Thoracic Outlet Syndrome in the Pediatric and Young Adult Population.

PURPOSE: This study aimed to assess both nonsurgical and operative treatment outcomes of pediatric and young adult patients with thoracic outlet syndrome (TOS) at a tertiary care pediatric hospital. METHODS: A retrospective chart review of patients diagnosed with TOS, who were seen between January 2010 and August 2022 at a tertiary care pediatric hospital, was conducted. Collected pre- and postoperative data included symptoms, provocative testing (ie, Roo's, Wright's, and Adson's tests), participation in sports or upper-extremity activities, additional operations, and surgical complications. Assessment of operative treatment efficacy was based on pre- and post-provocative testing, pain, venogram results, alleviation of symptoms, and return to previous activity level 6 months after surgery. RESULTS: Ninety-six patients, (70 females and 26 males) with an average age at onset of 15 ± 4 (4-25) years, met the inclusion criteria for TOS. Among them, 27 had neurogenic TOS, 29 had neurogenic and vasculogenic TOS, 20 had vasculogenic TOS, 19 had Paget-Schroetter Syndrome, and one was asymptomatic. Twenty-six patients were excluded because of less than 6 months of follow-up. Of the remaining 70, 6 (8.6%) patients (4 bilateral and 2 unilateral) underwent nonoperative management with activity modification and physical therapy only, and one was fully discharged because of complete relief of symptoms. Sixty-four (90.1%) patients (45 bilateral and 19 unilateral) underwent surgery. A total of 102 operations were performed. Substantial improvements were observed in provocative maneuvers after surgery. Before surgery, 79.7% were involved in sports or playing musical instruments with repetitive overhead activity, and after surgery, 86.2% of these patients returned to their previous activity level. CONCLUSIONS: Few patients were successfully managed with nonoperative activity modification and physical therapy. In those requiring surgical intervention, first or cervical rib resection with scalenectomy using a supraclavicular approach provided resolution of symptoms with 86.2% of patients being able to return to presymptom sport or activity level. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Development and validation of a prediction model for outcomes after transaxillary first rib resection for neurogenic thoracic outlet syndrome following strict Society for Vascular Surgery diagnostic criteria.

OBJECTIVE: Neurogenic thoracic outlet syndrome (NTOS) is the most common form of thoracic outlet syndrome. However, NTOS has remained difficult to diagnose and treat successfully. The purpose of the present study was to generate a predictive clinical calculator for postoperative outcomes after first rib resection (FRR) for NTOS. METHODS: We performed a retrospective review of patients who had undergone FRR for NTOS at a single tertiary care institution between 2016 and 2020. A multivariate stepwise logistic regression analysis was performed to assess the association of the percentage of improvement after FRR with the patient baseline characteristics, pertinent clinical characteristics, and diagnostic criteria set by the Society for Vascular Surgery. The primary outcome was subjective patient improvement after FRR. A prediction risk calculator was developed using backward stepwise multivariate logistic regression coefficients. Bootstrapping was used for internal validation. RESULTS: A total of 208 patients (22.2% male; mean age, 35.8 ± 12.8 years; median follow-up, 44.9 months) had undergone 243 FRRs. Of the 208 patients, 94.7% had had symptoms localized to the supraclavicular area, and 97.6% had had symptoms in the hand. All the patients had had positive symptoms reproduced by the elevated arm stress test and upper limb tension test. Another reasonably likely diagnosis was absent for all the patients. Of the 196 patients who had received a lidocaine injection, 180 (93.3%) had experienced improvement of NTOS symptoms. Of the 95 patients who had received a Botox injection, 82 (74.6%) had experienced improvement of NTOS symptoms. Receiver operating characteristic curve analysis was used to assess the model. The area under the curve for the backward stepwise multivariate logistic regression model was 0.8. The multivariate logistic regression analyses revealed that the significant predictors of worsened clinical outcomes included hand weakness (adjusted odds ratio [aOR], 4.28; 95% confidence interval [CI], 1.04-17.74), increasing age (aOR, 0.93; 95% CI, 0.88-0.99), workers' compensation or litigation case (aOR, 0.09; 95% CI, 0.01-0.82), and symptoms in the dominant hand (aOR, 0.20; 95% CI, 0.05-0.88). CONCLUSIONS: Using retrospective data from a single-institution database, we have developed a prediction calculator with moderate to high predictive ability, as demonstrated by an area under the curve of 0.8. The tool (available at: https://jhhntosriskcalculator.shinyapps.io/NTOS_calc/) is an important adjunct to clinical decision-making that can offer patients and providers realistic and personalized expectations of the postoperative outcome after FRR for NTOS. The findings from the present study have reinforced the diagnostic criteria set by the Society for Vascular Surgery. The calculator could aid physicians in surgical planning, referrals, and counseling patients on whether to proceed with surgery.

