This is a Chest Xray of a  man who came to the GP complaining of pain in the neck and the shoulder region and numbness along the inner aspect of his left hand which have been having for years. But he did not pay any attention to that.He had noticed that his symptoms  were getting worsened in the recent past.On examination of his left hand,  trophic skin changes,impaired sensation on the ulnar forearm and  wasting of the hypothenar muscles of the left hand  were noticed.
What are the differential diagnosis in this patient?
What is the abnormality you can identify in this Xray?






ANSWER - LEFT SIDED CERVICAL RIB RESULTS IN THORACIC OUTLET SYNDROME

It is a congenital abnormality in which cervical rib results from the over-development of the costal element of the seventh cervical vertebra which is  located above the normal first rib.It is the Most common neurovascular compression at neck base.A cervical rib is present in only about  0.2% of population. Rib narrows interval between scalenes and compresses the nerves and vessels to pass over.(C8,T1 nerve roots and Subclavian Artery)
Compression Worsened by
     Shoulder sag (in elderly or Muscle Weakness)
     Carrying heavy object in hand
Cervical rib is a common cause of the thoracic outlet syndrome

CLINICAL FEATURES
Symptoms
   1. Affects hand and inner forearm
   2. Pain and Paresthesia along Ulnar Nerve course
   3. Hand weakness, numbness, and clumsiness
   4. Associated symptoms may be variably present
          Hand cold sensation
          Raynaud's Phenomenon
          Gangrene
Signs
   1.  Palpable cervical rib
   2. Tender brachial Plexus distribution
   3. Muscle Weakness and atrophy (lower trunk)
         1. Interosseus muscles
         2. Hypothenar muscles
   4. Sensation decreased
         1. Ulnar forearm
         2. Arm
         3. Ulnar 1.5 fingers
   5. Circulatory insufficiency
         1. Swelling
         2. Cold sensation
         3. Distal cyanosis
         4. Trophic skin change
   6. Adson's Test

How to do Adson's Test corectly?
It is done to evaluate Thoracic Outlet Syndrome
Technique
  Ask Patient breathes deeply with  extended Neck and then ask to turn Chin  toward affected side.Repeat test with chin to opposite side
Interpretation - Decreased Radial Pulse in +ve tests


INVESTIGATIONS
 Chest XRay
 Electromyogram


TREATMENT
Physiotherapy to strengthen elevators of the shoulder
Remove the Rib Surgically


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19 comments

  1. Anonymous Says:
  2. tb?!

     
  3. thisaru Says:
  4. cervical rib,differencial diagnosis with pancoast tumor.

     
  5. Anonymous Says:
  6. cervical rib which caused pneumothorax..

     
  7. Anonymous Says:
  8. cervical rib injury and compression of plexus about the cerviacl vertebrae.

     
  9. xtotox Says:
  10. cervical rib/pancoast/LMNL etc

     
  11. Anonymous Says:
  12. arash from iran
    absence of aortic notch , mybe coarcation of aorta

     
  13. Anonymous Says:
  14. CT or MRI help to prove Ca (pencost tumor)
    Dfd: scalenus or cervical rib
    +Adson test, electromiography

     
  15. Anonymous Says:
  16. some enlargement pressing the brachial plexus can be cervical rib or pancoast tumour

     
  17. Anonymous Says:
  18. can it be cervical spondilosis

     
  19. Anonymous Says:
  20. cervical rib,,,dif dx is other causes of thoracic outlet syndrome like pancoast,scalene anticus syndrome,cerv spond,,etc

     
  21. Yousof Says:
  22. The left cervical rip is obvious in CXR, moreover, the history is typical. The patient has those symptoms for years, so how could malignancy such as pancoast tumor be suspected?!!!!

     
  23. Anonymous Says:
  24. cervical rib....as per the x ray.....clearly seen on the left side

     
  25. Anonymous Says:
  26. Acai Berry comes from Brazil and it combats free radicals.Acai Berry

     
  27. Anonymous Says:
  28. canacer

     
  29. Anonymous Says:
  30. clearly a case of thoracic outlet syndrome. Note the anomalous cervical rib on the left of the CXR.

     
  31. Anonymous Says:
  32. rediculopathy/brachial plexopathy due to
    cs
    cervical rib
    trauma
    pancoast syndrome

    xray shows lt. cervical rib.

     
  33. Anonymous Says:
  34. cannot the location of the rib well

     
  35. TIN Says:
  36. easy. TOS!

     
  37. Anonymous Says:
  38. adasd

     

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