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Compression of the lower trunk of the brachial plexus by a cervical rib in two adolescent girls: case reports and surgical treatment.

Dahlin LB, Backman C, Düppe H, Saito H, Chemnitz A, Abul-Kasim K, Maly P - J Brachial Plex Peripher Nerve Inj (2009)

Bottom Line: Presence of a cervical rib in children is extremely rare, particularly when symptoms of compression of the lower trunk of the brachial plexus occur.We present two cases with such a condition, where two young girls, 11 and 16 years of age were treated by resection of the cervical rib after a supraclavicular exploration of the lower trunk of the brachial plexus.The procedure led to successful results, objectively verified with tests in a work simulator, at one year follow-up.

View Article: PubMed Central - HTML - PubMed

Affiliation: Hand Surgery, Department of Clinical Sciences in Malmö, Lund University, Malmö, Sweden. lars.dahlin@med.lu.se

ABSTRACT
Presence of a cervical rib in children is extremely rare, particularly when symptoms of compression of the lower trunk of the brachial plexus occur. We present two cases with such a condition, where two young girls, 11 and 16 years of age were treated by resection of the cervical rib after a supraclavicular exploration of the lower trunk of the brachial plexus. The procedure led to successful results, objectively verified with tests in a work simulator, at one year follow-up.

No MeSH data available.


Related in: MedlinePlus

Case 1: (A-B) MRI T1-weighted coronal images showing that the space between the cervical rib (arrow) and the first rib (arrow head) diminishes upon lifting the upper arm with subsequent impingement of the brachial plexus in image B.
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Figure 2: Case 1: (A-B) MRI T1-weighted coronal images showing that the space between the cervical rib (arrow) and the first rib (arrow head) diminishes upon lifting the upper arm with subsequent impingement of the brachial plexus in image B.

Mentions: An 11 year old right-handed girl with a history of a bilateral tumour in the neck was referred to our hospital for a second opinion. She had previously been examined at another hospital due to a tumour on the right side. Diagnosis was based on a conventional X-ray and a biopsy which showed bone tissue. No further treatment was done. We had no information available of the diagnostic and treatment considerations from that hospital. The girl also had symptoms such as paraesthesia and pain in the middle ring and little fingers, particularly on the right side, often during night time. The history of the patient included fatigue and pain while writing and working on a computer. She had problems carrying things in the hands, especially when the arm was pulled in the axial direction. Lifting the arms above the shoulder plane elicited similar symptoms in the fingers on the right side. She experienced intolerance to cold. Range of motion in the shoulder, elbow, wrist and fingers was normal, but she expressed pain in the three ulnar fingers during abduction above 90 degrees. She had impaired internal rotation/adduction/extension ("hand on the back") on the right side. Examination showed palpable cervical ribs bilaterally, where percussion in the area elicited symptoms in the three ulnar fingers. Subjectively, she expressed a somewhat impaired sensibility in the little fingers, particularly on the right side. The strength of the first dorsal interosseous muscle and the other ulnar nerve innervated muscles was equal (no atrophy in the extremity) to the contralateral side, but she had a positive Froment's sign. Two-point discrimination (2-PD) was 2-3 mm in all fingers. A normal pulse in the radial artery was noted even with the arm lifted. Assisted hand assessment (AHA) showed no abnormality. Isometric and dynamic tests of the right hand in a work stimulator (BTE Primus) showed 8-10% lower values than in the left hand. Electrophysiological investigation showed no abnormalities except a slightly increased F-wave (latency 18.9 ms; upper border 18.1). No EMG recordings were done from individual intrinsic muscles of the hand. Radiographs and CT of the cervical spine showed bilateral cervical ribs articulating against a bone prominence on the cranial surface of the first rib (Fig. 1). The cervical rib with the "pseudoarthrotic" bony formation slightly dislocated the lower part of the brachial plexus ventrally. On MRI performed with the arms lifted, the space between the cervical rib, the bone formation and the clavicle decreased (Fig. 2). MRI also showed fibrous tissue formation around the pseudoarthrotic bone formation. There were no similar findings of the brachial plexus on the left side despite the presence of a cervical rib.


