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Costoclavicular Compression Associated with Cervical Rib *

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Costoclavicular Compression Associated with Cervical Rib * Costoclavicular Compression Associated with Cervical Rib * E. S. BRINTNALL, M.D., 0. R. HYNDMAN, M.D., M. W. VAN ALLEN, M.D. From the Surgical Service, Veterans Administration Hospital and the College of Medicine, State University of Iowa, Iowa City, Iowa SYMPTOMS of neurovascular compression, carried out. Symptoms were not relieved. in patients with cervical rib, may be due At the second operation (November 1951) completely or partially to costoclavicular a notch was cut from the first rib beneath compression. Unless the costoclavicular in- the neurovascular bundle. A 4 cm. segment terval is widened in such patients, symp- of the mid-portion of the clavicle was re- toms are unrelieved or are only partially re- sected, and the lower part of the scalenus lieved by the standard operation of scalen- anticus was excised. Partial relief of symp- otomy and cervical rib excision. toms followed this second operation. The The costoclavicular space should always clavicle healed with shortening. At a third be investigated after removal of a cervical operation (July 1953), an attempt was rib. Our experience prompts us to empha- made to lengthen the foreshortened right size the importance of this examination. clavicle with a fibular graft. Normal clavic- The "finger-pinch" test 2 is a helpful means ular length was not obtained and the of evaluating the role that a narrowed in- wound became infected. Deformity of the terval between clavicle and first rib may clavicle and bulky callus formation resulted. play in causing vascular or neural symp- Shoulder and arm pain persisted but symp- toms. Extraperiosteal excision of the first toms of vascular compression appeared only rib effectively relieves costoclavicular com- with a "shoulder droop" position. pression and is not disabling or deforming. Examination. On the left side there was a palpable cervical rib in the left supra- CLINICAL OBSERVATIONS clavicular region. The left radial pulse was The following case report clearly illus- obliterated by bracing the shoulders back trates the coexistence of costoclavicular and by moving the horizontally outstretched compression and cervical rib. left arm to a plane behind the coronal plane R. E. P. (RE 15914), a white male physi- of the trunk. There was hypalgesia of the cian, aged 34, entered the hospital January distal portions of the first three fingers of 4, 1954, complaining of symptoms of vascu- the left hand. Examination of the right side lar insufficiency in the left upper extremity. revealed the mid-portion of the clavicle to These symptoms were aggravated by cer- be bulky and deformed. A grating sensa- tain shoulder positions and by cold, tobacco tion was palpable in the acromioclavicular and coffee. Use of the left hand was handi- region. The right hand was cool and moist. capped by cramping pain in the forearm The right radial pulse was strong but and by rapid loss of strength. seemed to be reduced in strength by brac- History Relating to Right Upper Extrem- ing the right shoulder back and by forcibly ity. Similar symptoms beginning three years depressing the right shoulder. There was no previously in the right upper extremity led sensory loss in the right upper extremity. A to a series of operations at another hospital. radiograph of the chest revealed a complete At the first operation (October 1951) left cervical rib with its tip reaching the scalenotomy and cervical rib resection were first rib anteriorly. The right clavicle was * Submitted for publication March, 1956. deformed and shortened and the posterior 921 BRINTNALL, Annals of Surgery 922 HYNDMAN AND VAN ALLEN November 1956 .. FiC;. I A. FiI;. 1B. FIG. 1. A. Preoperative roentgenogram (R.E.P.) showing right clavicle deformity and resec- tion of cervical rib on the right. A complete left cervical rib articulates with first rib. B. Roent- genogram of January 8, 1954, following resection of left cervical rib and left first rib. segment of a right cervical rib was seen hand were relieved. From the patient's (Fig. 1, A). point of view, the extremity had been re- Operation on the Left Side. On January stored to normal. The patient was re-ex- 6, 1954, an exploration of the left supra- amined frequently as an out-patient be- clavicular space was carried out through cause of pain and symptoms of mild inter- an anterior (supraclavicular) incision. The mittent neurovascular compression in the lower 4 cm. of the scalenus anticus muscle right upper extremity. It was felt that pre- and the complete left cervical rib were vious operations and infection in the region excised. This appeared to relieve elevation of the right cervico-axillary canal would and lateral compression of the artery and make first rib excision