First Rib

A 36-year-old woman developed supraclavicular skin necrosis, followed by sloughing of subcutaneous tissue down to the first rib, including the dorsal roots of the brachial plexus, after receiving an interscalene block followed by an infusion 5 months later she still had complete sensory and motor paralysis of the C5 nerve root requiring nerve grafting. 

Fracture of a central venous catheter due to compression between the clavicle and the adjacent first rib has been reported (5). A pinched-off sign on X-ray indicates the need to remove the catheter, because of a significant risk of subsequent fracture, which has an incidence of 0.9%. Catheters lying anterior to the subclavian vein between the clavicle and the first rib are hable to be compressed and to fracture subsequently. This is a potentially life-threatening complication that can be averted by correct placing of the central venous catheter and by immediate chest radiography to search for evidence of catheter kinking or compression. 

This pinched-off effect appears to be due to narrowing of the catheter as it passes over the first rib and beneath the clavicle, when using the Seldinger technique, but it is usually only observed after long-term use. The authors recommended that the cephalic cut-down (Seldinger) technique is best avoided. 

Ramsden WH, Cohen AT, Blanshard KS. Case report central venous catheter fracture due to compression between the clavicle and first rib. Clin Radiol 1995 50(l) 59-60. 

Each subclavian vein is a continuation of the axillary vein and runs from the outer rim of the first rib to the medial rim of the anterior scalene muscle. Here the subclavian and internal jugular veins join inside the anterior edge of the superior thoracic opening and create right and left innominate veins behind the sternal manubrium. The vein usually has a pair of valves about 2 cm from its end. The heads of clavicles extend posteriorly into the superior thoracic opening, displacing the veins posteriorly from the sternum. Because of the anteroposterior slope of the superior aperture, the arteries are... 

Fig.1. 39 Subclavian venous system and skeletal landmarks relevant to percutaneous access. Subclavius muscle and costoclavicular ligament complex are shown between the clavicle and the first rib (from [29], Chap. 5, p. 212, by permission of Mayo Foundation for Medical Education and Research. All rights reserved)...

Historically, surgeons believed that the subclavian vein could be entered at the junction of the middle and the inner thirds of the clavicle, creating a very medial approach to the vein. There is now evidence, however, that this traditional percutaneous subclavian approach predisposes the lead to crush injury between the clavicle and the first rib. At this point, the lead may become entrapped... 

Fig. 5.1 Pacemaker patient, anteroposterior chest X-ray. Two functional bipolar leads (atrial and ventricular) are connected to a device housed in a lower left subclavicular region there are also two abandoned, nonfunctional bipolar leads (both in the right ventricle). Note the three anatomically crucial lead extraction points A, the subclavicular region where the leads lie between the clavicle and the first rib B, the innominate-superior vena cava junction, noting lead angle at that level C, lead-tip position in the right ventricle...

The venous-entry-site approach can be troublesome and risky in presence of (1) tight space between clavicle and first rib (as in medial access to the intrathoracic subclavian vein) (2) tenacious adher-ences in some critical points, such as at the innominate vein-SVC junction, SVC-right atrium spring, right atrium, tricuspid valve, and right ventricle. 

Narrow space between clavicte and first rib Difficult sheath advancement Use oflargc sheaths often precluded Transjugular approach... 

Once again, it is important for the operator to be completely familiar with normal anatomy and superficial anatomic landmarks. The traditional subclavian puncture is carried out in the middle third of the clavicle. This location is frequently associated with an increased risk of vascular trauma, pneumothorax, and a lack of success. An alternate approach calls for the puncture at the apex of an angle formed by the clavicle and first rib (Fig. 4.11) (57). This location is remote from the apex of the lung, and the venous structure is generally much larger. 

The needle is inserted at an angle of 45 degrees parallel to the deltopectoral groove, l-2cm medial (Figs. 4.21 and 4.22).If the vein is not entered, fluoroscopy is then used to define the first rib. The needle is advanced and touches the first rib. Sequential needle punctures are walked laterally and posteriorly until the vein is entered. It should be noted that one cannot palpate the axillary artery pulse and, thus, it is not a reliable landmark. The axillary artery and brachial plexus are usually much deeper and more posterior structures. This simple technique using basic anatomic landmarks of the... 

Fig. 4.18 Byrd s technique for access of the extrathoracic portion of the subclavian vein. Sequential needle punctures are walked posterolaterally along the first rib until the vein is entered. (From Belott PH, Reynolds DW. Permanent pacemaker implantation. In EUenbogen KA, Kay N, Wilkoff BL, eds. Clinical cardiac pacing. Philadelphia WB Saunders, 1995, with permission.)...

