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194
Manipal Manual of Surgery
• Procedure should be abandoned if the clot does
not undergo dissolution.
• Repeat angiogram is necessary to check for
patency.
Contraindications for thrombolytic therapy: Key
Box 27.16.
Key Box 27.16
Contraindications to Thrombolytic Therapy
Absolute
Recent major bleeding
Recent major surgery
Recent ophthalmologic procedure
Recent stroke
Relative
Active peptic ulcer disease
Pregnancy
Uncontrolled hypertension
Coagulation abnormalities
Recent advances: Trans-Atlantic inter-Society Consensus:
TASC guidelines.
Type RX
A. Single stenosis <10 cm PTA
Single occlusion ≤5 cm
B. Multiple stenoses (or) occlusions each ≤5 cm PTA (or)
Single stenosis (or) occlusion ≥15 cm open
C. Multiple stenoses (or) occlusions totalling PTA (or)
>15 cm with or without heavy calcifications open
D. Chronic occlusion of CFA (or) SFA >20 cm Open
(or) involving the popliteal artery surgery
PTA: Percutaneous transluminal angioplasty
REPERFUSION INJURIES OR SYNDROME (Fig. 27.37)
• This dangerous event follows revascularisation of
the limbs, resulting in acute compartment syndrome
with compartmental pressure exceeding capillary
pressure (30 mmHg).
• Most of the injury is believed to be due to O
free radicals. The most important ones include
superoxide radical, hydrogen peroxide, and hydroxyl
radical.
• These radicals attach unsaturated bonds of fatty acids
within the phospholipid membranes, resulting in
damage.
Section II • General Surgery
• Oedema and swelling of the muscles take place.
surgery
surgery
derived
2
Fig. 27.37: Pathophysiology of reperfusion injuries
Management
• Diagnosis is clinical, as suggested by severe pain in
the limb, oedema of the leg, and muscle tenderness.
• Raised intra-compartmental pressure measured by a
transducer cannula will help in the diagnosis.
• Creatinine is elevated (renal failure).
• Creatine kinase is elevated (rhabdomyolysis).
• Treated by urgent multiple fasciotomy and decom-
pression, followed by debridement of dead tissues.
• Supportive treatment such as antibiotics and hydra-
tion, is given.
PERIPHERAL ANEURYSMS
• These can affect the popliteal artery, femoral artery,
iliac artery, etc.
• 70% of peripheral aneurysms affect the popliteal
artery, and two-thirds of them are bilateral.
• However, students should realise that aneurysms are
uncommon (rare) causes of lower limb ischaemia.
Early diagnosis and effective treatment are essential
to save the limb. Aortic aneurysms are discussed in
Chapter 37 under abdominal mass.
POPLITEAL ANEURYSMS
They are the most common peripheral aneurysms
because of the following reasons:
• Turbulence beyond stenosis at the adductor magnus
hiatus.
• Repeated flexion at the knee.
Lower Limb Ischaemia and Popliteal Aneurysm
195
Clinical Features
• They affect elderly patients and are caused by athero-
sclerosis. Age at presentation is 65 years.
• One-third of the cases are associated with aortic
aneurysm.
• Striking preponderance in males. Male
: female ratio
is 20–30 : 1.
• Presents as a swelling behind the knee.
• Dull aching pain is common. Severe bursting pain
indicates rapid expansion and impending rupture.
• Pulsatile, tense, cystic, fluctuant swelling behind the
knee in the popliteal fossa, in the line of the popliteal
artery.
• Its size diminishes on extending the knee as the
aneurysm is deep to popliteal fascia.
• Proximal compression test: On occluding the femoral
artery proximally, the swelling may diminish in size.
In all cases of popliteal aneurysm, please search for a femoral
or aortic aneurysm.
Investigations
• Duplex ultrasonography is the investigation of
choice, which can measure the diameter and
determine the extent of mural thrombus.
• Angiography can demonstrate the extent of the
involved segment to look for patency and check the
quality of runoff vessels.
Complications
Thrombosis causes severe acute ischaemia of the
1.
lower limb (incidence: 40%).
