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n Case Report
Quadrilateral Space Syndrome With
Involvement of the Tendon of the Latissimus
Dorsi
Ryuji Koga, MD; Kozo Furushima, PhD; Hiroshi Kusano, MD; Junichiro Hamada, PhD;
Yoshiyasu Itoh, PhD
abstract
Quadrilateral space syndrome (QSS) is the term used to describe axillary
nerve palsy due to compression of the axillary nerve and posterior circumflex
artery in the quadrilateral space. The precise pathophysiology of QSS is still
unclear; hence, a consensus of diagnosis and treatment for QSS has not yet
been achieved. The authors present the case of a 17-year-old male baseball
player with symptoms of QSS, including right elbow and shoulder joint pain
and upper limb numbness while throwing. The symptoms had worsened during baseball. Conservative management for 3 months failed to resolve the
symptoms, so surgery was performed. Axillary nerve decompression resulted
in functional improvement. The cause of QSS has been previously reported to
be fibrous bands, the long head of the triceps, and Bennett lesions. However,
the cause of QSS in this case was compression of the axillary nerve between
the proximal humerus and the tendinous attachment of the latissimus dorsi.
The authors incised a 10- to 15-mm segment of the medial edge of the tendinous insertion of the latissimus dorsi, which resulted in resolution of QSS
symptoms. [Orthopedics. 201x; xx(x):xx-xx.]
O
riginally defined by Cahill and
Palmer,1 quadrilateral space syndrome (QSS) is a rare clinical
syndrome in which the axillary nerve and
the posterior circumflex humeral artery
are compressed in the quadrilateral space.
Patients with QSS experience a variety of
symptoms, which makes definitive diagnosis difficult. Moreover, no clear surgical
criteria have been established. The pathophysiology of QSS has been thought to be
caused by fibrous bands, the long head of
the triceps,2,3 and Bennett lesions of the
shoulder. The current authors propose a
new pathophysiology of QSS caused by
axillary nerve compression by the tendinous insertion of the latissimus dorsi.
Case Report
The authors’ institutional review board
approved a patient registry, and the patient
provided informed consent. A 17-yearold, right-hand–dominant boy presented
with right elbow and shoulder joint pain
MONTH/MONTH 201x | Volume xx • Number X
and upper limb numbness while throwing.
He was a pitcher for a high school baseball team, and the symptoms had prevented him from playing baseball effectively
for several months. There was no history
of trauma or surgery of the shoulder or
elbow. Physical examination revealed
tenderness over the quadrilateral space,
especially at the anterior entrance of the
quadrilateral space that is the medial edge
of the insertion of the latissimus dorsi
tendon. Sensory disturbances were localized in the axillary nerve region. The pain
worsened when the arm was abducted and
externally rotated. Physical examination
did not suggest glenohumeral instability
and internal impingement. Radiography
showed no bony abnormalities. Magnetic
resonance imaging of the elbow showed
no ligamentous injury or osteochondritis dissecans. The patient was diagnosed
with QSS. The authors initially treated
The authors are from Keiyu Orthopaedic Hospital (RK, KF, HK, YI), Gunma, and Kuwano Kyoritsu Hospital (JH), Koriyama, Japan.
The authors have no relevant financial relationships to disclose.
Correspondence should be addressed to:
Ryuji Koga, MD, Keiyu Orthopaedic Hospital,
1741 Hanetsuku Tatebayashi, Gunma 374-0011,
Japan ([email protected]).
Received: September 1, 2016; Accepted: December 12, 2016.
doi: 10.3928/01477447-20170117-06
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n Case Report
Figure 1: Intraoperative photograph of the lateral
aspect of the axillary region. A 4-cm transverse incision was made at the lateral margin of the axilla
over the neck of the humerus (black line: skin incision site).
Figure 3: Schematic drawing showing the axillary
nerve (AN) entrapped by the tendon of the latissimus dorsi (LD) against the humerus. The incision
of 10 to 15 mm of the medial edge of the tendon
successfully decompressed the nerve (red line: resection line).
the patient conservatively with medication (mecobalamin) and physical therapy
(stretching of the glenohumeral joint and
muscle strengthening around the scapula);
however, there was no improvement for 3
months. Hence, surgery was conducted.
