Quadrilateral Space Syndrome Research Articles

A rare case of acute traumatic complicated right axillary artery pseudoaneurysm with quadrangular space syndrome

Axillary artery pseudoaneurysms are relatively rare, with few reported cases found in the literature. There have been high rates of rupture and compression-related complications in trauma-related pseudoaneurysms of the upper limb. Prompt diagnosis with non-invasive imaging modalities such as ultrasound, magnetic resonance imaging, and computed tomography. Angiography is required for immediate intervention and prevention of complications. Here, we present a case of an extremely rare right-sided acute traumatic axillary artery pseudoaneurysm with compression, resulting in quadrangular space syndrome in a 31-year-old male patient. We performed a critical literature review of the same and identified only a few previously reported cases.

Bilateral Long Head of the Triceps Brachii Muscle Innervation via Axillary Nerve: A Case Report

The radial nerve has traditionally been considered the innervation of the long head of the triceps brachii (LHT). However, cadaveric studies have discovered LHT innervation via the axillary nerve in roughly 6-15 % of shoulders. A cadaver with exclusive axillary nerve innervation to the LHT bilaterally was discovered during cadaveric dissection in a graduate course at Samford University. This anatomical variation may have clinical implications for surgeries, shoulder dislocations, and quadrilateral space syndrome. Axillary nerve injuries may additionally present with shoulder extension and elbow extension weakness if this variation is present.

Quadrangular Space Syndrome: a systematic review of surgical and medical therapeutic advances.

The axillary nerve and posterior circumflex humeral artery are compressed in Quadrangular Space Syndrome (QSS), which can be treated with conservative approaches or surgical decompression in recalcitrant instances. There are no clear guidelines for determining which surgical method is optimal for treating QSS and other disorders that mirror QSS. The goal of this study is to grade and review past, current, and planned medicinal and surgical care modalities for QSS. The review protocol is registered with PROSPERO (ID: CRD42022332766). To identify recent advances in the methods/techniques of medical and surgical management of QSS, PubMed and Medline databases were searched until March 2022 for publications, including case studies, case reports, and review articles, using medical subject headings terms like quadrilateral space syndrome, surgical management, and medical management. Throughout the study, all the authors scrupulously followed a well-developed registered review process and the risk of bias in systematic reviews guidance tool. Data on proposed medical and surgical management methods/techniques were compiled, and each was analyzed based on the underlying neuro-vascular systems. There were 88 items found in the first search. Following applying the inclusion and exclusion criteria, 16 papers were chosen for synthesis in the review study after a thorough assessment. Three studies (conservative and advanced) focused on medical care of QSS, while 12 articles (prior, current, and newer) focused on surgical management of QSS. Only four of the 15 studies reviewed proposed different surgical approaches/techniques for surgical decompression in QSS. There were two regularly used surgical procedures discovered, one anterior/delto-pectoral and the other posterior/ scapular. The anterior route is more technically straightforward and can be employed for surgical QSS decompression.

The Posterior Circumflex Humeral Artery with Variant Origin and Course

The posterior circumflex humeral artery (PCHA) typically emanates from the axillary artery (AxA) that supplies the shoulder region and surrounding structure. During routine dissection, we noticed that a truncus profundocircumflexus arose as a branch of Brachial Artery distal to teres major (TM), which branches into profunda brachii, besides PCHA. This circumflex humeral artery, winding around the TM muscle, coursed superolaterally and reached the quadrangular space for its usual vascular territory. Adequate awareness of such rare variations observed in the present study is pertinent for physicians for quadrangular space syndrome, radiologists to avert misreading of angiographs, and orthopedics in case of trauma to the axilla, shoulder region, and upper arm or during invasive vascular procedures.