Management of Paget-Schroetter Syndrome: a Systematic Review and Meta-Analysis.

OBJECTIVE: Currently, there is no consensus on the optimal management of Paget-Schroetter syndrome (PSS). The objective was to summarise the current evidence for management of PSS with explicit attention to the clinical outcomes of different management strategies. DATA SOURCES: The Cochrane, PubMed, and Embase databases were searched for reports published between January 1990 and December 2021. REVIEW METHODS: A systematic review and meta-analysis was conducted following PRISMA 2020 guidelines. The primary endpoint was the proportion of symptom free patients at last follow up. Secondary outcomes were success of initial treatment, recurrence of thrombosis or persistent occlusion, and patency at last follow up. Meta-analyses of the primary endpoint were performed for non-comparative and comparative reports. The quality of evidence was assessed using the GRADE approach. RESULTS: Sixty reports were included (2 653 patients), with overall moderate quality. The proportions of symptom free patients in non-comparative analysis were: anticoagulation (AC), 0.54; catheter directed thrombolysis (CDT) + AC, 0.71; AC + first rib resection (FRR), 0.80; and CDT + FRR, 0.96. Pooled analysis of comparative reports confirmed the superiority of CDT + FRR compared with AC (OR 13.89, 95% CI 1.08 - 179.04; p = .040, I2 87%, very low certainty of evidence), AC + FRR (OR 2.29, 95% CI 1.21 - 4.35; p = .010, I2 0%, very low certainty of evidence), and CDT + AC (OR 8.44, 95% CI 1.12 - 59.53; p = .030, I2 63%, very low certainty of evidence). Secondary endpoints were in favour of CDT + FRR. CONCLUSION: Non-operative management of PSS with AC alone results in persistent symptoms in 46% of patients, while 96% of patients managed with CDT + FFR were symptom free at end of follow up. Superiority of CDT + FRR compared with AC, CDT + AC, and AC + FRR was confirmed by meta-analysis. The overall quality of included reports was moderate, and the level of certainty was very low.

The first rib as a method of adult age-at-death estimation in a modern South African sample.

An age-at-death estimation method using the first rib may be particularly advantageous as this rib is relatively easy to identify, not easily damaged postmortem, and associated with less mechanical stresses compared to other age indicators. Previously, mixed results have been achieved using the first rib to estimate age-at-death. This study aimed to develop and test an age-at-death estimation method using the first rib. An identified modern black South African sample of 260 skeletons were used to collect age-related data from the first rib. Multiple linear regression analysis equations were created from this data for male, female, and combined samples. When tested on a hold-out sample, equations generated mean inaccuracies of 7-13 years for point estimates. The 95% confidence intervals contained the true age in 11-33% of individuals depending on the equation used, but wider intervals generated using 95% prediction intervals contained true ages for 100% of individuals. Point estimate inaccuracies are comparable to other age-at-death estimation methods and may be useful if single indicator estimation is unavoidable in the case of missing or damaged bones. However, combined methods that use indicators from many areas of the skeleton are preferable and may reduce interval widths.

Successful paraclavicular surgical decompression for recurrent venous thoracic outlet syndrome following transaxillary first rib resection in an elite athlete.