Fig. 4.19 Deep (A) and superficial (B) anatomic relationships of the Magney approach to subclavian vena puncture. Point M indicates the medial end of the clavicle. X defines a point on the clavicle directly above the lateral edges of the clavicular/subclavius muscle (tendon complex). Rl. Point D overlies the center of the subclavian vein as it crosses the first rib. St, the center of the sternal angle Cp, coracoid process Ax, axillary vein star, costoclavicular ligament open circle with closed circle, costoclavicular ligament open circle with closed circle inside, costoclavicular ligament sm, subclavius muscle. The arrow points to Magney s ideal point for venous entry. (Magney JE, Staplin DH, Flynn DM, et al. A new approach to percutaneous subclavian venipuncture to avoid lead fracture or central venous catheter occlusion. Pacing Clin Electrophysiol 1993 16(11) 2133-2142, with permission.)...

Fig. 4.22 Axillary vein puncture and its relationship to surface landmarks as well as the first rib. (From Belott PH. Unusual access sites for permanent cardiac pacing. In Barold SS, Mugica J, eds. Recent advances in cardiac pacing goals for the 21st century. Armonk, NY Futura Publishing, 1997, with permission.)...

Fig. 4.24 Doppler location of the axillary vein crossing the first rib. AV, axillary vein CCL, costo-clavicular ligament CL, clavicle P, Doppler probe Rl, first rib R2, second rib SCM, subclavius muscle SCV, subclavian vein. (From Fyfce FE. Doppler guided extralboracic introducer insertion. Pacing Cbn Electrophysiol 1995 18 (5Pt 1) 1017-1021, with permission.)...

Venous access. In adnlt pacemaker practice, it is common to obtain a cut-down on the cephalic vein that will accommodate one or two leads. However, in children, becanse of the size of the vein, this is less likely. Still, the cephalic approach is preferable to the snbclavian approach, when available, as it completely avoids the complication of subclavian crush injury to the lead (39,40). Subclavian crnsh injnry resnlts from entrapment of the lead between the clavicle and the first rib, where it is subject to great stress with patient movement. 

Fig. 19.11 A cone-down view of two leads passing between the inferior margin of the clavicle and the first rib. An x-ray obtained at 6 months postimplant demonstrated totally intact leads. The patient presented at 18 months postimplant with oversensing and a very low telemetered lead impedance (< 250 Q) consistent with a breach of the internal insulation of the coaxial bipolar lead. While the insulation is radiolucent, there is a deformity of the conductor coil which is seen best on the view on the right. The lead was subsequently replaced and was able to be extracted. The deformity identified on the chest x-ray corresponded to a visible deformity on the explanted lead and the manufacturer confirmed this to the location of the insulation failure between the proximal and distal conductor coils.

Lidocaine has a rapid onset of action of 5-7 minutes, but can even approach 3 minutes depending on added adjuvants such as sodium bicarbonate, the volume and concentration of drug injected, and the site of peripheral nerve blockade. Alkalinization of the drug to a pH closer to its pKa to increase the nonionized fraction, higher concentration such as 2%, larger volume, and the nerve sheath lying within a confined space (such as the supraclavicular brachial plexus which passes between the clavicle and first rib) all help to speed the local anesthetic saturation of Na+ channels and thus onset of action [2,3]. 

As with pacemaker leads, the leads of an ICD system can fracture at the first rib and clavicle due to crush injury between the two bones, especially when inserted by a subclavian vein puncture, in my experience. 

The axillary vein can be accessed lateral to the junction of the first rib and clavicle. The cephalic vein can be accessed by a "cut-down" approach in the delto-pectoral groove. Some physicians believe both of these avenues of venous entry may be less likely to fracture due to trauma between the first rib and clavicle. 

The heads of the second through twelfth ribs articulate with the bodies of the corresponding vertebrae and the one above, as well as with the corresponding intervertebral disk. However, the first rib articulates only with the superior aspect ofTl. The costovertebral articulation is a synovial joint, with a joint capsule that is strengthened by the radiate ligament (see Costovertebral Ligaments). 

The first, second, tenth, eleventh, and twelfth ribs are considered atypical ribs. The first rib is flat, has the greatest curvature and the shortest length of all the ribs, and has no angle or costal groove. Its superior surface has grooves for passage of the subclavian vessels and elevations for the attachment of the anterior and middle scalene muscles. The single facet of the head articulates with the body of the T1 vertebra. 

The clavicle is located at the anterosuperior aspect of the thoracic cage. Its medial end articulates with the manubrium and the cartilage of the first rib. Even though the clavicle and its component joints are considered a part of the shoulder in function, it is important during respiration. As the occiput can be considered C., the clavicle can be thought of as Rib,. It must remain mobile during each phase of respiration for the rib cage, especially the first rib. to function properly. 

The first rib is unlike the other ribs because of its attachments to the scalene muscles and its functional relationship to the clavicle. It is customarily palpated at three sites ... 

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