Clavicular Duplication Causing Thoracic Outlet Obstruction: An Uncommon Cause to be Remembered

Thoracic Outlet Syndrome (TOS) as a term was first coined by Peet in 1956. This clinical condition is
very perplexing for the clinicians and is characterized by variable constellation of neck pain, shoulder
or arm pain and associated vascular and neurological symptoms in the upper extremity which is
attributed to the compression of neurovascular structures coursing through the thoracic inlet. The
various types being vascular, which involves compression of either the subclavian artery or vein, true
neurogenic due to affection of brachial plexus and the disputed or nonspecific neurogenic TOS which
is the most controversial type. This article aims to provide a glimpse into this challenging problem
faced by orthopods with special emphasis on clinical workup based on proper history, physical
examination, direct observation and provocation tests and at the same time highlighting clavicular
duplication, a clinical entity as an unusual etiological cause of TOS. Early identification of TOS is
pertinent to ensure success in treatment of TOS. Treatments vary and largely guided by the type of
TOS and symptom logy. As of now, there is no single “gold standard” test for establishing diagnosis of
TOS. The goals of treatment aim at controlling symptoms and managing any etiological cause which
might be the cause of the condition. The first line of clinical care centers on conservative treatment,
which has been found to be quite effective in regaining normal functioning in most of the cases. It is
also worthwhile to mention that occasionally, thoracic outlet syndrome may be bilateral affecting both
the upper extremities. So clinician should not forget to inquire about symptoms and examine the other
side as well. However, such a patient should not be treated unless he shows definite signs or
symptoms with disability requiring some intervention.