OBJECTIVES: Recurrent effort thrombosis after prior surgical intervention for venous thoracic outlet syndrome (TOS) is an uncommon problem, and there are multiple alternative surgical approaches in the management of recurrent venous TOS. METHODS: We present a case of a 23 year-old female professional athlete who presented with arm swelling, pain, and recurrent effort thrombosis after prior transaxillary rib resection. Imaging at our institution revealed subclavian vein thrombosis, confirmed with dynamic venography, as well as a remnant first rib. RESULTS: Thrombolysis of the subclavian vein and balloon angioplasty was followed by paraclavicular thoracic outlet decompression with complete first rib resection. Success was confirmed with intraoperative dynamic venography demonstrating a patent subclavian vein and resulted in complete elimination of symptoms. CONCLUSION: Additional surgical decompression with complete medial first rib resection of remnant rib, which was potentially causing compression of the subclavian vein, may be necessary to prevent recurrent venous compression and thrombosis for venous TOS.

Long-Term Outcomes of Nonoperative and Surgical Management of Paget-Schroetter Syndrome.

PURPOSE: In Paget-Schroetter Syndrome (PSS), subclavian vein thrombosis is caused by external compression of the subclavian vein at the costoclavicular junction. Paget-Schroetter Syndrome can be treated nonoperatively, surgically, or with a combination of treatments. Nonoperative management consists, in most cases, of anticoagulation (AC) or catheter-directed thrombolysis (CDT). With surgical management, decompression of the subclavian vein is performed by resection of the first rib. No prospective randomized trials are available to determine whether nonoperative or surgical management is superior. We report our long-term outcomes of both nonoperative and surgically treated patients. MATERIALS AND METHODS: We retrospectively analyzed all patients with PSS who were treated between January 1990 and December 2015. Patients were divided based on primary nonoperative or primary surgical therapy. Long-term outcomes regarding functional outcomes were assessed by questionnaires using the "Disability of the Arm, Shoulder, and Hand" (DASH) questionnaire, a modified Villalta score, and a disease-specific question regarding lifestyle changes. RESULTS: In total, 91 patients (95 limbs) were included. Seventy patients (73 limbs) were treated nonoperatively and 21 patients (22 limbs) surgically. Questionnaires were returned by 67 patients (70 limbs). The mean follow-up was 184 months (range, 43-459 months). All functional outcomes were better in the surgical group compared with the nonoperatively treated group (DASH general 3.11 vs 9.86; DASH work 0.35 vs 11.47; DASH sport 5.85 vs 17.98, and modified Villalta score 1.11 vs 3.20 points). Surgically treated patients were more likely to be able to continue their original lifestyle and sports activities (84% vs 40%, p=0.005). Patients with recurrence of thrombosis or the need for surgical intervention after primary nonoperative management reported worse functional outcomes. CONCLUSION: Surgical management of PSS with immediate CDT followed by first rib resection leads to excellent functional outcomes with low risk of complications. The results of nonoperative management in our non-matched retrospective comparative series were satisfactory, but resulted in worse functional outcomes and more patients needing to adjust their lifestyle compared with surgically treated patients. CLINICAL IMPACT: Patients with Paget-Schroetter Syndrome and their attending physicians are burdened by the lack of evidence concerning the optimal treatment of this entity. Case series comparing the outcomes of non-operative treatment with surgical treatment are scarce and often not focussed on functional outcomes. Data from this series can aid in the shared decision making after diagnosis of Paget-Schroetter Syndrome. Functional outcomes of non-operative management can be satisfying although high demand patient who are not willing to alter their daily activities are probably better off with surgical management.

Comparison of DNA preservation between ribs and vertebrae.

The choice of skeletal element types and their intra-bone parts is important because of differences in DNA preservation, and this must be considered when sampling bones for DNA testing. When incomplete skeletons are found, ribs and vertebrae have been shown to be the most suitable for genetic identification of bones from the torso. This study compares the preservation of DNA between 12th thoracic vertebrae and first ribs to determine which bone type is more suitable for genetic typing. The study analyzed 35 12th thoracic vertebrae and 29 first ribs from one mass grave from the Second World War with commingled skeletal remains excavated. Bone DNA preservation was estimated by measuring nuclear DNA concentration and its degradation and through short tandem repeat (STR) typing success. Previous studies performed on aged skeletal remains have shown that the DNA content of the first ribs and 12th thoracic vertebrae has high intra-bone variability, and this was considered when sampling the bones. After full demineralization extraction, the PowerQuant System (Promega) was used to measure the quantity and quality of DNA, and the GlobalFiler kit (Applied Biosystems) was used for STR typing. The results showed that DNA yield and degradation and STR typing success exhibited no statistically significant difference between first ribs and 12th thoracic vertebrae, and there was no intra-individual difference when comparing only paired bones from the same individuals. Consequently, with intra-bone DNA variability considered, the first ribs or the 12th thoracic vertebrae can be selected when sampling to genetically identify the skeletal remains of highly degraded torsos. HIGHLIGHTS: The first ribs and thoracic vertebrae are the most suitable bones for sampling from the torso. The proximal part of first rib and posterior vertebral column of the 12th thoracic vertebrae yielded the most DNA. The first ribs were compared with the 12th thoracic vertebrae, and the sampling process considered intra-bone DNA variability. The quality and quantity of nuclear DNA and success of STR typing were measured. The first ribs yielded the same DNA yields as well as STR typing success as the 12th thoracic vertebrae. When only the torso is present, it is not of high importance whether the first ribs or the 12th thoracic vertebrae are collected.

