Quadrilateral Space Research Articles

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.

Arthroscopic Axillary Nerve Neurolysis From the Anteroinferior Glenoid Through the Quadrilateral Space to the Terminal Deltoid Branches

Axillary nerve compression is a rare cause of posterolateral shoulder pain. Once the diagnosis is confirmed and after failure of conservative measures, open procedures have been the mainstay of treatment for several decades. More recently, arthroscopic techniques have been proposed, which offer several advantages, including improved access to difficult locations, better visualization, and less surgical morbidity. The objective of this Technical Note is to describe an arthroscopic neurolysis of the axillary nerve from the inferior humeral pouch, through the quadrilateral space and into the subdeltoid recess.

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.

Iyengar-Botchu (IB) confluence of the medial knee- anatomy and clinico-radiological review

The Iyengar-Botchu confluence is a quadrilateral space on the medial side of the knee. Due to the presence of unique anatomical structures, this region is prone to injuries. The aim of this pictorial review is to illustrate an anatomical description of the structures, which form the IB complex confluence. Clinico-pathological correlation of common conditions associated with these structures will increase awareness of injuries in this area. A complementary imaging guidance will support clinical diagnosis and appropriate patient management.

Examining vocal attractiveness through articulatory working space.

Robust gender differences exist in the acoustic correlates of clearly articulated speech, with females, on average, producing speech that is acoustically and phonetically more distinct than that of males. This study investigates the relationship between several acoustic correlates of clear speech and subjective ratings of vocal attractiveness. Talkers were recorded producing vowels in /bVd/ context and sentences containing the four corner vowels. Multiple measures of working vowel space were computed from continuously sampled formant trajectories and were combined with measures of speech timing known to co-vary with clear articulation. Partial least squares regression (PLS-R) modeling was used to predict ratings of vocal attractiveness for male and female talkers based on the acoustic measures. PLS components that loaded on size and shape measures of working vowel space-including the quadrilateral vowel space area, convex hull area, and bivariate spread of formants-along with measures of speech timing were highly successful at predicting attractiveness in female talkers producing /bVd/ words. These findings are consistent with a number of hypotheses regarding human attractiveness judgments, including the role of sexual dimorphism in mate selection, the significance of traits signalling underlying health, and perceptual fluency accounts of preferences.

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

MODELLING AND DYNAMIC ANALYSIS OF THREE-DIRECTION GRID PRESTRESSED RETICULATED MEGA-STRUCTURE


 
 
 In this paper, the generation way of three-direction grid prestressed reticulated mega- structure is studied, and the three-direction grid prestressed reticulated mega-structure composite joint specific formation ideas are proposed. The important control parameters of three-direction grid prestressed reticulated mega-structure are determined, and the geometric modelling method of hexagon across the middle joint and octagon across the side joint is proposed. Coordinate formula of hexagonal and octagonal joints are derived to ensure reasonable grid arrangement and uniform stress distribution of the structure. Combined with the geometric parameters of the mega grid, a new method for creating the geometric model of three-direction grid prestressed mega reticulated structure is realized. The quadrangular pyramid space grid structure with the same length, span, rise and grid size and the three-direction grid prestressed grid structure are calculated, and the advantages of three-direction grid prestressed grid structure in dynamic performance are compared and analyzed.
 
 

Axillary nerve schwannoma at the quadrilateral space of Velpeau

Axillary nerve schwannoma at the quadrilateral space of Velpeau

A unique lpsilateral axillary artery variation

In an 87-year-old male cadaver received through the Gift Body Program at Saint Louis University School of Medicine, a common arterial trunk arose from the third part of the left axillary artery (AA) that divided into the subscapular artery (SA) and a common stem for the deep brachial artery (DBA), the anterior humeral circumflex artery (AHCA), and the posterior humeral circumflex artery (PHCA). Both the SA and AHCA appeared normal. The PHCA traveled through the quadrangular space and gave off the radial collateral artery (RCA) in the posterior arm which anastomosed with the radial recurrent artery. The DBA traveled through the triangular interval and continued as the middle collateral artery (MCA) in the posterior arm to anastomose with the interosseous recurrent artery. Lastly, the medial and lateral cord contributions to the median nerve formed posteriorly to the AA. Knowing anatomical variation of the AA has clinical and embryological significance.

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.

Characterization and implications of the lingual process of the sphenoid bone: a cadaveric and radiographic study.

