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Quadrilateral Space Syndrome
From WikiSM
Other Names
- QSS
- Quadrilateral Space Syndrome
Background
- This page covers Quadrilateral Space Syndrome (QSS)
History
- First described by Cahill and Palmer in 1983[1]
Epidemiology
- Rare disease with unknown incidence, prevalence
- Most commonly seen in men, aged 20-40 involing dominant shoulder[2][3]
Introduction
General
- Relatively rare condition in which the Axillary Nerve and Posterior Circumflex Humeral Artery are compressed within the Quadrilateral Space (QS)
- Leads to poorly localized shoulder pain, tenderness over the QS and denervation of Teres Minor and Deltoid
- Typically seen in young athletes in their dominant/ throwing shoulder
Etiology
- Compression and reduction of quadrangular space occurs due to:
- Tight fibrous bands can occur from shoulder abduction with internal/external rotation
- Iatrogenic (tight fibrous bands, muscular hypertrophy)
- Paralabral Cyst (most commonly inferior labral tears)
- Trauma including Scapular Fracture, Shoulder Dislocation
- Malignancy (lipoma, osteochondroma, schwannoma)
- Muscle hypertrophy in overhead athletes[4]
Anatomy of the Quadrilateral Space
- Boundaries of Quadrilateral Space
- Superior: Subscapularis and Teres Minor
- Inferior: Teres major, Latissimus Dorsi
- Medial: Long head of Triceps Brachii
- Lateral: Surgical neck of the Humerus
- Contents
Risk Factors
- Overhead athletes including
- Volleyball[4]
- Swimming
- Baseball
- Basketball
- Contact or throwing sports
Differential Diagnosis
Differential Diagnosis Shoulder Pain
- Fractures
- Proximal Humerus Fracture
- Humeral Shaft Fracture
- Clavicle Fracture
- Scapula Fracture
- First Rib Fracture (traumatic or atraumatic)
- Dislocations & Separations
- Arthropathies
- Muscle & Tendon Injuries
- Rotator Cuff
- Bursopathies
- Ligament Injuries
- Neuropathies
- Other
- Pediatrics
- Coracoid Avulsion Fracture
- Humeral Head Epiphysiolysis (Little League Shoulder)
Clinical Features
History
- Poorly localized posterior/lateral shoulder pain with insidious
- No history of trauma
- Parasthesia of upper extremity in non-dermatomal distribution
- Weakness of external shoulder rotators
- Worse with abduction, exeternal rotation
Physical Exam: Physical Exam Shoulder
- May observe atrophy of teres minor, deltoid
- Typically demonstrate point tenderness over quadrangular space
- Strength: Weakness in external rotation, especially with arm abducted
- Pain with active or resisted abduction, external rotation
Special Tests
- Holding arm in abduction, flexion and external rotation for 1-2 minutes may recreate symptoms
Evaluation
Radiographs
- Standard Radiographs Shoulder
- Typically normal, recommended first line evaluation to exclude other causes
MRI
- Findings
- Atrophy of teres minor
- Compression of quadrilateral space
- Inferior Paralabral Cyst
EMG/NCS
- Can confirm diagnosis, demonstrates axillary neuropathy
- Can be negative due to positional nature of QSS[5]
Ultrasound
- Can use color doppler on posterior circumflex humeral artery with arm abducted to 90°[6]
- Can also demonstrate
- Swelling, lesions of axillary nerve
- Space occupying lesions of the QS
Arteriogram
- Historically recommended to evaluate for compression of posterior circumflex humeral artery
- No longer recommended due to high false positive rate
Classification
- N/A
Management
Nonoperative
- Typically considered first line therapy
- Not a lot of literature or evidence to guide management
- Most literature is based on expert opinion or case series
- NSAIDS
- Activity Restriction or modification
- Physical Therapy
- Emphasis on soft tissue manipulation to break up the fibrotic tissue
- Includes Soft tissue Massage
- Shoulder range of motion, rotator cuff strengthening, scapular stabilization
- Corticosteroid Injection
- Suggested by no evidence to support/refute its use
- Diagnostic block may be used to help confirm diagnosis
Operative
- Indications
- Failure of nonoperative management (typically minimum of 6 months)
- Technique
- Surgical release of quadrilateral space
- Repair of paralabral cyst if appropriate
- Treatment of vascular abnormality of appropriate
Rehab and Return to Sport
Rehab
- Early post op pendulum exercises, range of motion exercises
- Goal is to prevent adhesion formation[7]
- Some surgeons recommend avoiding hyperextension, abduction, and external rotation for 4 weeks postoperatively[8]
- Start sport specific therapy at ~6 weeks
Return to Sport/Work
- Needs to be updated
Prognosis and Complications
Prognosis
- Most cases resolve with conservative treatment
- Literature on surgical outcomes is scarce
- Most cases report good outcomes after excision of fibrous bands[9]
Complications
- Unknown
See Also
Internal
- Physical Exam Shoulder
- Shoulder Anatomy (Main)
- Shoulder Pain (Main)
- Neck Pain (Main)
- Elbow Pain (Main)
External
- Sports Medicine Review Shoulder Pain: https://www.sportsmedreview.com/by-joint/shoulder/
References
- ↑ Cahill, Bernard R., and Ronald E. Palmer. "Quadrilateral space syndrome." Journal of Hand Surgery 8.1 (1983): 65-69.
- ↑ Aval, Soheil M., Pierre Durand Jr, and James A. Shankwiler. "Neurovascular injuries to the athlete's shoulder: Part I." JAAOS-Journal of the American Academy of Orthopaedic Surgeons 15.4 (2007): 249-256.
- ↑ Brown, Sherry-Ann N., et al. "Quadrilateral space syndrome: the Mayo Clinic experience with a new classification system and case series." Mayo Clinic Proceedings. Vol. 90. No. 3. Elsevier, 2015.
- ↑ 4.0 4.1 Paladini, D., et al. "Axillary neuropathy in volleyball players: report of two cases and literature review." Journal of Neurology, Neurosurgery & Psychiatry 60.3 (1996): 345-347.
- ↑ McAdams, Timothy R., and Michael F. Dillingham. "Surgical decompression of the quadrilateral space in overhead athletes." The American journal of sports medicine 36.3 (2008): 528-532.
- ↑ Brestas, Paraskevas S., et al. "Ultrasound findings of teres minor denervation in suspected quadrilateral space syndrome." Journal of Clinical Ultrasound 34.7 (2006): 343-347.
- ↑ McAdams, Timothy R., and Michael F. Dillingham. "Surgical decompression of the quadrilateral space in overhead athletes." The American journal of sports medicine 36.3 (2008): 528-532.
- ↑ McAdams, Timothy R., and Michael F. Dillingham. "Surgical decompression of the quadrilateral space in overhead athletes." The American journal of sports medicine 36.3 (2008): 528-532.
- ↑ Flynn, Lindsay S., Thomas W. Wright, and Joseph J. King. "Quadrilateral space syndrome: a review." Journal of shoulder and elbow surgery 27.5 (2018): 950-956.
Created by:
John Kiel on 14 June 2019 09:00:54
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Last edited:
18 April 2023 16:15:27
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