Robot-assisted transthoracic first rib resection for venous thoracic outlet syndrome.

BACKGROUND: Venous thoracic outlet syndrome (vTOS) is caused by external compression of the subclavian vein at the costoclavicular junction. It can be subdivided in McCleery Syndrome and Paget-Schroetter Syndrome (PSS). To improve the venous outflow of the arm and to prevent recurrent thrombosis, first rib resection with venolysis of the subclavian vein can be performed. Open transaxillary, supraclavicular, infraclavicular or combined paraclavicular approaches are well known, but more recent robot-assisted techniques are introduced. We report our short- and long-term results of a minimal invasive transthoracic approach for resection of the anteromedial part of the first rib using the DaVinci surgical robot, performed through three trocars. METHODS: We analyzed all patients with vTOS who were scheduled to undergo robot-assisted transthoracic first rib resection in the period July 2012 to May 2016. Outcomes were: technical success, operation time, blood loss, hospital stay, 30-day complications and patency. Functional outcomes were assessed using the "Disability of the Arm, Shoulder and Hand" (DASH) questionnaire. RESULTS: Fifteen patients (8 male, 7 female; mean age 32.9 years, range 20-54 years) underwent robot-assisted transthoracic first rib resection. Conversion to transaxillary resection was necessary in three patients. Average operation time was 147.9 min (range 88-320 min) with a mean blood loss of 79.5 cc (range 10-550 cc). Mean hospital stay was 3.5 days (range 2-9). In three patients, complications were reported (Clavien-Dindo grade 2-3a). Patency was 91% at 15.5 months' follow-up. DASH scores at one and three years showed excellent functional outcomes (7.1 (SD= 6.9, range 0-20.8) and 6.0 (SD= 6.4, range 0-25)) and are comparable to the scores of the normative general population. CONCLUSION: Robot-assisted transthoracic first rib resection with only three trocars is a feasible minimal invasive approach for first rib resection in the management of vTOS. This technique enables the surgeon to perform venolysis under direct 3D vision with good patency and long-term functional outcome. Studies with larger cohort size are needed to compare the outcomes of this robot-assisted technique with other more established approaches.

Our technique of thoracoscopic first rib resection - case report.

INTRODUCTION: First rib resection is a standard surgical treatment for decompressing the neurovascular structures in thoracic outlet syndrome (TOS). Historically, open approaches were used. In this report, we present technical details of thoracoscopic first rib resection. CASE REPORT: This year, we performed two operations in a row using this mini-invasive technique. Three ports were introduced. The used equipment included a laparoscopic camera (30 degree), endoscopic grasper, harmonic scalpel, long neurosurgical bone punch and a long intervertebral disc rongeur. The first rib was cut, separated and removed under thoracoscopic control. CONCLUSION: Thoracoscopic first rib resection for TOS is a safe and promising technique.

Rib-sparing scalenectomy for neurogenic thoracic outlet syndrome: Early results.