Quadrangular Space Decompression

Background: The quadrangular (or quadrilateral) space is defined by its anatomical borders and is the passageway for the axillary nerve and posterior circumflex humeral artery (PCHA). Quadrangular space syndrome (QSS) can present due to various compressive pathologies but is commonly seen in overhead athletes. Quadrangular space syndrome can present with neurogenic symptoms including pain and paresthesias, as well as vascular complications from compression of the PCHA including thrombosis, aneurysm formation, and distal emboli. Indications: Surgical decompression of the quadrangular space is indicated for severe neurogenic or vascular compromise in the case of QSS refractory to nonoperative treatment. Technique Description: After appropriate preoperative physical examination findings and trial of nonoperative treatment, including physical therapy and injections, surgical decompression was indicated. The posterior border of the deltoid was marked, and an incision centered over the posterior border of the deltoid lateral to the axillary fold was made. Posterior border of deltoid was identified and retracted, revealing the interval of the teres minor and major. The nerve to the teres minor was identified, protected, and fibrous bands compressing the nerve were released. The nerve to the teres minor was tracked deep to find the axillary nerve. This was identified and fibrous bands around the nerve were decompressed. The circumflex vessels were protected throughout. Following decompression of the nerves, there was free movement of the nerves indicating adequate surgical decompression. Results: Adequate surgical decompression of the axillary nerve and PCHA achieved with resolution of neurogenic symptoms of pain and paresthesias at first postoperative visit. Discussion/Conclusion: Quadrangular space syndrome is a rare disorder, can be difficult to diagnose, and is the cause of significant morbidity, particularly in overhead athletes. If symptoms persist after nonoperative treatment, operative decompression of the quadrangular space may be indicated. Adequate surgical decompression results in relief of neurogenic and vascular symptoms.

Revisiting the Surgical Approaches to Decompression in Quadrilateral Space Syndrome: A Cadaveric Study.

BackgroundQuadrangular space syndrome involves compression of the axillary nerve and posterior circumflex humeral artery. In a few cases, its management requires surgical decompression. The current study reviews the surgical approaches used in the decompression of neurovascular structures and presents our reflections and recommendations.MethodologyIn this study, four human cadavers were used for dissection of the axillae and the scapular region by the senior residents of the Department of Anatomy and Department of Orthopedics. The residents dissected the quadrangular space in the eight upper limbs using anterior and posterior surgical approaches.ResultsTo identify the quadrangular space and secure its contents, the posterior approach was recognized as the easier and quicker method by both Anatomy and Orthopedic residents; however, it may result in increased postoperative morbidity. Although the anterior (deltopectoral) approach involves more skill, it reduces postoperative morbidity.ConclusionsThe anterior (deltopectoral) approach with suggested modifications can be an effective method in the surgical decompression of quadrangular space syndrome. The authors suggest more cadaveric studies to provide anatomists and surgeons with the opportunity to practice and evaluate older and newer surgical approaches.

呼吸器外科手術後の稀な合併症：四辺形間隙症候群が原因と考えられた腋窩神経麻痺の一例

呼吸器外科手術後の稀な合併症：四辺形間隙症候群が原因と考えられた腋窩神経麻痺の一例

Quadrilateral space syndrome.

The quadrilateral space is a confined area through which the axillary nerve and posterior circumflex humeral artery (PCHA) travel in the shoulder. Both structures are susceptible to impingement and compression as they travel though this space resulting in a constellation of symptoms known as quadrilateral space syndrome (QSS). Patients may experience paresthesias, loss of motor function, pain and vascular complications. Individuals who perform repetitive overhead arm movements such as elite athletes are at greater risk of developing QSS. The diagnosis can be difficult, but in the setting of clinical suspicion, physical exam and imaging studies can provide specific findings. On MRI, patients may have atrophy of the deltoid or teres minor muscles and angiography may show aneurysm or vascular occlusion of the PCHA. Treatment is initially conservative, with physiotherapy. Surgical decompression is effective in patients with severe or progressive symptoms. Causes of external compression such as fibrous bands, scarring, or other space occupying lesion may be addressed at that time. Neurolysis and aneurysm resection may also be performed. In some cases, emboli from the PCHA can cause ischemia in the involved upper extremity resulting in an acute presentation. Catheter directed therapy such as thrombolysis or thrombectomy may performed emergently in these cases. Though rare, in patients presenting with arm weakness, paresthesia, pain and/or arterial thrombosis in the arm, QSS is an important entity to consider.

