Quadrangular Space Syndrome: a systematic review of surgical and medical therapeutic advances
https://doi.org/10.4081/jphia.2023.2239
Accepted: 29 June 2022
HTML: 24
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
Background: 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.
Objective: The goal of this study is to grade and review past, current, and planned medicinal and surgical care modalities for QSS.
Materials and Methods: 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.
Results: 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.
Conclusions: 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.
Miller RH, Azar FM, Throckmorton TW. Campbell’s Operative Orthopedics. 12th ed. Volume 3. Par Sports Medicine. Chapter 46. Shoulder and elbow injuries. Berlin; Springer; 2017. p 2238.
Van de PD, Kuijer PP, Langenhorst T, Maas M. High prevalence of self-reported symptoms of digital ischemia in elite male volleyball players in the Netherlands: a cross-sectional national survey. Am J Sports Med 2012;40:2296-8. DOI: https://doi.org/10.1177/0363546512456973
Cormier PJ, Matalon TA, Wolin PM. Quadrilateral space syndrome: a rare cause of shoulder pain. Radiology 1988;167:797-8. DOI: https://doi.org/10.1148/radiology.167.3.3363143
McClelland D, Hoy G. A case of quadrilateral space syndrome with involvement of the long head of the triceps. Am J Sports Med 2008;36:1615-7. DOI: https://doi.org/10.1177/0363546508321476
Reutter D, Hunziker R, Husmann M. Computed angiogram of the upper extremities for diagnosing a rare cause of brachial arterial embolism: the “Pitcher Syndrome”. Eur Heart J 2010;31:2782. DOI: https://doi.org/10.1093/eurheartj/ehq269
Chautems RC, Glauser T, Waeber-Fey MC, et al. Quadrilateral space syndrome: case report and review of the literature. Ann Vasc Surg 2000;14:673-6. DOI: https://doi.org/10.1007/s100169910120
Snell Richard S. Clinical Anatomy by Regions. 9th edition. Chapter 9. The Upper Limb. Quadrangular space. 359. https://www.yumpu.com/en/document/view/55653009/snells-clinical-anatomy-by-regions-9th-edition.
Manske RC, Sumler A, Runge J. Quadrilateral space syndrome. Hum Kinet. 2009;14:45-47. https://dx.doi.org/10.1123%2Fatt.14.2.45. DOI: https://doi.org/10.1123/att.14.2.45
Rea P. Essential clinically applied anatomy of the peripheral nervous system in the head and neck. Science Direct Neck. 3.15.1 Axillary Nerve. 2016. https://www.elsevier.com/books/essential-clinically-applied-anatomy-of-the-peripheral-nervous-system-in-the-head-and-neck/rea/978-0-12-803633-4. DOI: https://doi.org/10.1016/B978-0-12-803633-4.00001-6
Juneja P, Hubbard JB. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Aug 22, 2020. Anatomy, Shoulder and Upper Limb, Arm Teres Minor Muscle. https://www.ncbi.nlm.nih.gov/books/NBK513324/.
Elzanie A, Varacallo M. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Aug 22, 2020. Anatomy, Shoulder and Upper Limb, Deltoid Muscle. https://www.ncbi.nlm.nih.gov/books/NBK537056/
Whiting P, Savovic J, Higgins JP, et al. ROBIS: A new tool to assess risk of bias in systematic reviews was developed. J Clin Epidemiol. 2016;69:225-234. doi:10.1016/j.jclinepi.2015.06.005. DOI: https://doi.org/10.1016/j.jclinepi.2015.06.005
Dalagiannis N, Tranovich M, Ebraheim N. Teres minor and quadrilateral space syndrome: A review. J Orthop. 2020 Jan 21;20:144-146. doi: 10.1016/j.jor.2020.01.021. DOI: https://doi.org/10.1016/j.jor.2020.01.021
Hoskins WT, Pollard HP, McDonald AJ. Quadrilateral space syndrome: a case study and review of the literature. Br J Sports Med. 2005 Feb;39(2):e9. doi: 10.1136/bjsm.2004.013367. DOI: https://doi.org/10.1136/bjsm.2004.013367
Gregory T, Sangha H, Bleakney R. Spontaneous resolution of quadrilateral space syndrome: a case report. Am J Phys Med Rehabil. 2015 Jan;94(1):e1-5. doi: 10.1097/PHM.0000000000000237. DOI: https://doi.org/10.1097/PHM.0000000000000237