OBJECTIVE: Neurogenic thoracic outlet syndrome (NTOS) is no longer either "controversial" or "disputed"; however, its optimal surgical management remains unclear. Many thoracic outlet decompression procedures are performed by first rib resection, usually via a transaxillary route. METHODS: A retrospective review of a prospectively maintained NTOS database was performed. Patients with NTOS associated with a cervical rib and those with recurrent NTOS were excluded from the present analysis. All study patients had satisfied a 5-point clinical diagnostic protocol and had experienced a positive response to a local anesthetic scalene block. Surgical decompression included anterior, minimus, and middle scalenectomy and brachial plexus neurolysis via a supraclavicular incision and pectoralis minor tenotomy through a small vertical infraclavicular incision. No first ribs were excised. All the patients had completed QuickDASH (11-item version of the Disability of the Arm, Shoulder, and Hand questionnaire) preoperatively and at 3 or 6 months postoperatively. RESULTS: From 2011 to 2019, 504 thoracic outlet decompression procedures had been performed in 442 patients. The average operative time was 1.15 hours, and the average hospital length of stay was 1.05 days. Major complications, including intraoperative arterial injury, postoperative wound hematoma requiring reoperation, and chylothorax, occurred in 7 patients (1.4%). All but 2 patients (99.6%) had symptomatic improvement. Using a more rigorous definition of operative success of ≥50% improvement in the 3- or 6-month QuickDASH score, 458 rib-sparing NTOS operations (90.9%) were successful. In contrast to the mean preoperative QuickDASH score of 62.6, the average postoperative QuickDASH score was 25.2 (P = .001). CONCLUSIONS: These results suggest that (1) adherence to a rigorous preoperative diagnostic regimen, including performance of a scalene block, ensures, at the least, that surgery for NTOS can be successfully restricted to patients actually with the condition; (2) fibrotic, contracted scalene muscles are the cause of NTOS; (3) the first rib does not require removal for successful surgical treatment of NTOS; and (4) 90% of the patients so treated can expect significant early symptomatic and functional improvement.

Specialty Mediated 30-Day Complications in First Rib Resection for Thoracic Outlet Syndrome.

BACKGROUND: Thoracic outlet syndrome (TOS) takes on heterogenous upper extremity manifestations depending on whether the artery, vein or brachial plexus is primarily compressed. As a result of these variable vascular and neurogenic symptoms, these patients present to surgeons of various training backgrounds for surgical decompression. Surgeon specialty is known to correlate with outcomes for numerous vascular procedures, but its role in TOS is unclear. In this work we examine the association of surgeon specialty with short-term outcomes following first rib resection (FRRS) for TOS. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database, 3,070 patients were identified who underwent FRRS for TOS between 2006-2017. The primary outcomes of the study were 30-d complications, including postoperative hemorrhage requiring transfusion, wound complications, pneumothorax and deep venous thrombosis. Arterial, venous, and neurogenic TOS were distinguished with ICD-9 and 10 codes while patient characteristics, provider specialty, and postoperative outcomes were classified through a combination of standard National Surgical Quality Improvement Program variables and ICD data. RESULTS: Most FRRS were performed by vascular surgeons (87.9%), general (6.9%) and thoracic surgeons (4.4%). The relative distribution of vascular TOS between the specialties was not significantly different, with non-vascular surgeons performing an equivalent amount of FRRS for arterial (1.1% versus 2.4%) and venous TOS (8.6% versus 9.1%, both P> 0.05). Patients who underwent FRRS with non-vascular surgeons experienced more frequent perioperative transfusions (3.2% versus 1.2%, P = 0.001) and wound infections (1.9% versus 0.8%, P= 0.04). On multivariable regression, patients undergoing FRRS for venous TOS were more likely to require blood transfusion (odds ratios:3.63, 95% CI 1.43-9.25). Patients operated on by surgeons whose specialty was not among the top three most common specialties performing FRRS had a 40% longer operative time (incidence rate ratios:1.42, 95% CI 1.15-1.74) as well as a significantly increased odds of requiring a transfusion (odds ratios:9.87, 95% CI 2.28-42.68). CONCLUSIONS: The significantly increased operative times and transfusion requirements associated with specialties who uncommonly perform FRRS suggest the role of surgeon experience and volume in this procedure may play more of a role than specialty training. These data also suggest that vascular TOS carries unique risks that should be kept in mind when performing FRRS.

Intra-bone nuclear DNA variability and STR typing success in Second World War first ribs.

