Quadrilateral Space Syndrome

Abstract

Quadrilateral space syndrome (QSS) arises from compression or mechanical injury to the axillary nerve or the posterior circumflex humeral artery (PCHA) as they pass through the quadrilateral space (QS). Quadrilateral space syndrome is an uncommon cause of paresthesia and an underdiagnosed cause of digital ischemia in overhead athletes. Quadrilateral space syndrome can present with neurogenic symptoms (pain and weakness) secondary to axillary nerve compression. In addition, repeated abduction and external rotation of the arm is felt to lead to injury of the PCHA within the QSS. This often results in PCHA thrombosis and aneurysm formation, with distal emboli. Because of relative infrequency, QSS is rarely diagnosed on evaluation of athletes with such symptoms. We report on 9 patients who presented at Mayo Clinic with QSS. Differential diagnosis, a new classification system, and the management of QSS are discussed, with a comprehensive literature review. The following search terms were used on PubMed: axillary nerve, posterior circumflex humeral artery, quadrilateral space, and quadrangular space. Articles were selected if they described patients with symptoms from axillary nerve entrapment or PCHA thrombosis, or if related screening or imaging methods were assessed. References available within the obtained articles were also pursued. There was no date or language restriction for article inclusion; 5 studies in languages besides English were reported in German, French, Spanish, Turkish, and Chinese.

Ultrasound assessment of the posterior circumflex humeral artery in elite volleyball players: Aneurysm prevalence, anatomy, branching pattern and vessel characteristics

“…Interestingly, in the current study all thirteen aneurysms were detected in PCHAs that originated directly from the axillary artery. This is consistent with the location of pathology seen in volleyball players who were diagnosed and treated in our academic hospital [1, 14, 20, 21], as well as in other reports on PCHA aneurysms in the medical literature [13, 15, 19, 22, 23, 34, 41]. This implies that a PCHA originating directly from the axillary artery is a risk factor for the development of PCHA aneurysms and thrombosis and that variant anatomy might be protective against aneurysm and thrombus formation.…”

“…No PCHA pathology was detected in some 350 examined PCHAs of healthy subjects [3, 36, 37]. Several studies suggest that repetitive powerful overhead movements in volleyball, like spiking and serving, cause chronic vessel wall injury as a result of positional traction and compression of the proximal PCHA [14, 15, 21]. This cumulative PCHA trauma can cause a continuum of pathology ranging from local intimal hyperplasia to vessel widening of <150 % (dilatation) and >150 % (aneurysm), and occlusion [30].…”

Omuz çevresi tuzak nöropatiler: supraskapular sinir sıkışması ve kuadrangüler aralık sendromu

“…Bu boşluk içerisinde bası altında kalan yapı, eğer aksiller sinir ise kliniğin adı nörojenik kuadrangüler aralık sendromu (nKAS), posterior sirkumfleks humeral arter ise vasküler kuadrangüler aralık sendromu (vKAS) olarak adlandırılır. [16] nKAS, göreceli olarak 1,5:1 oranında, vKAS'tan daha sıktır. Özellikle, 20-40 yaş aralığındaki erkekler etkilenir ve bu hastalar, subakromiyal sıkışma sendromu ile karışırlar.…”

B‐Mode Sonographic Assessment of the Posterior Circumflex Humeral Artery

“…However, the prevalence of digital ischemic symptoms is as high as 31% in elite volleyball players 1 . A late diagnosis can disable the overhead athlete and threaten the athlete's career 15 …”

“…Early detection of PCHA degeneration, aneurysm formation, and intravascular thrombosis can potentially prevent thromboembolic complications and irreversible tissue damage. Currently, there is no standardized vascular sonographic protocol for the PCHA 15 . A standardized sonographic protocol is important because worldwide standardization and implementation will aid in targeted and accurate PCHA imaging.…”