Frizziero A, Vittadini F, Del Felice A, Creta D, Ferlito E, Gasparotti R, Masiero S. Conservative treatment after axillary nerve re-injury in a rugby player: a case report. Eur J Phys Rehabil Med. 2019 Aug;55(4):510-514. doi: 10.23736/S1973-9087.18.05165-1. Epub 2018 Dec 21. DOI: https://doi.org/10.23736/S1973-9087.18.05165-1
Brown SA, Doolittle DA, Bohanon CJ, Jayaraj A, Naidu SG, Huettl EA, Renfree KJ, Oderich GS, Bjarnason H, Gloviczki P, Wysokinski WE, McPhail IR. Quadrilateral space syndrome: the Mayo Clinic experience with a new classification system and case series. Mayo Clin Proc. 2015 Mar;90(3):382-94. doi: 10.1016/j.mayocp.2014.12.012. Epub 2015 Jan 31. DOI: https://doi.org/10.1016/j.mayocp.2014.12.012
Cahill BR, Palmer RE. Quadrangular space syndrome. J Hand Surg Am. 1983;8(1):65-69. https://doi.org/10.1016/s0363-5023(83)80056-2. DOI: https://doi.org/10.1016/S0363-5023(83)80056-2
Zhang J, Zhang T, Wang R, Wang T. Musculoskeletal ultrasound diagnosis of quadrilateral space syndrome: A case report. Medicine (Baltimore). 2021;100(10):e24976. doi:10.1097/MD.0000000000024976 DOI: https://doi.org/10.1097/MD.0000000000024976
Francel, Thomas J. M.D.; Dellon, A Lee M.D.; Campbell, James N. M.D. Quadrilateral Space Syndrome: Diagnosis and Operative Decompression Technique, Plastic and Reconstructive Surgery: May 1991 - Volume 87 - Issue 5 - p 911-916. https://doi.org/10.1097/00006534-199105000-00016. DOI: https://doi.org/10.1097/00006534-199105000-00016
Feng SH, Hsiao MY, Wu CH, Özçakar L. Ultrasound-Guided Diagnosis and Management for Quadrilateral Space Syndrome. Pain Med. 2017 Jan 1;18(1):184-186. doi: 10.1093/pm/pnw256. DOI: https://doi.org/10.1093/pm/pnw256
Borrel F, Desmoineaux P, Delcourt T, Pujol N. Feasibility of arthroscopic decompression of the axillary nerve in the quadrilateral space: Cadaver study. Orthop Traumatol Surg Res. 2021 Feb;107(1):102762. doi: 10.1016/j.otsr.2020.102762. Epub 2020 Dec 14. DOI: https://doi.org/10.1016/j.otsr.2020.102762
McAdams TR, Dillingham MF. Surgical decompression of the quadrilateral space in overhead athletes. Am J Sports Med. 2008 Mar;36(3):528-32. doi: 10.1177/0363546507309675. Epub 2007 Nov 30. DOI: https://doi.org/10.1177/0363546507309675
Steinmann SP, Moran EA. Axillary nerve injury: diagnosis and treatment. J Am Acad Orthop Surg. 2001 Sep-Oct;9(5):328-35. doi: 10.5435/00124635-200109000-00006. DOI: https://doi.org/10.5435/00124635-200109000-00006
Reeser JC. Diagnosis and management of vascular injuries in the shoulder girdle of the overhead athlete. Curr Sports Med Rep. 2007 Oct;6(5):322-7. PMID: 17883968 DOI: https://doi.org/10.1007/s11932-007-0070-3
Perlmutter GS, Apruzzese W. Axillary nerve injuries in contact sports: recommendations for treatment and rehabilitation. Sports Med. 1998 Nov;26(5):351-61. doi: 10.2165/00007256-199826050-00005. DOI: https://doi.org/10.2165/00007256-199826050-00005
Andermah Jr, McKee M, Nam D. AO Surgery Reference. First edition. 2015. Deltopectoral approach. https://surgeryreference.aofoundation.org/orthopaedic-trauma/adult trauma/clavicle/additional credits. https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/scapula/approach/deltopectoral-approach.
Feigl G, Aichner E, Mattersberger C, Zahn PK, Avila Gonzalez C, Litz R. Ultrasound-guided anterior approach to the axillary and intercostobrachial nerves in the axillary fossa: an anatomical investigation. Br J Anaesth. 2018;121(4):883-89. https://doi.org/10.1016/j.bja.2018.06.006. DOI: https://doi.org/10.1016/j.bja.2018.06.006
Charmode S, Mehra S, Kushwaha S. Revisiting the Surgical Approaches to Decompression in Quadrilateral Space Syndrome: A Cadaveric Study. Cureus. 2022 Feb 26;14(2):e22619. doi: 10.7759/cureus.22619. DOI: https://doi.org/10.7759/cureus.22619
Supporting Agencies
This research study received no external funding.Copyright (c) 2023 the Authors
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Downloads
Citations