DNA sampling and typing are used for identifying missing persons or war victims. In recent forensic studies, little focus has been placed on determining intra-bone variability within a single skeletal element. When dealing with aged human bones, complete skeletal remains are rarely present. In cases in which only the torso is available, studies have shown that ribs are one of the most appropriate samples, but intra-bone variability has not yet been studied. A higher degree of remodeling was found to contribute to higher DNA yield in the parts of the skeletal element where the most strain is concentrated. This study explores intra-bone variability in proximal, middle, and distal parts of the first human rib by determining the quantity and quality of DNA using the PowerQuant System (Promega) and autosomal STR typing success using the PowerPlex ESI 17 Fast System (Promega). Thirty first ribs from a single Second World War mass grave were sampled. No variation in DNA degradation was observed across the individual rib. The highest quantity of DNA was measured in the proximal part of the first rib, and in all ribs except three, full or almost full genetic profiles were obtained. Thus, when only the torso is present in archaeological or medico-legal cases, first ribs are recommended to be collected if possible, and the proximal or vertebral ends should be sampled for genetic analysis.

Anesthetic management of tracheal laceration from traumatic dislocation of the first rib: a case report and literature of the review.

BACKGROUND: Tracheobronchial lacerations from trauma can be life-threatening and present significant challenges for safe anesthetic management. Early recognition of tracheal injuries and prompt airway control can be lifesaving. CASE PRESENTATION: A 56-year-old man with no significant medical history presented with difficulty breathing after a blunt trauma to his chest to the emergency room and was diagnosed with dislocation of the first rib and tracheal laceration after a chest tomography (CT) study. Subcutaneous emphysema in neck area quickly worsened indicating continuous air leak. Emergent surgical repair was scheduled. General anesthesia with maintaining spontaneous ventilation was performed and a 5.5 mm endotracheal tube was placed under the guidance of flexible bronchoscopy. Depth of anesthesia was maintained to achieve a Bispectral Index Score of 40-60. Once the offending first rib was removed, a 7.5 mm endotracheal tube was inserted distal to the laceration site with the guidance of flexible bronchoscopy. Once confirmed location of the endotracheal tube, cisatracurium was administered intravenously and the patient was managed on mechanical ventilation with interval positive pressure ventilation. The operation was successful and he was transferred to the ICU intubated. He then received elective surgical repairs for sternum fracture, multiple rib fractures and hemopneumothorax under general anesthesia on day 5 after the first surgery and was extubated on postoperative day 7. The subsequent course was uneventful. Comprehensive rehabilitation was done for 2 weeks and he was discharged home on postoperative day 41. CONCLUSIONS: Early diagnosis and multidisciplinary collaborations are keys to the successful management of this patient. Flexible bronchoscopy is particularly useful in airway management for urgent trachea tracheal laceration repair.

Isolated open comminuted fracture of the first rib.

In the emergency department, open isolated rib fractures are rarely seen. There is scarce literature related to open isolated first rib comminuted fracture. We report a 33-year-old male who presented with an isolated open first rib comminuted fracture following a road traffic accident. He did not have any neurovascular or major organ injuries and was managed successfully with conservative treatment.

Outcomes following operative management of thoracic outlet syndrome in the pediatric patients.

Objectives Thoracic outlet syndrome, a condition commonly reported in adults, occurs infrequently in the pediatric population. The objective of this study was to assess the outcome of surgical interventions of thoracic outlet syndrome in pediatric patients. Methods Clinical records of all pediatric patients with thoracic outlet syndrome who underwent operative repair from 2002 to 2015 in a tertiary pediatric hospital were reviewed. Pertinent clinical variables and treatment outcomes were analyzed. Results Sixty-eight patients underwent a total of 72 thoracic outlet syndrome operations (mean age 15.7 years). Venous, neurogenic, and arterial thoracic outlet syndromes occurred in 39 (57%), 21 (31%), and 8 (12%) patients, respectively. Common risk factors for children with venous thoracic outlet syndrome included sports-related injuries (40%) and hypercoagulable disorders (33%). Thirty-five patients (90%) with venous thoracic outlet syndrome underwent catheter-based interventions followed by surgical decompression. All patients underwent first rib resection with scalenectomy via either a supraclavicular approach (n = 60, 88%) or combined supraclavicular and infraclavicular incisions (n = 8, 12%). Concomitant temporary arteriovenous fistula creation was performed in 14 patients (36%). Three patients with arterial thoracic outlet syndrome underwent first rib resection with concomitant subclavian artery aneurysm repair. The mean follow-up duration was 38.4 ± 11.6 months. Long-term symptomatic relief was achieved in 94% of patients. Conclusions Venous thoracic outlet syndrome is the most common form of thoracic outlet syndrome in children, followed by neurogenic and arterial thoracic outlet syndromes. Competitive sports-related injuries remain the most common risk factor for venous and neurogenic thoracic outlet syndromes. Temporary arteriovenous fistula creation was useful in venous thoracic outlet syndrome patients in selective children. Surgical decompression provides durable treatment success in children with all subtypes of thoracic outlet syndrome.