2. Embolisation causes ischaemic ulceration of the
lower limb.
3. Rupture causes pain and haematoma (rare: 2–5%).
4. Compression on the popliteal vein causes pain,
tenderness, and swelling of the leg.
5. Compression on the lateral peroneal nerve causing
foot drop, due to paralysis of the peronei and the
extensors of the foot.
calf region, loss of plantar flexion, and clawing of the
toes due to paralysis of the intrinsic muscles of the
foot.
MISCELLANEOUS
AINHUM (Fig. 27.38)
It affects those who do not use footwear/walk barefoot.
It starts as a fissure at the level of the interphalangeal
joint of a toe, usually the fifth. Repeated minor trauma
may be present. The tissue becomes a fibrous band resulting in tight constriction and necrosis. If it continues, it
may culminate in autoamputation.
• Division of the band or early Z-plasty may be needed
to avoid amputation.
• In early cases—thrombolysis with catheter in situ.
FROSTBITE
• It occurs due to excessive exposure to cold weather.
• High altitudes with excessive cold precipitate vaso-
spasm and damage the blood vessel wall. It causes
sludging of blood and thrombosis.
• Malnutrition and aging are the other precipitating
factors. Severe burning pain, discolouration of the
foot, and development of blisters suggest that
gangrene is imminent.
Treatment
• Slow warming of the parts and protection with cotton
wool.
• Analgesics and antibiotics.
• Paravertebral injection into the sympathetic chain
may help in a few patients.
• Elevation of the foot to reduce oedema.
• Frank cases of frostbite with gangrene require
conservative amputation.
Treatment
• Proximal and distal ligation of the artery followed
by reversed saphenous vein bypass graft is the
treatment of choice. This results in total obliteration
of the sac and revascularisation of the limb.
• Excision of the sac is better avoided because of the
risk of injury to the popliteal vein and nerves. Lateral
popliteal nerve injury causes foot drop, and tibial
(medial popliteal) nerve injury causes thinning of the
Fig. 27.38: Ainhum
Section II • General Surgery
196
Manipal Manual of Surgery
FAT EMBOLISM
Definition
Often a potentially lethal condition which occurs due
to blockage of major arteries by the aggregation of
chylomicrons.
Causes
• Fracture femur (long bones)
• Orthopaedic surgery, multiple fractures
• Liposuction
• Sickle cell disease
• Pancreatitis
• Diabetes mellitus
Triad of fat embolism syndrome—respiratory failure, confusion,
and petechial haemorrhages. Early diagnosis and prophylactic
administration of oxygen to patients at risk is recommended.
Clinical Features
• Pulmonary: Central cyanosis, tachypnoea, right heart
failure, and froth in the mouth and nostrils. Respira-
tory distress is the most common presenting feature.
• CNS: Drowsiness, disorientation, restlessness,
constricted pupils, pyrexia, and coma.
• Retinal artery: Striate haemorrhages, fluffy exudates
on fundoscopic examination, and cotton wool spots.
• Cutaneous: Petechial rashes in the nondependent
parts of the body—chest, axilla and conjunctiva.
Pathogenesis
• 50% of cases occur within 72 hours.
• Free fatty acids (FFAs), released at the time of trauma
or breakdown of fat in the lung, directly affect
pneumocytes resulting in Acute Respiratory Distress
Syndrome (ARDS).
• Another theory is that there is blockage by the
aggregation of chylomicrons.
Investigations
• Arterial blood gases—hypoxaemia and respiratory
alkalosis from hyperventilation.
• Chest X-ray—bilateral interstitial and alveolar
infiltrates in severe cases (‘snowstorm’ pattern).
Treatment
• Close monitoring with pulse oximetry.
• Supportive therapy with oxygen and mechanical
ventilation as required.
Section II • General Surgery
• Surgical—early internal fixation of the fracture.
AIR EMBOLISM (Key Box 27.17)
Definition
It is a potentially fatal condition that occurs due to
blockage of the pulmonary artery by a large volume of
air in the venous circulation.
