused with TOS because hands are cold but does NOT have shoulder pain associated with it or correlation of arm/shoulder body posture changes associated with it?

Raynaud's syndrome

if a patient actively places palm on top of their head and they have increased radiating arm pain, what does this suggest?

TOS

what TOS test is performed by

-pt seated and examiner abducts unaffected shoulder to 90 degrees and pts elbow is flexed to 90 degrees

-radial pulse is located and assessed for amplitude

-pt rotates head to opposite side

allen's maneuver

what makes Allen's maneuver test positive?

if amplitude of pulse decreases or disappears