First-rib stress fracture in two adolescent swimmers: a case report.

First-rib stress fractures have been described in adolescent athletes in various sports, with only one prior case report of first-rib stress fractures in an adolescent female swimmer. There is a need for research on the cause, management, and prevention of these injuries as they lead to significant morbidity and critical time away from sport for these aspiring athletes. We aimed to describe first-rib stress fractures as a potential cause for non-specific atraumatic chronic shoulder pain in adolescent swimmers and to discuss the different presentations, unique risk factors, treatment, and potential injury prevention strategies of such fractures. We discussed two such cases which were successfully treated with activity modification with restriction of all overhead activity, gradually progressive physical therapy and a return to swimming protocol. First-rib stress fractures can vary in presentation and should be in the differential diagnosis in adolescent swimmers with chronic shoulder pain. These injuries can be successfully managed with rest from overhead activities and physical therapy. Gradual return to competitive swimming can be achieved even with non-union of a first-rib stress fracture. Emphasis on balanced strength training in different muscle groups and proper swimming technique is essential to prevent these injuries.

First Rib Fracture Resulting in Horner's Syndrome.

BACKGROUND: First rib fractures and traumatic Horner's syndrome are both quite rare, which can make it difficult to properly diagnose the combination of these 2 conditions in the emergency department. These conditions may be associated with severe medical emergencies, such as ongoing carotid dissection. CASE REPORT: We present the case of a 33-year-old man who sustained fractures to his right second, third, and fourth ribs and a delay in the diagnosis of left Horner's syndrome after he was involved in a traffic accident. Left Horner's syndrome was caused by a left transverse fracture of the first rib. This fracture was not detected on chest radiographs and required a 3-dimensional reconstructed neck computed tomography scan for detection. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In the diagnosis of carotid artery dissection, conventional angiography is the criterion standard but is considered invasive. CTA is less invasive, time-saving, and can show more anatomic structures in the neck in addition to the carotid arteries. It is a good screening diagnostic modality in the traumatology department. Although the treatments for Horner's syndrome and first rib fracture are conservative, the early diagnosis of both conditions can resolve the anxiety and uncertainty experienced by both doctors and patients.

The relationship between various anatomical landmarks used for localizing the first rib during surface palpation.

OBJECTIVES: To assess the relationship between anatomical landmarks used to locate the first rib during surface palpation. One currently cited technique suggests locating the width of the transverse processes (TPs) of the first cervical vertebrae (C1) to determine the estimated width of the first thoracic vertebrae (T1) TP, allowing for subsequent palpation of the first rib laterally to the transverse process of T1. Based on anatomical structural relationships, the authors propose an additional method of locating the first rib, lateral to T1 TP, by palpating through the trapezius muscle at the width of the mastoid process (MP). METHODS: Overlying tissue of the bilateral MP, C1 TPs, and T1 TPs of 28 cadavers were removed. Measurements of the left to right spans at the following structures were collected using a digital caliper: mastoid process, C1 TP, and T1 TP. Measurements were used to determine the agreement between each anatomical structural span. RESULTS: The mean absolute difference (standard deviation, SD) between C1 TP span versus T1 TP span was 3.9 (±2.58) mm with an intraclass correlation coefficient (ICC) of 0.88 (95% CI = 2.9-4.9). The mean absolute difference between MP span and T1 TP span was 35.4 (±6.46) mm with an ICC of 0.71 (95% CI = 33.0-37.8). DISCUSSION: This study confirms the anatomical accuracy and feasibility of using the C1 TP span to determine the general width of the T1 TP span while palpating for the first rib just lateral to the T1 TP. Additionally, this study demonstrates that the more easily palpated mastoid process serves as an effective landmark to identify a width sufficiently lateral to the T1 TP, appropriate for first rib palpation through the trapezius muscle.

