Thoracic outlet syndrome and gangrene with indication of amputation

Thoracic inlet syndrome

1. THORACIC OUTLET SYMDROME Thoracic Outlet Syndrome refers to a group of disorders caused by compression of neurovascular structures (brachial plexus, subclavian artery, or subclavian vein) as they pass through the thoracic outlet, the space between the clavicle and the first rib

2. Anatomy of thoracic outlet Bounded by: • Anteriorly: Clavicle and subclavius muscle • Posteriorly: Scapula and first rib • Medially: Cervical vertebrae • Laterally: Axilla Important structures passing through • Brachial plexus • Subclavian artery • Subclavian vein

3. CAUSES Transverse process of C7 long Hyperabduction syndrome—compression by pectoralis minor Operative scars-fibrous bands Rib- cervical rib nomalous first rib—abnormal Costoclavicular syndrome-compression between clavicle and first rib Insertion of scalenus-anomalous (Scalenus antics syndrome) Callus- maligned fracture clavicle

4. TYPES

5. Clinical features Common in young females . Dull aching pain in the neck is caused by expanded bony end of cervical rib. Features of upper limb ischaemia – low temp., pallor , excessive sweating ,splinter haemorrhage, ischaemic ulcer in fingers ,arms muscle wasting and gangrene of the skin . Features of ulnar nerve weakness- Weakness (mainly first thoracic nerve )manifest as tingling and numbness or paraesthesia in the distribution of C8 ,T1.

6. Physical Examination Test The following are the tests which confirm ulnar nerve weakness. A) Card Test – The patient is asked to hold a thin paper or a card in between the fingers. In cases of ulnar nerve paralysis, due to weakness of interossei muscles, the patient will not be able to hold the card tightly .

7. 2) Froment Sign –Patient is asked to hold a book between the hand and the thumb. In cases of ulnar nerve paralysis, since the adductor pollicis is Paralysed, there is flexion at the distal interphalangeal joint of the thumb. This is because flexor pollicis longus, which is supplied by median nerve, contracts.

8. 3) Adson’s test -Feel radial pulse, ask the patient to take deep inspiration and turn the neck to the same side. The pulse may disappear or it may become feeble. This test indicates compression on subclavian artery .

9. 4) Allen’s Test – Ask the patient to clench his fist tightly and compress the radial and ulnar arteries at the wrist with the thumbs. Wait for 10 seconds and ask the patient to open his hands. Pallor can be seen in the palm. Now release pressure on the radial artery and watch for the blood flow. Repeat test for ulnar artery. If there is occlusion of either artery, colour changes occur in the fingers slowly.

10. 5) Hyperabduction test (Halsted test ) - This test is done to rule out hyperabduction syndrome caused by pectoralis minor. The radial pulse becomes weak on hyperabduction due to angulation of axillary vessels and brachial plexus, which gets compressed between pectoralis minor and its attachment to the coracoid process 6) Military attitude test- When shoulders are set in backward and downward positions the radial pulse becomes weak. This is due to the compression of subclavian artery between the clavicle and the first rib. This is seen in costoclavicular syndrome.

11. Elevated arm stress test (EAST) (Roos’): Patient is asked to abduct the shoulders to 90 degrees and to flex the elbow. Then he is asked to pronate/ supinate forearms continuously. Appearance of symptoms suggests thoracic outlet syndrome • A hard mass may be visible or palpable in the root of the neck (Type I). On palpation of supraclavicular region, a thrill and on auscultation, a bruit can be heard in cases of poststenotic dilatation.

12. Differential Diagnosis Cervical spondylosis Cervical disc protrusion and spinal cord tumors Carpel tunnel syndrome Reynaud’s phenomenon Costovertebral anomalies Pancost tumor

13. Investigations X-rays – Neck may show a cervical rib . MRI - Cervical disc protrusion and spinal cord tumours may have predominant neurological features and thus may mimic cervical rib. When in doubt, ask for MRI . Duplex scan of affected limb, to detect any aneurysm. It can also detect thrombus.

14. X ray of neck showing cervical rib

15. Treatment Treatment Conservative - Patients with mild neurological symptoms are managed by shoulder girdle exercises or correction of faulty posture. I. Surgery- Presence of vascular symptoms and signs are the definite indications for surgery. . Excision of cervical rib including periosteum is called extraperiosteal excision of cervical rib

16. (so that it will not regenerate). This is combine with cervical sympathectomy if vascula symptoms are predominant. . If there is a thrombus in the subclavian artery,i is removed and the artery is repaired Cervical Rib Surgery.. ○ Remove cervical rib ○ Repair subclavian artery ○ Restore circulation ○ Reduce vasospasm-sympathectomy ○ Recognise other caus

17. At exploration, if cervical rib is not found, scalenus anterior muscle is divided. This is called scalenotomy . If hyperab- duction syndrome is diagnosed, pectoralis minor is divided from its insertion into the coracoid process. If cervical rib is not found ... Scalenotomy Division of pectoralis minor, scalenus anterior Extraperiosteal resection of the first rib

18. GANGRENE Definition Macroscopic death of tissue with superadded putrefaction which turns black because of the breakdown of haemoglobin and the formation of iron sulphide. It usually affects Distal part of limbs, intestines, appendix etc.