Shoulder Weakness- Basketball And Weight Lifting

HISTORY: A 32-year-old left handed male with history of two left shoulder dislocations in 2011, managed conservatively, presented to the outpatient sports medicine clinic for evaluation of acute left shoulder weakness. Four days prior he was playing basketball and noted consistently short shots with air balls despite adjustments. Thereafter, he noted left shoulder instability and unsteadiness with front to side lateral shoulder raises, overhead lifting program, and difficulty tightening his belt. The 2-3 months prior he had noted mild dull, achy pain over his left posterolateral shoulder mainly with shoulder presses and running 2-3 miles. PHYSICAL EXAMINATION: Exam demonstrated normal cervical spine range of motion and palpation. Reflexes, sensation, and strength of bilateral upper extremities were normal except for 4-/5 external rotation strength on the left. Bilateral shoulder range of motion was normal. On the left, O’Brien’s, Hawkins, and load and shift were positive. DIFFERENTIAL DIAGNOSIS: . Shoulder labral tear2. Rotator cuff tear3. Brachial neuritis 4. Cervical radiculopathy TESTS AND RESULTS:Left shoulder US:-Glenohumeral joint effusion-Posterior labral tear-Prominent spinoglenoid notch paralabral cyst Left Shoulder MRI:-Posteroinferior glenoid labral tear -Two paralabral cysts. Largest extending into spinoglenoid notch abutting the suprascapular neurovascular bundle, but no supraspinatus or infraspinatus atrophy or edema-Diffuse teres minor muscle edema, which could reflect traction of terminal axillary nerve muscular branch to teres minorLeft upper extremity EMG/NCS-Nerve conduction studies were normal-Needle EMG of deltoid, triceps, biceps, FDI, FCR, and infraspinatus were normal. Teres minor showed evidence of axonal injury, no active denervation, and likely early neurogenic reinnervation. FINAL/WORKING DIAGNOSIS: Neurogenic quadrilateral space syndrome with axillary nerve injury and reinnervation TREATMENT AND OUTCOMES: 1. Meloxicam 15 mg daily for seven days 2. US guided spinoglenoid notch cyst aspiration and steroid injection (done prior to EMG/NCS) 3. Paused upper body weight lifting and running for 1 month 4. Initiated posterior capsule stretching and external rotation strengthening program with improved strength and pain

Feasibility of arthroscopic decompression of the axillary nerve in the quadrilateral space: Cadaver study

IntroductionAxillary nerve compression is a rare, but disabling condition. The three main causes are quadrilateral space syndrome among young athletes, compression due to an inferior glenohumeral osteophyte in early osteoarthritis and isolated teres minor atrophy secondary to triceps hypertrophy. The diagnosis is clinical, but may be reinforced by an electromyogram or corticosteroid injection. The usual surgical treatment is open nerve decompression using a posterior approach. Arthroscopy is a less invasive approach that should be useful in theory. HypothesisArthroscopic decompression of the axillary nerve is safe and less invasive than open techniques. Material and methodsArthroscopic nerve decompression was performed as described by PJ Millet and TR Gaskill on 10 shoulders from 6 frozen cadavers. An open posterior approach was then made to verify the effectiveness of the nerve decompression. ResultsThe axillary nerve and its branches, the circumflex artery and the triceps were always sufficiently released in the space below the joint capsule. When the joints were subsequently opened by a posterior approach, complete nerve decompression was confirmed in all cases with no iatrogenic lesions. DiscussionThe good results of this study are encouraging, but should be supplemented with a comparative study in patients of open versus arthroscopic axillary nerve release. ConclusionWe think this arthroscopic technique is a good option for treating axillary nerve compressions. The complication risk is expected to be low. Level of evidenceIV.

Bilateral Upper Extremity Weakness in a Wrestler

HISTORY: A19-year-old male college Wrestler with a history of right labral repair presented with 4-month insidious 10/10 neck pain and band-like pain over his shoulders. In the last month he developed bilateral dorsal hand paresthesias with shoulder fatigue while wrestling. After a month off, symptoms would emerge after 2.5 minutes of wrestling and progressively longer. No illness, increase in activity, color changes, temperature differences, loss of dexterity. PHYSICAL EXAMINATION: General: Well-developed male Skin: No rashes or lesions Vascular: Normal pulse and capillary refill Neuromuscular: Normal muscle bulk and tone. Normal range of motion, strength, deep tendon reflexes, and sensation to light touch and pinprick in the bilateral upper extremities. Positive Tromner reflex bilaterally, otherwise negative special testing of the cervical spine, shoulder, scapula, and neurovascular bundle. DIFFERENTIAL DIAGNOSIS: 1. Cervical Radiculopathy 2. Transient quadriplegia 3. Suprascapular or Axillary Mononeuropathy 4. Brachial Plexopathy 5. Thoracic Outlet Syndrome 6. Myopathy 7. Quadrilateral Space Syndrome 8. Spinal cord injury 9. Cervical facet pathology TEST AND RESULTS: Cervical MRI identified absent right C5 pedicle with no spinal cord signal abnormality. C5 and C6 spinal nerve roots were separate with no dural extension Cervical CT showed no fracture of the right C5 pedicle; likely congenital absence. Anterior and posterior columns were normal Cervical radiographs revealed no dynamic instability Bilateral upper extremity electrodiagnostics were normal with no axillary or suprascapular mononeuropathy, upper trunk plexopathy, or radiculopathy. FINAL WORKING DIAGNOSIS: Congenital absent right C5 pedicle with C6 subluxation TREATMENT AND OUTCOMES: 1. Neurosurgical consultation which confirmed spinal stability with no restriction on sporting activities 2. Progressed from limited sporting activities including aerobic activities without upper body utilization and non-Olympic lower body weight lifting without barbell utilization, to stabilization exercises aimed at cervical musculature, trapezius, deltoids, and rhomboids. 3. Return to sport in process, focusing on Folk style wrestling given less submission and upper extremity rapid force transmission.