Causes
• Neck surgeries in which a large vein is inadvertently
opened and the patient is in head-elevated position
(thyroid surgery) or sitting position (posterior fossa
surgery).
• Rapid infusion of intravenous fluids where emptying
of the bottle and infusion set may go unnoticed and
a fresh bottle is connected and infused without
eliminating air from the infusion set.
Effects
Formation of an air lock within the pulmonary artery
and right heart failure.
Treatment
• Position the patient head down (Trendelenburg
position) so that air entrainment is stopped.
• Turn the patient to his/her left side so that air will
float to the ventricular apex, reducing its entry into
the pulmonary artery.
• Administer oxygen and resuscitate as necessary.
Key Box 27.17
Air Embolism
Large veins get opened in the neck
Open heart surgery or if pulmonary vein is punctured
Fallopian tube insufflation
Illegal abortion (through paravertebral veins)
Paradoxical embolism, reaching coronary artery
through patent foramen ovale
INTENSIVE CARE UNIT (ICU) GANGRENE (Fig. 27.39)
• It is as a rare clinical entity. It was first described by
Jonathan Hutchinson in 1891 as multiple extremity
ischaemia and was termed ‘symmetrical peripheral
gangrene.’
• Possible aetiological factors include sepsis, DIC, and
the use of vasopressor agents. The possible responsible drug is noradrenaline.
• Patients in ICU have multiple arterial punctures for
securing intra-arterial line for invasive monitoring.
These arterial punctures may also be a possible
aetiological factor.
Lower Limb Ischaemia and Popliteal Aneurysm
Fig. 27.40: Bilateral symmetrical digital gangrene due to
atherosclerosis, diabetes, sepsis and hypotensionFig. 27.39: ICU gangrene
197
• Sepsis in the presence of sluggish blood flow has been
described to be responsible for the development of
symmetrical peripheral gangrene (Fig. 27.40).
• Vasospastic conditions, small vessel obstruction, and
very low cardiac output states (perfusion pressure
falling to 35–60 mmHg) may also contribute.
• Medical conditions, such as diabetes mellitus, malig-
nancy, protein C or S or antithrombin III deficiency
are other contributing factors.
• The usual manifestation is pallor or cyanosis,
coldness, and pain in the extremity. They become
erythematous and there is dusky discolouration of
skin with bullae or blisters, followed by gangrene.
• Pulses may be intact in the early stages. Large vessels
are often spared. Low flow states result in occlusion
of the microcirculation of the affected parts.
• The first line of management is immediate discontinua-
tion of vasopressors as soon as discolouration is seen.
• Aggressive treatment of sepsis with intravenous
antibiotics and anticoagulation for DIC are the
suggested measures.
• Local debridement and secondary skin grafting have
been unsuccessful.
• Amputation should be considered only after a clear
line of demarcation develops. The condition has a
high mortality rate of 40%.
Please note: Aortic aneurysm is discussed in Chapter 62 under cardiothoracic surgery.
Section II • General Surgery
198
Manipal Manual of Surgery
1. Which of the following is false regarding thromboangiitis obliterans?
A. The dorsalis pedis and posterior tibial arteries are
often affected
B
. The radial artery may also be affected
C. The superficial femoral artery is also affected
D. Bruit is present over the femoral artery
2. The following are true for atherosclerotic arterial
disease except:
A. Large-sized arteries are affected
. The upper limb is often affected
B
C. It may be associated with an aortic aneurysm
D. A bruit may be present over the artery
3. The following are features of thromboangiitis
obliterans except:
A. Raynaud’s phenomenon
. Migrating thrombophlebitis
B
C. Segmental panarteritis
D. Polymorphs and giant cells are absent on histo-
pathology
4. The following are uses of a Doppler probe except:
A. To feel the nonpalpable pulse
. To look for pressure index
B
C. To measure blood pressure
D. To detect triphasic pattern
5. Lumbar sympathectomy has the following advantages
except:
A. Rest pain improves to a small extent
. Ulcerations heal
B
C. Claudication and claudication distance improve
D. Nutritive value of the blood flow improves
6. A Fogarty catheter is used in:
A. Chronic arterial occlusion
. Acute arterial embolic occlusion
B
C. Vasospastic disease
D. Femoral vein thrombosis
7. The characteristic feature of critical limb ischaemia is:
A. Intermittent claudication
. Ankle pressure <70 mm of Hg
B
C. Toe systolic pressure <30 mmHg
D. Absent pulses
8. The triad of fat embolism includes:
A. Respiratory failure, confusion, petechial haemorr-
hages
B.
