William H. Pearce Precourse Notes https://www.assh.org/videos/precourse-5-surgical-management-of-thoracic-outlet-syndrome-38172?fs=true

• shoulder - tripod on thorax
• scalene muscles
• vessels - fixed at posterior circumflex humeral and proximal subclavian
• nerves - brachial plexus

• Cause: abnormal bony structure (cervical rib/clavicle fractures) vs normal structure in abnormal position (overhead positions - swimming/pitching)
• Cervical rib: bony parts, fibrous, clavicular fractures
• Site:
  • 3rd part of subclavian
  • or axillary - pect minor/ humeral head
  • posterior circumflex humeral artery

• splinter hemorrhages
• arm claudication vs “fatigue”
• digital gangrene/pain
• raynaud's phenomenon - digital/ unilateral hand
• neurogenic symptoms (30%) - true vs disputed
• pulsatile neck mass

• history: overuse/ direct trauma
• physical
  1. position of use
  2. arterial exam

• need good imaging in correct position - {when to do CTA/3D Recon vs angiography?}
  • need proper angiogram in position of use

• decompression - remove aneurysm
• reconstruction
• peripheral emboli

• Prep: Ix: 3D recon with CTA
• Access - supra and infra-clavicular incisions

Normal structures in abnormal positions

1. first rib/ clavicle
2. scalene?
3. humeral head
4. quadrilateral space

Humeral head problems

1. mobilization
2. patch
3. interposition
4. bypass

Quadrilateral space problem

1. between teres minor/ major/ two heads of triceps

1. unusual problems
2. flexible surgical approach
3. non-medical issues

febe - shoulder - pect major nerve release - ? triceps tight - finger release

1. Female with shoulder and periscapular pain treated with botox and first rib excision:
   • case: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2966747/
   • transaxillary first rib excision: https://www.youtube.com/watch?v=4ADbPso_vyM

https://wiki.nus.edu.sg/display/HS/Thoracic+Outlet+Syndrome