Cervical Rib & Thoracic Outlet Syndrome (TOS): Tests & Rehab MCQs

Cervical Rib & Thoracic Outlet Syndrome

A Cervical Rib is a congenital anomaly where an extra rib arises from the 7th cervical vertebra (C7). It causes Thoracic Outlet Syndrome (TOS) by compressing the neurovascular structures exiting the neck.

[Image of Cervical Rib and Brachial Plexus]

1. Anatomy

• Complete Rib: Fuses with the 1st thoracic rib.
• Incomplete Rib: A fibrous band connects it to the 1st rib (often more dangerous as the band is tight).
• Structures Compressed: Lower Trunk of Brachial Plexus (C8-T1) and Subclavian Artery.

2. Clinical Features

• Neural (90%): Pain/Tingling in the ulnar aspect (C8-T1 distribution). Wasting of small hand muscles.
• Vascular: Weak radial pulse, cold hand, Raynaud's phenomenon.

3. Special Tests

Adson's Test: Extend neck, rotate head TO affected side, take deep breath. Positive if pulse disappears.
Roos Test: "Hands up" opening and closing fists for 3 minutes.

4. Physiotherapy

• Postural Correction: Correct drooping shoulders.
• Stretching: Scalene muscles and Pectoralis Minor.
• Strengthening: Trapezius and Rhomboids to lift the clavicle.

25 Practice MCQs

Q1. A Cervical Rib arises from which vertebra?

Answer: A). It is an extra rib above the first thoracic rib.

Q2. Which nerve roots are most commonly compressed?

Answer: B). Causing ulnar side symptoms.

Q3. Adson's Test is positive if:

Answer: A). Indicates vascular compression by scalenes.

Q4. The fibrous band often connects the cervical rib to:

Answer: A). The plexus passes over this tight band.

Q5. Which artery is compressed in TOS?

Answer: B). Leads to ischemic pain.

Q6. Roos Test is also known as:

Answer: A). Arms up at 90 degrees for 3 minutes.

Q7. Wasting of small muscles of the hand (Thenar/Hypothenar) indicates:

Answer: A). T1 supplies the intrinsic hand muscles.

Q8. The Scalene Triangle is formed by:

Answer: A). The plexus and artery pass through this triangle.

Q9. Paresthesia in Cervical Rib is mostly felt in:

Answer: A). C8-T1 dermatome.

Q10. Halstead maneuver involves:

Answer: A). Another test for TOS.

Q11. "Costoclavicular Syndrome" is compression between:

Answer: A). Often caused by carrying heavy backpacks.

Q12. Wright's Hyperabduction Test checks for compression at:

Answer: B). Arm abducted to 180.

Q13. Paget-Schroetter syndrome is:

Answer: A). "Venous TOS" seen in athletes.

Q14. Double Crush Syndrome implies:

Answer: A). The nerve is compromised at two levels.

Q15. Which muscle should be stretched in TOS?

Answer: A). These are the muscles that entrap the neurovascular bundle.

Q16. "Drooping shoulders" posture:

Answer: A). PT focuses on elevating the shoulder girdle.

Q17. Incidence of Cervical Rib in population is roughly:

Answer: A). And only 10% of those are symptomatic.

Q18. Raynaud's Phenomenon in TOS is due to:

Answer: A). Fingers turn white/blue in cold.

Q19. Surgery is indicated when:

Answer: A). Conservative management is first line for neural type.

Q20. Horner's syndrome (ptosis, miosis, anhidrosis) may occur if:

Answer: A). Rare complication of TOS.

Q21. Which muscle attaches to the 1st Rib?

Answer: A). They lift the 1st rib, compressing the outlet.

Q22. What is a "Pseudoarthrosis" of the cervical rib?

Answer: A). Can form a large lump and compress nerves.

Q23. Nerve Conduction Studies (NCS) in TOS often show:

Answer: A). Though specific, false negatives are common.

Q24. Elvey's Test (ULTT) for Ulnar nerve involves:

Answer: A). Stretches the ulnar nerve distribution.

Q25. Surgical removal of cervical rib is usually done via:

Answer: A). Transaxillary is cosmetically better (hidden scar).