Respiratory failure, confusion, large purpuric spots
C. Respiratory failure, alertness, petechial haemorr-
hages
D. Cardiac failure, confusion, petechial haemorrhages
9. The following are true for popliteal aneurysm except:
A. It is caused by atherosclerosis
B. It is the most common type of peripheral aneurysm
C. It is always unilateral
D. Foot drop may occur
10. The following are true about lumbar sympathectomy
except:
A. It is a postganglionic sympathectomy
B
. The sympathetic trunk is divided below the first
sympathetic ganglion
C. It is a preganglionic sympathectomy
D. It is usually done by an extraperitoneal approach
11. The following are true for infra-inguinal bypass
surgery for diabetic ulcer except:
A. Long saphenous vein is inferior to the PTFE graft
. Preoperative vein marking is helpful
B
C. 2-year patency is around 70%
D. Amputation rate after bypass surgery is still high
12. The following are major risk factors for atherosclerosis except:
A. Dyslipidaemia
B
. Tobacco smoking
C. Hyperhomocystinaemia
D. Alcohol intake
13. The following are true for profundoplasty except:
A. It is done using a patch of Dacron
B
. It is done using a vein graft
C. It is done after endarterectomy
D. It is done in TAO patients
14. The following are true about tissue plasminogen
activator except:
A. It was first purified from melanoma cells
. It is an endogenous enzyme like urokinase
B
C. It is sometimes elevated in carcinoma stomach
D. Streptokinase also has plasminogen activating action
Answers
1. D 2. B 3. D 4. D 5. C 6. B 7. C 8. A 9. C 10. A
11. A 12. D 13. D 14. C
Section II • General Surgery
28
Upper Limb Ischaemia
and Gangrene
Raynaud’s disease
Thoracic outlet syndrome
Axillary vein thrombosis
Vasculitis syndromes
Gangrene, cancrum oris
INTRODUCTION
Upper limb ischaemia (ULI) is a well-recognised clinical
entity like lower limb ischaemia, though it is less
common. There are certain specific conditions (such as
cervical rib, Raynaud’s disease, etc.) responsible for
causing ULI. It is important to note that reconstructive
surgery is rarely done in the upper limb, as opposed to
the lower limb.
Causes of Upper Limb Ischaemia
1. Raynaud’s disease and Raynaud’s syndrome—
vasospastic.
. Embolic causes.
2
3. Thoracic outlet syndrome (Fig. 28.1).
4. Trauma.
5. Buerger’s disease—vasospastic.
6. Axillary vein thrombosis.
7. Ergotism: These drugs are used for severe headache
due to migraine.
8. Vinyl chloride exposure can give rise to vasospasm
(Raynaud’s phenomenon).
9. Vasculitis syndromes : Takayasu’s arteritis, giant cell
arteritis, polyarteritis nodosa, systemic sclerosis—
scleroderma—CREST syndrome.
RAYNAUD’S DISEASE
Primary Raynaud’s Phenomenon)
(
• It occurs in young women, commonly.
• The upper limb is more involved than the lower limb.
Acrocyanosis
Drug abuse and gangrene
Intra-arterial drug and gangrene
Subclavian steal syndrome
Fig. 28.1: Gangrene of the tip of fingers due to cervical rib
• It is commonly seen in Western countries in white-
skinned people. Cold climate is possibly a precipitating factor. It was first described by Raynaud as
bilateral episodic digital ischaemia of the upper
limb on exposure to cold and emotions. It is also
referred to as primary Raynaud’s phenomenon.