Surgery was performed under general
anesthesia, with the patient in the lateral
decubitus position using the SPIDER2
Limb Positioner (Smith & Nephew, Bridgeville, Pennsylvania) to bring the upper
limb into “zero” position. The authors
performed axillary nerve decompression
through the lateral margin of the axilla. A
4-cm transverse incision was made over
the lateral margin of the axilla (Figure 1).
The authors confirmed that abduction and
2
Figure 2: Intraoperative photograph of the pseudoneuroma of the axillary nerve (AN). Abbreviation:
LD, latissimus dorsi.
external rotation of the upper arm tightly
compressed the axillary nerve between
the proximal humerus and the tendon of
the latissimus dorsi. The axillary nerve
was released through a 10- to 15-mm incision along the medial edge of the latissimus dorsi tendon insertion. There was
a pseudoneuroma of the axillary nerve
(Figure 2).
Surgery completely relieved the QSS
symptoms, and the patient had an uneventful recovery. The patient was allowed to throw a ball as hard as possible
at 1 month postoperatively. He successfully returned to competitive baseball as a
pitcher 3 months postoperatively.
Discussion
Quadrilateral space syndrome is an
uncommon syndrome that is characterized by vague symptoms; consequently,
clinical diagnostic criteria are lacking.
Additionally, the sensitivity of imaging
findings is unclear. Atrophy or abnormal
signal around the teres minor muscle on
magnetic resonance imaging may suggest
QSS; however, this finding is rare, with
an incidence rate of 0.8%.4 Occlusion of
the posterior circumflex humeral artery on
abduction and external rotation of the arm
shown with subclavian angiography is reportedly useful in QSS diagnosis.5,6
In the current case, the diagnosis of
QSS was supported by clinical signs such
as tenderness over the anterior entrance
of the quadrilateral space, sensory disturbances in the deltoid region innervated
by the axillary nerve, and an increase in
shoulder or elbow pain when the patient’s
arm was abducted and externally rotated.
The authors confirmed that the axillary
nerve compression was caused by the tendinous attachment of the latissimus dorsi,
and the entrapment was firm during abduction and external rotation of the arm.
Therefore, incision of a 10- to 15-mm segment of the medial edge of the tendinous
insertion of the latissimus dorsi released
the axillary nerve and improved the QSS.
Previous research has shown that the
quadrilateral space can cause an entrapment syndrome that compresses the axillary nerve and the posterior circumflex
humeral artery. Fibrous bands in the quadrilateral space are believed to be the cause
of nerve and artery compression in most
patients with QSS.1,7 The most common
site for fibrous band development is between the teres major and the long head
of the triceps.7 However, the pathogenesis
of QSS in the current case was axillary
nerve compression caused by the tendinous attachment of the latissimus dorsi.
The current authors expanded the quadrilateral space using the posterior approach8
but found no obvious entrapment site or
fibrous bands as previously reported.1,8 In
fact, a large amount of muscle tissue at the
attachment of the teres major was found.
The firm entrapment that causes neurovascular compression was not found in this
area. One of the authors (Y.I.) determined
that the mechanism of axillary nerve compression was the rolling up of the latissimus dorsi tendon when the humerus was
in an abducted and externally rotated position, based on previous reports of latissimus dorsi muscle transfer with the neurovascular pedicle for reconstructions of the
paralyzed shoulder and elbow.9,10
The current authors detected the typical pseudoneuroma of the axillary nerve
(Figure 2), which confirmed the entrapment on visual inspection. The QSS was
due to the entrapment of the axillary nerve
by the tendon of the latissimus dorsi while
the shoulder was abducted and externally
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n Case Report
rotated (Figure 3). This arm position is
necessary for throwing. The authors believe that repetitive overhead arm motions
caused the pseudoneuroma of the axillary
nerve to develop. To completely understand the pathology of QSS, further study,
including anatomic or clinical research,
may be necessary.
Conclusion
To the authors’ knowledge, this is the
first report of QSS caused by entrapment
of the axillary nerve between the insertion of the tendon of the latissimus dorsi
and the proximal humerus, exacerbated
by an abducted and externally rotated arm
position. The incision of 10 to 15 mm of
the medial edge of the tendon of the latis-
simus dorsi decompressed the nerve and
relieved the patient’s symptoms.
References
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