on this side tech- nerve trunks. However, with the shoulder nically difficult and perhaps hazardous. The depressed and braced backward, a finger residual symptoms were considered to be tip placed alongside the neurovascular due as much to deformity of the clavicle as structures was severely pinched between to costoclavicular compression. Pain and the clavicle and first rib. This indicated an grating in the region of the right acromio- abnormally narrow costoclavicular interval. clavicular joint prompted excision of the Therefore, the first rib was removed extra- lateral 1 cm. of clavicle under local anes- periosteally from its tubercle to its cartilage. thesia (August 25, 1954). This procedure This provided an adequate space for the did not afford relief. With someL reluctance, passage of neurovascular structures from right claviculectomy was advised to relieve neck to axilla (Fig. 1, B). costoclavicular compression and to relieve Postoperative Course. The patient's re- pain that was felt to be related to malunion covery from operation was uncomplicated. and shortening of the bone. All symptoms referable to the left arm and Operation on the Right Side. Total (ex- Volume 144 COSTOCLAVICULAR COMPRESSION Number 5 923 FIG. 2. R. E. P. (RE 15914). The photograph reveals droop and medial position of the right shoulder and the scars resulting from several operations. No deformity of the left shoulder has resulted from resection of cervical rib, first rib and lower part of the Scalenus anticus on the left. ''~~~~~~~~~~~~~~. ...... .. ..... ..: ..: .. ... .: ... ....... .:......... iBS~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~..;..:CALENUSt9~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~.............. ......;.;-..-;....:.......0ffJ .::......::.....C.....LAVILEN..:: XlAV{U~ d*CAENS .ANL FIG. 3. Diagramatic illustration of the boundaries of the cervico-axillary canal. Symptoms may result from lateral compression between cervical rib and scalenus anticus or from vertical compression between first rib and clavicle. These compression mechanisms may coexist in the same patient. traperiosteal) resection of the right clavicle Some deformity (shoulder droop) resulted was performed June 17, 1955. Scarring of and the shoulder was abnormally mobile. the supraclavicular region was extensive, Shoulder, arm and hand function were The "finger-pinch" test was not applicable. good. Six months after his last operation, Postoperative Course. No complications the patient had no serious complaints. The followed removal of the right clavicle. All left upper extremity remained normal 18 symptoms referable to vascular compres- months after resection of cervical rib, first sion were relieved and most of the shoulder rib and lower portion of scalenus anticus. region discomfort disappeared. Pain refer- The right upper extremity was free of able to the clavicular joints was relieved. neural and vascular symptoms 6 months BRINTNALL, HYNDMAN AND VAN ALLEN Annals of Surgery 924 November 1956 after resection of the clavicle. The right neither was there evidence of costoclavicu- shoulder drooped moderately, was some- lar space narrowing at operation and hence what unstable and was the site of occa- the first ribs were not removed. sional mild and vague aching discomfort (Fig. 2). TECHNICAL CONSIDERATIONS The anatomical boundaries of the cervico- COMMENTS axillary canal must be considered in pa- Although this patient had cervical ribs tients with evidence of neurovascular com- on both sides which articulated with the pression at this site. The axillary artery and first ribs, the symptoms were due more to the trunks of the brachial plexus lie on the costoclavicular compression than to the first rib and beneath the clavicle and be- cervical ribs themselves. The persistence tween scalenus anticus and cervical rib, or of costoclavicular compression accounted between scalenus anticus and medius if for the failure of scalenotomy and cerv- no cervical rib exists. In the patient with a ical rib excision to relieve symptoms on complete cervical rib, the boundaries en- the right side. Finally, resection of the close a quadrilateral space as indicated in clavicle was required to afford relief.3 The Figure 3. relief obtained by claviculectomy is consid- The operation for relief of symptoms in ered satisfactory though the shoulder is not the patient with cervical rib is regarded as functionally normal and slight deformity is an exploratory procedure. The anterior ap- evident. On the left side costoclavicular proach is utilized. The supraclavicular space compression was suspected preoperatively and the cervico-axillary canal are exposed and was confirmed by investigation at the through a transverse incision above clavicle time of operation. Complete relief of symp- which parallels lines of skin tension at the toms followed effective enlargement
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