| Introduction |
 Axillary nerve compression in the quadrilateral space (also known as quadrangular space) 
- atrophy/weakness of teres minor and deltoid
|
| Anatomy |
- Lateral to triangular space and medial to triangular interval
- Boundaries
- superior - subscapularis and teres minor
- inferior - teres major
- medial - long head of triceps brachii
- lateral - surgical neck of the humerus
- Contents
- axillary nerve
- posterior circumflex humeral artery
|
| Presentation |
- Presentation
- pain and paresthesias with overhead activity
- late cocking/acceleration phase of throwing
|
| Imaging |
- Radiographs
- recommended views
- findings
- MRI
- may show atrophy of teres minor (axillary innervation)
- may show inferior paralabral cyst associated with labral tear
- Arteriogram
- shows lesion in posterior humeral circumflex artery
|
| Treatment |
- Nonoperative
- rest, rotator cuff strengthening
- Operative
- nerve decompression
- indications
- only if extensive nonoperative management fails
|
|
Please Rate Educational Value!
|
3.0
t-3066
|
Average 3.0 of 11 Ratings
|
Qbank (3 Questions)
TAG
(OBQ10.233)
A 24-year-old patient complains of vague right shoulder pain. On physical exam the patient is noted to have weakness with external rotation. EMG findings are consistent with quadrilateral space syndrome. Along with the deltoid, what other muscle is affected?
Review Topic
DISCUSSION:
The axillary nerve passes through the quadrilateral space on its path to innervate the teres minor and deltoid and provide sensation to the lateral arm. This syndrome is caused by compression of the posterior humeral circumflex artery and axillary nerve or one of its major branches in the quadrilateral space. Forward flexion and/or abduction and external rotation of the humerus aggravate the symptoms. In some individuals, especially, throwers, the nerve can become irritated from the repetitive motion leading to nerve dysfunction. The condition is usually self-limited.
Cahill et al reviewed the clinical presentation, imaging, and treatment of this condition.
McClelland et al discuss a case report of involvement of the long head of the triceps which can have axillary innervation.
The illustration outlines the anatomy of the quadrilateral space as well as its contents.
Illustrations:
A
REFERENCES:
1.
Cahill BR, Palmer RE. Quadrilateral space syndrome. J Hand Surg Am. 1983 Jan;8(1):65-9.
PMID: 6827057 (Link to Abstract)
2.
McClelland D, Hoy G. A case of quadrilateral space syndrome with involvement of the long head of the triceps. Am J Sports Med. 2008 Aug;36(8):1615-7.
PMID:18658023 (Link to Abstract)
|
Please Rate Educational Value!
|
4.0
q-3332
|
Average 4.0 of 7 Ratings
|
TAG
(OBQ09.72)
A professional baseball pitcher develops shoulder pain and lateral arm parasthesias. The MRI shows atrophy of the deltoid and teres minor muscles (Figure 1). What is the diagnosis?
Review Topic
DISCUSSION:
The axillary nerve passes through the quadrilateral space on its path to innervate the teres minor and deltoid and to provide sensation to the lateral arm. In throwers, the nerve can become irritated presumably from the repetitive motion leading to nerve dysfunction. This is usually self-limited. The McAdams paper descibes good results in 4 overhead athletes treated with surgical release of the nerve following failure of nonoperative treatment.
REFERENCES:
1.
Fischgrund JS (ed): Orthopaedic Knowledge Update 9. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2008, pp 273-285
2.
DeLee JC, Drez D Jr, Miller MD (eds): Orthopaedic Sports Medicine, ed 2. Philadelphia, PA, WB Saunders, 2002, p 1247
3.
McAdams TR, Dillingham MF. Surgical decompression of the quadrilateral space in overhead athletes. Am J Sports Med. 2008 Mar;36(3):528-32. Epub 2007 Nov 30.
PMID:18055916 (Link to Abstract)
|
Please Rate Educational Value!
|
3.0
q-2885
|
Average 3.0 of 7 Ratings
|
TAG
(OBQ08.133)
An MRI of the shoulder in a patient with chronic quadrilateral space syndrome is most likely to show which of the following?
Review Topic
DISCUSSION:
Quadrilateral space syndrome involves dysfunction of the axillary nerve, perhaps by entrapment or compression, resulting in the functional denervation of the teres minor.
The quadrilateral space is a potential space formed by the long head of the triceps medially, the humerus laterally, the teres minor above, and the teres major below. The axillary nerve and posterior circumflex humeral artery travel through this space.
The Sanders article describes the MRI appearance, which is that the muscle appears streaked with white on MRI and atrophied (See illustration A) consistent with fatty atrophy. Sanders group report this finding in 3% of shoulder MRIs. The posterior circumflex humeral artery also travels with the axillary nerve as it travels through this space. Loss of capsular volume on an arthrogram study is suggestive of adhesive capsulitis.
Illustration B is a diagram which shows the borders of the quadrilateral (or quadrangular) space.
Illustrations:
A
B
REFERENCES:
1.
Sanders TG, Miller MD. Systematic approach to MRI interpretation of sports medicine injuries of the shoulder. Am J Sports Med. 2005 Jul;33(7):1088-105.
PMID:15983127 (Link to Abstract)
2.
Sofka CM, Lin J, Feinberg J, Potter HG. Teres minor denervation on routine magnetic resonance imaging of the shoulder. Skeletal Radiol. 2004 Sep;33(9):514-8.
PMID:15221220 (Link to Abstract)
|
Please Rate Educational Value!
|
4.0
q-519
|
Average 4.0 of 6 Ratings
|
Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions,
Personal Observations, and Biomechanic Studies)
-
McClelland D, Hoy G. A case of quadrilateral space syndrome with involvement of the long head of the triceps. Am J Sports Med. 2008 Aug;36(8):1615-7.
PMID:18658023 (Link to Abstract)
Textbooks
- Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
- AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
- Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
- Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
- Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
- Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Undefined
-
Cahill BR, Palmer RE. Quadrilateral space syndrome. J Hand Surg Am. 1983 Jan;8(1):65-9.
PMID: 6827057 (Link to Abstract)
-
DeLee JC, Drez D Jr, Miller MD (eds): Orthopaedic Sports Medicine, ed 2. Philadelphia, PA, WB Saunders, 2002, p 1247
-
Fischgrund JS (ed): Orthopaedic Knowledge Update 9. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2008, pp 273-285
-
McAdams TR, Dillingham MF. Surgical decompression of the quadrilateral space in overhead athletes. Am J Sports Med. 2008 Mar;36(3):528-32. Epub 2007 Nov 30.
PMID:18055916 (Link to Abstract)
-
Sanders TG, Miller MD. Systematic approach to MRI interpretation of sports medicine injuries of the shoulder. Am J Sports Med. 2005 Jul;33(7):1088-105.
PMID:15983127 (Link to Abstract)
-
Sofka CM, Lin J, Feinberg J, Potter HG. Teres minor denervation on routine magnetic resonance imaging of the shoulder. Skeletal Radiol. 2004 Sep;33(9):514-8.
PMID:15221220 (Link to Abstract)
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