• Raynaud’s phenomenon is the blanket term used to
describe cold-related digital vasospasm (see patho-
physiology). Raynaud’s phenomenon is subdivided
into Raynaud’s syndrome (associated disorder
present) and primary Raynaud’s disease (no
associated disorder).
• CREST syndrome: Calcinosis circumscripta,
Raynaud’s phenomenon, (O) Esophageal defects,
Sclerodactyly, Telangiectasia.
199
200
Manipal Manual of Surgery
• Causes of Secondary Raynaud’s phenomenon are
given in Key Box 28.1.
Currently, both primary and secondary varieties have
been grouped together.
Key Box 28.1
Causes of Secondary Raynaud’s Phenomenon
Atherosclerosis
Cervical rib
Systemic lupus
Carpal tunnel syndrome
Scleroderma
Vibrating tools—vibration white finger
Pathophysiology
1
On exposure to cold
, some kind of discomfort and
colour changes are observed. This is due to abnormal
sensitivity of the arterioles to cold. Three stages have
been described.
1. Stage of syncope: Arterioles undergo constriction as
an abnormal response to cold. As a result of this, the
part becomes blanched and severe pallor develops.
2. Stage of asphyxia: After a brief period of vasocons-
triction, capillaries dilate and fill with deoxygenated
blood, resulting in a bluish discolouration of the part
(cyanosis).
3. Stage of recovery or stage of rubor: As the attack
passes off, the arterioles relax, circulation improves,
and redness occurs. Because of capillary dilatation,
there is red engorgement of the part and tingling,
burning, or bursting pain in the fingers.
Raynaud’s Phenomenon—Investigations
• Blood counts, ESR: Increased ESR suggests auto-
immune etiology
• ANA: Antinuclear antibody (ANA) test for anti-
nuclear antibodies
• Nailfold capillaroscopy: It is to analyse micro-
vascular abnormalities in autoimmune rheumatic
diseases. It can detect capillaries, haemorrhages,
angiogenesis in cases of scleroderma.
• Thermography: To differentiates primary and secon-
dary Raynaud’s phenomenon. In case of primary
Raynaud’s disease, temperature gradients normalize.
• Wrist–Brachial Index
. Normal—0.85–1.0
a
b. Abnormal <0.85
Treatment
I. Conservative line of treatment
• Reassurance
• Avoid unnecessary exposure to cold
• Avoid smoking
• Calcium antagonists such as nifedipine 10–20 mg, two
times a day may be beneficial.
• If these measures fail, surgery is performed.
II. Cervical sympathectomy (Key Boxes 28.2 and 28.3)
• In this operation, the sympathetic trunk from the
lower half of the stellate ganglion to just below the
3rd thoracic ganglion is removed.
• The upper ½ of the stellate ganglion is preserved to
avoid Horner’s syndrome.
Clinical Features
• Affects young women.
• Typically causes bilateral episodic digital ischaemia
on exposure to cold.
• Thumb is usually spared.
• Peripheral pulses are normal.
• Pallor, cyanosis, and rubor are the colour changes that
occur during the attack, which are accompanied by pain.
Raynaud’s disease
TAO
Hyperhidrosis
Cervical rib
Causalgia
Key Box 28.2
Indications for Cervical Sympathectomy
• In a few patients, because of recurrent attacks,
gangrenous patches occur on the tip of the fingers
(superficial necrosis).
Differential Diagnosis
• Cervical rib
• Vasculitis syndromes
• TAO affecting the upper limb usually affects male
smokers. Peripheral pulses are feeble or weak.
1
Cold refers to temperature—cold climate (winter), cold environment (refrigerator), or cold substance like cold water or ice. Erythromelalgia is a
Section II • General Surgery
condition wherein heat provokes an attack of burning pain of hands and feet.
Perforation of pleura causing pneumothorax
Lymph fistula due to injury to thoracic duct
Horner’s syndrome
Injury to the accessory nerve
Haemorrhage
Key Box 28.3
Complications of Cervical Sympathectomy
Upper Limb Ischaemia and Gangrene
201
• All rami communicantes associated with the 2nd and
3rd ganglia are removed.