Origin of radial collateral artery from the posterior circumflex humeral artery in the quadrangular space of the shoulder region – an abnormality which could enhance the complications of quadrangular space syndrome

Origin of radial collateral artery from the posterior circumflex humeral artery in the quadrangular space of the shoulder region – an abnormality which could enhance the complications of quadrangular space syndrome

Quadrilateral Space Syndrome: Diagnosis and Clinical Management.

Quadrilateral space syndrome (QSS) is a rare disorder characterized by axillary nerve and posterior humeral circumflex artery (PHCA) compression within the quadrilateral space. Impingement is most frequently due to trauma, fibrous bands, or hypertrophy of one of the muscular borders. Diagnosis can be complicated by the presence of concurrent traumatic injuries, particularly in athletes. Since many other conditions can mimic QSS, it is often a diagnosis of exclusion. Conservative treatment is often first trialed, including physical exercise modification, physical therapy, and therapeutic massage. In patients unrelieved by conservative measures, surgical decompression of the quadrilateral space may be indicated.

Challenges in Rating Multiple Upper Extremity Conditions: A Case of Quadrilateral Space Syndrome and Medial Elbow Injury

Abstract Physicians sometimes are challenged with clinical presentations that do not fit perfectly within the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides); in such cases, the evaluator is instructed to apply clinical judgment and common sense when determining an impairment, with particular consideration of the effect of the medical condition on the individual's activities of daily living. In this case presentation, a 35-year-old male private security guard injured his right elbow performing a bench press while on assignment. After magnetic resonance imaging and electrodiagnostic evaluation, the patient underwent surgery that included a medial elbow Nirschl procedure and an ulnar nerve submuscular transposition. The patient underwent twelve months of rehabilitation, but he continues to experience a pins-and-needles sensation and perceives upper arm strength loss. Twenty-four months after surgery, the patient declines surgical treatment for quadrilateral space syndrome and presents for an impairment rating evaluation. Accepted medical conditions under the workers’ compensation program include quadrilateral space syndrome, medial epicondylopathy, and ulnar nerve entrapment at the elbow (cubital tunnel syndrome). The AMA Guides, Sixth Edition, does not include a listing for quadrilateral space syndrome, and the author discusses the challenges of teasing out functional limitations when multiple diagnoses are present within the same limb. Evaluators should note that the AMA Guides recommends using the impairment rating that most closely represents the actual functional loss.

Vascular Quadrilateral Space Syndrome in Three Overhead Throwing Athletes: An Underdiagnosed Cause of Digital Ischemia

Vascular quadrilateral space syndrome (vQSS) is an underdiagnosed cause of extremity ischemia, pain and paresthesia in overhand throwing athletes (football throwing, volleyball, baseball).

Les atteintes du nerf axillaire en pathologie du sport

The quadrilateral space syndrome described in 1983 is rare and difficult to recognize. Occurring in young athletes, this shoulder syndrome starts with poorly localized pain associated with poorly defined paresthesia. The symptoms are aggravated by abduction and external rotation of the upper limb. The physical examination provides little information other than a painful quadrilateral space at palpation. The standard x-ray is normal. MRI is the gold standard for a clinically suspected syndrome. The diagnosis is confirmed by EMG that shows signs of axillary neuropathy affecting the deltoid and teres minor muscles. A perfectly normal EMG does not however exclude the diagnosis. Conservative treatment is the rule: adapted movements and analytical rehabilitation. Surgery may be necessary to free an entrapped nerve.

The shoulder.

The shoulder.

Ultrasound-guided quadrilateral space block for the diagnosis of quadrilateral syndrome.