Compression of the lower trunk of the brachial plexus by a cervical rib in two adolescent girls: case reports and surgical treatment.

Dahlin LB, Backman C, Düppe H, Saito H, Chemnitz A, Abul-Kasim K, Maly P - J Brachial Plex Peripher Nerve Inj (2009)

Case 1: (A-B) MRI T1-weighted coronal images showing that the space between the cervical rib (arrow) and the first rib (arrow head) diminishes upon lifting the upper arm with subsequent impingement of the brachial plexus in image B.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2742518&req=5

Figure 2: Case 1: (A-B) MRI T1-weighted coronal images showing that the space between the cervical rib (arrow) and the first rib (arrow head) diminishes upon lifting the upper arm with subsequent impingement of the brachial plexus in image B.
Mentions: An 11 year old right-handed girl with a history of a bilateral tumour in the neck was referred to our hospital for a second opinion. She had previously been examined at another hospital due to a tumour on the right side. Diagnosis was based on a conventional X-ray and a biopsy which showed bone tissue. No further treatment was done. We had no information available of the diagnostic and treatment considerations from that hospital. The girl also had symptoms such as paraesthesia and pain in the middle ring and little fingers, particularly on the right side, often during night time. The history of the patient included fatigue and pain while writing and working on a computer. She had problems carrying things in the hands, especially when the arm was pulled in the axial direction. Lifting the arms above the shoulder plane elicited similar symptoms in the fingers on the right side. She experienced intolerance to cold. Range of motion in the shoulder, elbow, wrist and fingers was normal, but she expressed pain in the three ulnar fingers during abduction above 90 degrees. She had impaired internal rotation/adduction/extension ("hand on the back") on the right side. Examination showed palpable cervical ribs bilaterally, where percussion in the area elicited symptoms in the three ulnar fingers. Subjectively, she expressed a somewhat impaired sensibility in the little fingers, particularly on the right side. The strength of the first dorsal interosseous muscle and the other ulnar nerve innervated muscles was equal (no atrophy in the extremity) to the contralateral side, but she had a positive Froment's sign. Two-point discrimination (2-PD) was 2-3 mm in all fingers. A normal pulse in the radial artery was noted even with the arm lifted. Assisted hand assessment (AHA) showed no abnormality. Isometric and dynamic tests of the right hand in a work stimulator (BTE Primus) showed 8-10% lower values than in the left hand. Electrophysiological investigation showed no abnormalities except a slightly increased F-wave (latency 18.9 ms; upper border 18.1). No EMG recordings were done from individual intrinsic muscles of the hand. Radiographs and CT of the cervical spine showed bilateral cervical ribs articulating against a bone prominence on the cranial surface of the first rib (Fig. 1). The cervical rib with the "pseudoarthrotic" bony formation slightly dislocated the lower part of the brachial plexus ventrally. On MRI performed with the arms lifted, the space between the cervical rib, the bone formation and the clavicle decreased (Fig. 2). MRI also showed fibrous tissue formation around the pseudoarthrotic bone formation. There were no similar findings of the brachial plexus on the left side despite the presence of a cervical rib.

Bottom Line: Presence of a cervical rib in children is extremely rare, particularly when symptoms of compression of the lower trunk of the brachial plexus occur.We present two cases with such a condition, where two young girls, 11 and 16 years of age were treated by resection of the cervical rib after a supraclavicular exploration of the lower trunk of the brachial plexus.The procedure led to successful results, objectively verified with tests in a work simulator, at one year follow-up.

View Article: PubMed Central - HTML - PubMed

Affiliation: Hand Surgery, Department of Clinical Sciences in Malmö, Lund University, Malmö, Sweden. lars.dahlin@med.lu.se

ABSTRACT
Presence of a cervical rib in children is extremely rare, particularly when symptoms of compression of the lower trunk of the brachial plexus occur. We present two cases with such a condition, where two young girls, 11 and 16 years of age were treated by resection of the cervical rib after a supraclavicular exploration of the lower trunk of the brachial plexus. The procedure led to successful results, objectively verified with tests in a work simulator, at one year follow-up.

No MeSH data available.


Related in: MedlinePlus