The surgical significance of the lingual process of the sphenoid bone (LPSB) has not been sufficiently addressed. The purpose of this study was to describe the anatomical details of the LPSB in relation to the quadrangular space. Moreover, the incidence of the LPSB and its correlation with the pneumatization of the sphenoid sinus and the development of the lateral recess of the sphenoid sinus (LRSS) were also evaluated. A dissection and exposure of the LPSB and the quadrangular space was performed on 10 cadaveric specimens (20 sides). The incidence, length, and height of the LPSB were also assessed on computed tomography (CT) images (60 patients, 120 sides). The association between the presence of the LPSB with the pneumatization type of the sphenoid sinus and the presence of a LRSS was evaluated. In a cadaveric model, the LPSB, in association with the petrolingual ligament extending from the LPSB to the petrous apex, was identified on 7 sides (35%). The LPSB was continuous with the mandibular strut. The overall incidence of a LPSB was 48.33% on CT images, and the average length and height of the LPSB was (mean ± standard deviation) 5.30 ± 1.44 mm and 6.51 ± 1.32 mm, respectively. A significant correlation was identified between presence of the LPSB with the pneumatization type of the sphenoid sinus (p = 0.004) but no correlation was identified with the presence of the LRSS (p = 0.071). The LPSB and the petrolingual ligament are useful landmarks for procedures in the quadrangular space and Meckel's cave. However, the LPSB is not consistently present.

Anarthria caused by a Lesion in the Quadrilateral Space of Pierre Marie (2273)

Anarthria caused by a Lesion in the Quadrilateral Space of Pierre Marie (2273)

Correlations between swallowing function and acoustic vowel space in stroke patients with dysarthria.

Dysphagia and dysarthria tend to coexist in stroke patients. Dysphagia can reduce patients' quality of life, cause aspiration pneumonia and increased mortality. To evaluate correlations among swallowing function parameters and acoustic vowel space values in patients with stroke. Data from stroke patients with dysarthria and dysphagia were collected. The formant parameter representing the resonance frequency of the vocal tract as a two-dimensional coordinate point was measured for the /a/, /ae/, /i/, and /u/vowels, and the quadrilateral vowel space area (VSA) and formant centralization ratio (FCR) were measured. Swallowing function was evaluated by a videofluoroscopic swallowing study (VFSS) using the videofluoroscopic dysphagia scale (VDS) and penetration aspiration scale (PAS). Pearson's correlation and linear regression analyses were used to assess the correlation of VSA and FCR to VDS and PAS scores. Thirty-one stroke patients with dysphagia and dysarthria were analyzed. VSA showed a negative correlation to VDS and PAS scores, while FCR showed a positive correlation to VDS score, but not to PAS score. VSA and FCR were significant factors for assessing dysphagia severity. VSA and FCR values were correlated with swallowing function and may be helpful in predicting dysphagia severity associated with stroke.

The relationship between vowel space area and intelligibility of speech in children with velopharyngeal insufficiency

Speech of individuals with velopharyngeal insufficiency is characterized by nasalized vowels. It is well known that velopharyngeal coupling significantly alters the acoustic spectrum of vowels. Aside from changes in formant amplitude and bandwidth, formant frequencies may be modified. Centralized F1 and lowered F2 due to effects of nasalization could change the dimensions of the quadrilateral space. Such variations might cause the vowel space area to be compressed which might contribute to speech unintelligibility. In pursuing research on speech intelligibility in cleft palate, this study was conducted to address the relation between speech intelligibility and spectral characteristics of American English vowels in nasal speech. The hypotheses is that narrower vowel space will result in higher degrees of unintelligibility. Ten children aged 4-12 years with different degrees of hypernasality repeated words with four corner vowels. F1 and F2 midpoint frequencies were measured, and vowel space areas were calculated using the formula for an irregular quadrilateral. In order to determine intelligibility, seventy naive listeners were asked to orthographically transcribe the sentences produced by the participants. Correlational analysis were used to determine the relationship between the vowel space and intelligibility deficits. Further results will be discussed in the meeting.

Analysis of two low-order equal-order finite element pairs for Stokes equations over quadrilaterals

Two quadrilateral low-order equal-order finite element schemes are analyzed for Stokes equations. Both of these schemes adopt the quadrilateral P1-nonconforming finite element to approximate the pressure over a coarser mesh. The velocity spaces are constructed over a finer mesh, where the standard Q1-conforming element space and the quadrilateral P1-nonconforming element space are selected, respectively. The stability assertion is given for each pair. Moreover, the superconvergence property of the pressure is obtained over uniform rectangular meshes. All the analyses above are verified by numerical tests.

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.

Ultrasonography-guided anterior approach for axillary nerve blockade: An anatomical study.