Quadrilateral space syndrome (QSS) is a rare nerve entrapment disorder that occurs when the axillary nerve and posterior circumflex humeral artery (PCHA) become compressed in the quadrilateral space. QSS presents as vague posterolateral shoulder pain that is exacerbated upon the abduction and external rotation of the shoulder. Diagnosis of QSS is difficult because of the vague presentation of QSS. In addition, even though MRI and MR angiography can be used in QSS diagnosis, there is currently no “gold standard” diagnostic imaging studies for QSS. In this case report, we describe a novel ultrasound-guided technique for a diagnostic quadrilateral space block and present a case where the diagnostic block was used to diagnose QSS. We believe that a diagnostic block of the quadrilateral space is a useful adjunct in the evaluation of patients with suspected QSS, especially in cases where examination findings and other diagnostic modalities are indeterminate.

Poster 250 Pain Relief for Plantar Fasciitis after Hydrodissection of Plantar Fascia from Pseudofascia: A Case Report

Disclosures: T. P. DeWald, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: A right-hand-dominant 23-year-old male swimmer presented with persistent right shoulder pain, numbness, and paresthesia with radiation down the medial aspect of the right upper extremity. Patient stated that symptoms started gradually over a week and would only present during distances over 1,000 meters. Symptoms resolved when the athlete ceased activity. Setting: University Sports Medicine Clinic. Results or Clinical Course: Patient was treated conservatively with observation. Patient demonstrated normal physical examination. However, patient’s symptoms were reproduced with his right arm fully abducted and externally rotated and equivocal Adson’s test. Venous and arterial ultrasounds of the right upper extremity were obtained with no evidence of vessel obstruction. IR angiogram was then performed and did not show venous or arterial thoracic outlet syndrome. However, during provocative maneuver of extreme abduction and external rotation patient exhibited compression of the bilateral axillary arteries and circumflex humeral arteries. MRI of the right shoulder was negative for fat atrophy of teres minor and infraspinatus mucles. Electrodiagnostic studies did not demonstrate abnormalities in the axillary, ulnar, or median nerves with normal EMG of corresponding muscles. Patient resumed activity and continued to swim competitively with modification in training duration and regimen, demonstrating improvement in symptoms. The athlete will be evaluated for possible surgical decompression in the offseason. Discussion: Quadrilateral space syndrome is a rare condition arising from the compression of the axillary nerve and posterior circumflex humeral artery within the quadrilateral space. Ours is a unique case in which an athlete is demonstrating transient, ischemic quadrilateral space syndrome after long distance swimming. Muscle hypertrophy or fibrotic band formation have been implicated in pathology. Surgical decompression has proven to be successful in alleviating symptoms. Conclusions: Quadrilateral space syndrome should be considered as a differential diagnosis in young athletes with persistent shoulder pain and neuromuscular compromise as it can be missed.

Poster 249 Quadrilateral Space Syndrome in a Collegiate Male Swimmer: A Case Report

PM&RVolume 6, Issue 9S p. S272-S272 Friday Poster Presentations - Poster Hall Poster 249 Quadrilateral Space Syndrome in a Collegiate Male Swimmer: A Case Report Tad P. DeWald MD, MPH, Tad P. DeWald MD, MPH Wayne State University- Oakwood, Taylor, MI, United StatesSearch for more papers by this authorGeraldine Dapul MD, Geraldine Dapul MD Wayne State University- Oakwood, Taylor, MI, United StatesSearch for more papers by this authorPaul Withers MD, Paul Withers MD Wayne State University- Oakwood, Taylor, MI, United StatesSearch for more papers by this authorAashish Deshpande MD, Aashish Deshpande MD Wayne State University- Oakwood, Taylor, MI, United StatesSearch for more papers by this authorParmod Mukhi MD, Parmod Mukhi MD Wayne State University- Oakwood, Taylor, MI, United StatesSearch for more papers by this author Tad P. DeWald MD, MPH, Tad P. DeWald MD, MPH Wayne State University- Oakwood, Taylor, MI, United StatesSearch for more papers by this authorGeraldine Dapul MD, Geraldine Dapul MD Wayne State University- Oakwood, Taylor, MI, United StatesSearch for more papers by this authorPaul Withers MD, Paul Withers MD Wayne State University- Oakwood, Taylor, MI, United StatesSearch for more papers by this authorAashish Deshpande MD, Aashish Deshpande MD Wayne State University- Oakwood, Taylor, MI, United StatesSearch for more papers by this authorParmod Mukhi MD, Parmod Mukhi MD Wayne State University- Oakwood, Taylor, MI, United StatesSearch for more papers by this author First published: 29 September 2014 https://doi.org/10.1016/j.pmrj.2014.08.636Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume6, Issue9SSeptember 2014Pages S272-S272 RelatedInformation