19. It may be Dry ,wet and gas gangrene.

20. Gas gangrene Gas gangrene is a severe and rapidly progressing bacterial infection characterized by tissue death (necrosis) and gas production within the affected tissues. Identifying it early is crucial for effective treatment and preventing life-threatening complications. Key indicators include pain, swelling, skin discoloration, blister formation, foul-smelling discharge, and crepitus (a crackling sensation or sound).

21. Special varieties of gangrene Diabetic gangrene Diabetic gangrene refers to tissue necrosis (gangrene) occurring in a diabetic patient, usually as a complication of diabetic foot. It is usually caused by a combination of three factors: ischaemia secondary to macrovascular disease and microvascular dysfunction; peripheral sensorimotor neuropathy (PSN), which leads to trophic skin changes; and immunosuppression caused by an excess of sugar in the tissues, which predisposes to infection

22. Clinical feature • Non-healing foot ulcers • Black, dry or wet necrotic tissue • Foul-smeling discharge (wet gangrene) • Local signs: swelling, erythema, crepitus ◦ Systemic signs: fever, leucocytosis, sepsis

23. Management Medical Blood sugar control (insulin) • Broad-spectrum antibiotics •Wound care and dressings Surgical • Debridement of necrotic tissue • Amputation (minor or major) if non-salvageable • Revascularization if ischemic but viable

24. 2. Miscellaneous Other types of gangrene commonly encountered include bedsores and frostbite. Bedsores are gangrene caused by local pressure , whereas frostbite is caused by exposure to cold. Both are preventable with adequate protective measures

25. Amputation is the surgical removal of a limb or part of a limb through bone or joint. Amputation

26. Indications for amputation Dead limb :Gangrene Deadly limb :Wet gangrene E Spreading cellulitis Arteriovenous fistula Other (e.g. Malignancy) ‘Dead loss’ limb :.severe rest pain with unreconstructable critical leg ischaemia, paralysis ,Other (contracture, trauma) Indication for Amputation

27. PRINCIPLES OF AMPUTATION Preservation of function “Preserve as much limb as possible.” • The level of amputation should be as distal as feasible to retain maximal function, • Aim to preserve major joints (especially knee and elbow), as joint loss significantly reduces prosthetic function • Balance between removing diseased tissue and maintaining viable tissue for function

28. Adequate Blood Supply A successful stump requires good perfusion • Confirm adequate circulation at the proposed amputation level using: ◦ Clinical examination (temperature capillary refill, skin color) ◦ Doppler ultrasound or ankle-brachial index (ABI) ◦ CT angiography (in vascular cases)

29. Gentle Tissue Handling Minimizing trauma reduces infection and promotes healing • Sharp dissection with minimal crushing or devascularization. • Avoid unnecessary use of diathermy near nerves or vessels. • Handle skin flaps and muscles gently

30. Proper Skin Flaps Skin flaps must be tension-free and well-vascularized. • Skin closure should be primary, non-tension, and allow for padded coverage over the bone • Common types: ◦ Equal anterior-posterior flaps ◦ Long posterior flap (especially in below-knee amputations) ○ Skew flaps in ischemic limbs

31. Muscle Stabilization (Myoplasty ) Prevent retraction, improve padding, and enhance prosthetic control. • Myoplasty: Muscle to muscle suturing • Myodesis: Muscle to bone suturing (preferred when possible) • Provides stability and prevents neuroma formation and muscle atrophy

32. Bone management Smooth, beveled ends to prevent pressure sores and pain. • Bone is divided cleanly with minimal periosteal stripping • Beveling of sharp edges is crucial, • In major amputations, bone shortening may be necessary to allow good flap closure.

33. Nerve Handling Prevent neuroma and chronic stump pain. • Nerves should be: ◦ Gently stretched ◦ Cut sharply at a higher level ○ Allowed to retract into healthy tissue (deep layer)

34. Hemostasis Meticulous hemostasis is critical to prevent hematoma and infection • Use ligatures or bipolar diathermy • Avoid hematoma formation – drains may be used selectively,

35. Avoiding Infection Aseptic technique is mandatory • Prophylactic antibiotics (especially in traumatic or diabetic amputations) • Debridement of all non-viable/infected tissue

36. Post operative care and Rehabilitation Functional recovery depends as much on post-op care as on the surgery itself • Pain control (NSAIDs, opioids) • Early physiotherapy • Stump care and shaping (compression dressings or shrinker socks) • Prosthetic fitting once healing occurs • Psychological support and counseling