Thoracic outlet syndrome: single-center experience on the transaxillary approach with the aid of the TRIMANO Arthrex arm.

Thoracic outlet syndrome (TOS) is a pathology caused by compression on the neurovascular bundle by the first rib. The treatment of TOS is conservative management by analgesia and physiotherapy; however, if there is no response to conservative treatment, surgery is indicated through thoracic outlet decompression by first rib resection. Several surgical techniques are available, including supraclavicular, transaxillary, and transthoracic first rib resection approaches. The transaxillary approach provides better visualization on the neurovascular bundle and, thus, is sometimes the preferred method of treatment. The transaxillary approach has been criticized due to safety concerns regarding the neural bundle during surgical exposure. During surgery, hyperabduction of the arm is obtained by a surgical assistant, and the quality of exposure can decrease with time, or an iatrogenic injury to the neural bundle (brachial plexus) can occur from the hyperabduction. The use of the TRIMANO Arthrex arm can help in the exposure, instead of a surgical aide, because it provides stable exposure and visualization for the operating surgeon. We performed a retrospective review of patients undergoing transaxillary first rib resection using the TRIMANO Arthrex arm between June 2021 and December 2022. During installation, the patient is placed in the lateral decubitus position and the TRIMANO Arthrex arm is fixed at the operating table at the height of the patient's shoulder. Thus, the surgical aide can help the surgeon during the surgery, rather than placing the arm into and out of hyperabduction. The use of hyperabduction is limited to 15 minutes, followed by 5 minutes of rest, to decrease the tension on the neurovascular bundle. The surgeon then performs the transaxillary approach and systematically resects the first rib, scalene muscles, and subclavian muscles. By this approach, the inferior brachial plexus is also lysed. In our review, we found a total of 15 procedures of first rib resection for the treatment of TOS with the aid of the TRIMANO Arthrex arm that met our inclusion criteria. All procedures were performed by the same surgeon. None of the patients sustained an injury to the neurovascular bundle. All the patients had an uneventful hospital stay postoperatively, and none presented with a hematoma. The drain placed during surgery was removed on postoperative day 2. All patients had at least one radiograph taken during their hospitalization, with no pleural effusion or pneumothorax found. The use of the TRIMANO Arthrex arm is safe and can help in the positioning and installation of the patients undergoing transaxillary first rib resection. It decreases the number of surgical assistants and offers great comfort for the surgeon because it provides stable exposure for the operating surgeon.

Bilateral first rib fractures with multi-organ complications: A case report and literature review.

Background: Bilateral first rib fractures are rare. This article presented the diagnosis and treatment of a case of bilateral first rib fractures with multi-organ complications and discussed the injury mechanism. Case presentation: A 15-year-old girl fell off a motorcycle. She complained of right neck root pain and right upper limb weakness. The myodynamia of the right upper limb was grade 0, and the sensation disappeared below the level of the elbow joint. The computed tomography (CT) showed bilateral first rib fractures and transverse process fracture of the 6th cervical vertebra. Chest CT revealed a massive hemothorax in the right thoracic cavity, and head magnetic resonance imaging showed bilateral cerebellar infarction. Cervical computed tomography angiography (CTA) revealed a lumen occlusion at the origin of the right subclavian artery. The patient underwent an emergency thoracoscopy, and a re-examination of chest CT indicated that no obvious pleural effusion was found after the hemothorax was cleared. The patient underwent right subclavian arteriography and interventional endovascular thrombolysis, and the right subclavicular artery was patency postoperative. Bilateral first rib fractures and cerebellar infarction were treated conservatively. The brachial plexus injury did not show any signs of recovery after conservative treatment, and she was recommended to be transferred to a superior hospital for surgical treatment. Conclusions: The injury mechanism of bilateral first rib fractures with multi-organ complications was closely related to the initial factor of the right neck root colliding with a bulge on the ground. We believe that the fractures occur as a result of a combination including a high energy trauma from direct impact and a low-energy mechanism from violent muscle contraction caused by neck hyperextension. This case report was helpful for clinicians to understand bilateral first rib fractures and their complications.