Evolving Technique: I Have the Diagnosis: Quadrilateral Space - - PowerPoint PPT Presentation

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Evolving Technique: I Have the Diagnosis: Quadrilateral Space - - PowerPoint PPT Presentation

Oct 19, 2023 307 likes •527 views

Evolving Technique: I Have the Diagnosis: Quadrilateral Space Syndrome - Decompress the Nerve! Carl J. Basamania, MD, FACS Orthopedic Physician Associates Swedish Orthopaedic Institute Seattle, Washington Presenter Disclosure Information

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Evolving Technique: I Have the Diagnosis: Quadrilateral Space Syndrome - Decompress the Nerve!

Carl J. Basamania, MD, FACS

Orthopedic Physician Associates Swedish Orthopaedic Institute Seattle, Washington

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Presenter Disclosure Information

Carl J. Basamania, MD, FACS Disclosure Information The following relationships exist: DePuy/Johnson and Johnson: Consultant, Royalties Zimmer/Biomet: Consultant, Royalties Sonoma Orthopaedics: Consultant, Royalties Invuity: Consultant, Stock Options BioPoly: Consultant, Stock Options Nothing of value received for this presentation No “off label” use of any products

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Case

  • 41 year old RHD male concert “rigger”

– Mistaken for backstage “trespasser” and arrested – right arm forcefully pulled behind back – Has to lift 50-150 pound lighting up to stage scaffolding using a “hand over hand” technique – 6 months after “arrest” complains of posterior right shoulder pain and weakness

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PE

  • Full ROM
  • Tenderness posterior lower

scapular region

  • 4-4+/5 external rotation strength
  • ++O’Brien’s
  • Pain exacerbated by resisted

“cocking motion”

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Background

  • Quadrilateral space syndrome

–Relatively rare condition –Typically young athletic adults 25 to 35 years without a history of significant trauma –True prevalence is unknown

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Background

  • Teres minor atrophy or abnormal

signal may be present in as many as 0.8% (19/2436) of patients referred for shoulder MRI

– AJR. 2005;184: 989-992. 10.2214/ajr.184.3.01840989

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Background

  • The boundaries of the

quadrilateral space are:

– the shaft of humerus – teres minor – long head of triceps – teres major

  • Cadaveric study showed nerve

to the teres minor was found to have branched either in or before the quadrilateral space

JSES 2008,17(1),162-164

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Pathophysiology

  • Mechanism of injury
  • compression and reduction of quadrangular space due

to

  • iatrogenic (tight fibrous bands, muscular

hypertrophy)

  • paralabral cysts (most commonly inferior labral

tears)

  • trauma (scapular fracture, shoulder dislocation)
  • benign or malignant masses
  • Pathomechanics
  • greatest amount of compression occurs when the arm is

positioned in the late cocking phase of throwing (abduction and external rotation)

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Differential Diagnosis

  • Rotator cuff tear
  • Paralabral ganglion
  • Suprascapular neuropathy
  • Parsonage-Turner

Syndrome

  • Thoracic outlet

syndrome

  • Scapula Fxs
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Evaluation

  • MRI

– Diagnostic

  • EMG
  • US
  • Arteriography

– Seldom used anymore – Vascular occlusion can be seen in ~80% asymptomatic patients

  • AJR Am J Roentgenol 1994;163:625–7
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MRI Results

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MRI Results

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MRI Results

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MRI Results

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MRI Results

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Treatment Alternatives

  • PT
  • Analgesics/NSAID’s
  • Rest/avoidance of athletic activities
  • Deep soft tissue massage
  • Stretching
  • Surgery – acute and nonresponsive

cases

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Surgery

  • Arthroscopy

– Patient had degenerative SLAP – Debridement and tenodesis

  • Open quad space

release

JSES, 2015. 24(4),628–633. doi.org/10.1016/j.jse.2014.08.018

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Surgery

  • Posterior midaxillary

incision

  • Incise dense deltoid

fascia along inferior border of deltoid

  • Retract deltoid

superolateral

  • Abducting and

externally rotating arm relaxes deltoid

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Surgery

  • Open interval between

teres major and teres minor

  • Open fascia over teres

minor to quadrilateral space

  • Identify and

decompress axillary nerve

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Follow-up

  • 6 months postop
  • No pain
  • External rotation

strength normal

  • Lawsuit pending

against arresting security guard

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Published Results

  • Few large studies
  • 22 patients, follow-up 26 months.
  • 9 patients had concurrent procedures
  • Preoperatively, 12 of 14 (86%) had external

rotation weakness in Horn blower's position

  • Postoperatively, pain scores decreased an average
  • f 4 points; ASES scores increased 31.7 ± 20.2

points; SST scores increased 3.1 ± 2.3 points.

  • No external rotation weakness was noted

postoperatively in any tested patient.

  • Two patients developed adhesive capsulitis.

JSES, 2015. 24(4),628–633. doi.org/10.1016/j.jse.2014.08.018