Combined ultrasound (US)-guided blockade of the suprascapular and axillary nerves (ANs) has been proposed as an alternative to interscalene blockade for pain control in shoulder joint pathology or postsurgical care. This technique could help avoid respiratory complications and/or almost total upper limb palsy. Nowadays, the AN blockade is mostly performed using an in-plane caudal-to-cephalic approach from the posterior surface of the shoulder, reaching the nerve immediately after it exits the neurovascular quadrangular space (part of the spatium axillare). Despite precluding most respiratory complications, this approach has not made postsurgical pain relief any better than an interscalene blockade, probably because articular branches of the AN are not blocked.Cephalic-to-caudal methylene blue injections were placed in the first segment of the AN of six Thiel-embalmed cadavers using an US-guided anterior approach in order to compare the distribution with that produced by a posterior approach to the contralateral AN in the same cadaver. Another 21 formalin-fixed cadavers were bilaterally dissected to identify the articular branches of the AN.We found a good spread of the dye on the AN and a constant relationship of this nerve with the subscapularis muscle. The dye reached the musculocutaneous nerve, which also contributes to shoulder joint innervation. We describe the anatomical landmarks for an ultrasonography-guided anterior AN blockade and hypothesize that this anterior approach will provide better pain control than the posterior approach owing to complete blocking of the joint nerve. Clin. Anat. 33:488-499, 2020. © 2019 Wiley Periodicals, Inc.

Multiple Variations in Third Segment of Axillary Artery

Variations in the subscapular artery (SA) have been well documented and acknowledged as the most common variation in the axillary artery (AA). Although this is true, a variation of the third portion of the AA was found during dissection of the right upper limb of a female cadaver. This portion of the AA was found to give rise to a proximal SA, followed by a common trunk with 4 ramifications and distally, to the anterior circumflex humeral a. The common trunk gave rise to a second SA, posterior circumflex humeral a., scapular circumflex a., and the thoracodorsal a. Both SA branches were found to be irrigating the subscapularis m., implicating a possible dual and collateral supply. The posterior circumflex humeral a. was identified as it traversed posteriorly to reach the surgical neck of the humerus along with the axillary n. through the quadrangular space. The scapular circumflex a. was identified as it passed backward around the lower border of the scapula into the triangular space. Finally, the thoracodorsal a. gave off a branch to the latissimus dorsi m. and continued its course along the lateral thoracic wall to give off multiple branches to the serratus anterior m. It appears that the thoracodorsal branch reaching the serratus anterior m. is its main source of blood supply since the lateral thoracic a. was not found arising from the AA at any point. These findings are different from what is commonly documented. Usually, the AA is divided into three segments based on its relationship with the pectoralis minor m. The second portion of the AA gives rise to the thoracoacromial a., just posterior to the medial superior margin of the pectoralis m., and to the lateral thoracic a., passing downward behind the pectoralis minor m. along its inferolateral border. The third portion of the AA, which lies on the subscapularis m. and teres major m., gives rise to the anterior circumflex humeral a., the posterior circumflex humeral a., and the SA. The SA is commonly the largest branch of the AA, it runs downward on the costal surface of the subscapularis m. before it divides into the scapular circumflex a. and the thoracodorsal a. These arteries provide the major blood supply to the posterior wall of the axilla. Acknowledging the possibility of a variation from normal anatomy is relevant when interpreting imaging studies such as angiographs or during axillary surgical preparation due to possible pressure on the brachial plexus and vessels of the axilla when there is downward displacement of the head of the humerus. The suitability of the SA system as a donor for arterial grafts during upper limb circulation restoration is of great clinical importance. Their angle of rotation and their large, stable diameter render these arteries appropriate for a variety of flaps in plastic surgery. These clinical correlations can be further studied by exploring the embryology of these arteries. Normally, the subclavian a. arises from the 4th aortic arch and the 7th intersegmental a. It continues to develop as the limb bud grows; therefore, since the variations observed occur past the subclavian a., it seems that the vascular plexus was affected during development of the upper limb bud. Knowing this will help guide surgeons when exposed to such variations if a malformation during fetal limb development is suspected.This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Unsteady Natural Convection in a Differentially Heated Rectangular Enclosure Possessing Sinusoidal Corrugated Side Walls Loaded with Power Law Non-Newtonian Fluid

This research is a numerical analysis exhaustively investigating two-dimensional (2D) transient convective heat transfer in a differentially heated rectangle, possessing sinusoidal corrugated side walls at constant temperatures. The quadrilateral space is filled with a power-law non-Newtonian fluid, plus the right and left walls are uniformly cooled and heated, respectively. The top and bottom walls are retained as adiabatic and the side walls are recast exploiting sinusoidal corrugated shape. The governing equations of the problem are solved using the finite volume method. The evaluation of fluid flow and heat transfer is conducted in such a manner that the power law index n varies from 0.6 to 1.4, the Rayleigh number Ra from 103 to 107, the corrugation amplitude CA from 0.1 to 0.5, and the corrugation frequency CF of the sinusoidal side walls is in the range of 1 to 5. The results are studied at different values of Ra, n, CA, and CF; they are presented in the form of streamlines, isotherms, and average Nusselt numbers ( $$\overline{\rm{Nu}}$$ ) of the hot side wall. Further, the heat transfer characteristics are presented and the effect of sudden differential heating, as well as its consequential transient behavior, on the fluid flow, velocity, and temperature plots are demonstrated in accordance with the scope of the governing parameters.