• Nerve of Kuntz, a grey ramus which springs from
the 2nd thoracic ganglion to the 1st thoracic nerve, is
also divided.
• It is commonly done through a supraclavicular or
axillary route. Thoracoscopic sympathectomy is
becoming popular.
• Sympathectomy raises the threshold at which spasm
occurs (but the effect seems to be temporary).
However, the severity of the disease is reduced.
Other Vasospastic Disorders (Key Box 28.4)
These are rare.
Key Box 28.4
Other Vasospastic Disorders
Acrocyanosis
Women with cyanosis of hands and feet
Cutaneous vasoconstriction is the cause
Livedo reticularis
Spasm of arterioles and dilatation of venules
Worsening by cold
May be associated with systemic lupus erythematosus (SLE)
Erythromelalgia
Burning sensation of hands and feet due to heat
THORACIC OUTLET SYNDROME
SURGICAL ANATOMY OF THE THORACIC OUTLET
• The thoracic outlet is a tight space with bony struc-
tures all around (Key Box 28.5), such as the manubrium
sternum anteriorly, the spine posteriorly, and first
rib laterally.
• At the root of the neck, the brachial plexus and sub-
clavian artery pass through the scalene triangle into
the axilla.
• The scalene triangle is the posterior compartment of
the costoclavicular space. It is divideyd into anterior
and posterior compartments by the scalenus anticus.
The anterior compartment contains the subclavian
vein.
Key Box 28.5
Introduction to Thoracic Outlet
Tight space with bones all around
Brachial plexus and subclavian artery are chief contents
Scalenus anticus muscle is the muscle for landmark
Vascular compression is more dangerous
Neurological symptoms are often undiagnosed
• Boundaries of scalene triangle (Fig. 28.2)
Base: First thoracic rib
Anteromedially: Scalenus anticus
Posterolaterally: Scalenus medius
Fig. 28.2: Scalene triangle
• If the base (first thoracic rib) is raised by interposition
of the cervical rib or any other cause (Key Box 28.6),
it results in compression of the subclavian artery.
The thoracic outlet can be divided into 3 anatomical spaces
A. Scalene triangle is the most common site of brachial
plexus compression
Cervical rib and anomalous 1st rib compress the plexus
in this location
B. Costoclavicular space is the space between the 1st rib
and clavicle traversed by all 3 structures (subclavian
artery, vein, and brachial plexus)
• It is the most common site of subclavian vein
compression
C.Pectoralis minor and ribs of the chest wall, an
extension of the thoracic outlet area. It is also called
axillary compression syndrome.
• Types of thoracic outlet syndrome are given in
Table 28.1.
Key Box 28.6
Thoracic Outlet Syndrome: Causes
Transverse process of C7—long
Hyperabduction syndrome—compression by pectoralis
minor
Operative scars—fibrous bands
Rib—cervical rib
Anomalous first rib—abnormal
Costoclavicular syndrome—compression between
clavicle and first rib
Insertion of scalenus—anomalous
(Scalenus anticus syndrome)
Callus—malaligned fracture clavicle
Remember as THORACIC
Section II • General Surgery
202
Table 28.1 Types of thoracic outlet syndrome
Neurogenic Venous Arterial
Incidence 95% 30% 1%
Aetiology Neck trauma, whiplash injury Repeated overhead shoulder Cervical rib (or)
Pathology Scalene muscle fibrosis Subclavian vein stenosis with or Subclavian artery stenosis, thrombosis
Symptoms Neurological symptoms Swelling of whole arm, cyanosis, Pain, pallor, paraesthesia, digital
paresthesia, tingling pain—Paget-Schroetter syndrome ischaemia
Raynaud’s
Diagnosis Duplex scan, phenomenon Duplex scan, venogram Neck X-ray, duplex scan, arteriogram
EMG, NCS, MRI neck
Nonsurgical Physiotherapy Fibrinolysis, anticoagulants None (only surgical)
treatment
Surgical – – 1st rib resection, anterior scalenectomy,
treatment embolectomy, thrombectomy, arterial
Manipal Manual of Surgery
movements, sportsmen Anomalous 1st rib, rarely congenital band
without thrombosis (or) Aneurysm
grafting.
PATHOPHYSIOLOGY OF CERVICAL RIB WITH
COMPRESSION (Key Box 28.7)
• Due to slow compression, the artery distal to the
compression dilates due to a jet-like effect and
turbulence of blood flow. This is described as post-
stenotic dilatation (Venturi effect) (Fig. 28.3).
• In this dilated segment, multiple small thrombi
develop, which, when dislodged, result in emboli and
distal ischaemia. Vascular symptoms are strictly
unilateral.
Cervical Rib
• This is an extra rib presents in the neck in about 1–
2% of the population.
• It is commonly unilateral but may be bilateral in some
cases.
• It is more frequently encountered on the right side.
• It is the anterior tubercle of the transverse process of
the 7th cervical vertebra, which attains excessive
development and results in cervical rib.
Key Box 28.7
Subclavian Artery Occlusion Effects
Lumen narrowing
Fig. 28.3: Poststenotic dilatation of subclavian artery caused
by cervical rib
Types of Cervical Rib (Fig. 28.4)
Type I The free end of the cervical rib is expanded into a
hard, bony mass which can be felt in the neck.
Type II Complete cervical rib extends from C7 vertebra
posteriorly to the manubrium anteriorly.
Type III Incomplete cervical rib, which is partly bony, partly
fibrous.
Type IV A complete fibrous band which gives rise to
symptoms but cannot be diagnosed by X-ray.
Multiple thrombi Embolism Ischaemia®®
Section II • General Surgery
Fibrosis or thickening of arterial wall
Stenosis
Poststenotic dilatation
Clinical Features
• Common in young females. Even though it is
congenital, symptoms appear only at or after puberty.
This is because of development of the shoulder girdle
muscles and sagging of the shoulder, which narrow
the root of the neck. Nerve roots C8 and T1 are
stretched by around 25 years of age (completion of
growth).
Upper Limb Ischaemia and Gangrene
Fig. 28.4: Four types of cervical rib (see text)
• Dull-aching pain in the neck is caused by the
expanded bony end of the cervical rib.
• Features of upper limb ischaemia: Claudication pain
is apparent when the arm with muscle wasting is
used. Low temperature, pallor, excessive sweating
(vasomotor disturbances), splinter haemorrhages,
ischaemic ulcers in fingers, and gangrene of the skin
of the fingers are the other features. Peripheral pulses
may be absent/feeble. Oedema and venous distension
are very rare. These are called vascular symptoms of
cervical rib.
• Features of ulnar nerve weakness (involvement of
the lower nerve roots involvement, mainly T1)
manifest as tingling and numbness or paraesthesia
in the distribution of C8 and T1. The following tests
confirm ulnar nerve weakness. It includes sensory
disturbances and motor disturbances (performing
fine action—writing, buttoning, etc.)
1
A. Card test
: The patient is asked to hold a thin paper
or card between the fingers. In cases of ulnar nerve
paralysis, due to weakness of the interossei
muscles, the patient will not be able to hold the
card tightly (Fig. 28.5).
203
B. Froment’s sign: The 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 the median nerve,
contracts (Fig 28.6).
• Adson’s test: Feel the radial pulse, ask the patient to
take deep inspiration, and turn the neck to the same
side. The pulse may disappear or become feeble. This
test indicates compression on the subclavian artery
(Fig. 28.7).
• 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 the brachial plexus, which gets compressed
between pectoralis minor and its attachment to the
coracoid process.
• Military attitude test: When shoulders are set in
backward and downward positions, the radial pulse
becomes weak. This is due to compression of the
subclavian artery between the clavicle and the first
rib. This is seen in costoclavicular syndrome.
Fig. 28.6: Froment’s sign
Fig. 28.5: Card test
1
Card test and Froment’s sign are not seen in cases of cervical rib.
Fig. 28.7: Adson’s test
Section II • General Surgery