Quadrilateral space syndrome

Quadrilateral space syndrome
Other names	Quadrangular space syndrome
	Shoulder muscle (rotator cuff)
Specialty	Neurology

Last updated August 24, 2019

Quadrilateral space syndrome is a rotator cuff denervation syndrome in which the axillary nerve is compressed at the quadrilateral space of the rotator cuff.

In anatomy, the rotator cuff is a group of muscles and their tendons that act to stabilize the shoulder. Of the seven scapulohumeral muscles, four make up the rotator cuff. The four muscles are the supraspinatus muscle, the infraspinatus muscle, teres minor muscle, and the subscapularis muscle.

Denervation is any loss of nerve supply regardless of the cause. If the nerves lost to denervation are part of the neuronal communication to a specific function in the body then altered or a loss of physiological functioning can occur. Denervation can be caused by injury or be a symptom of a disorder like ALS and post-polio syndrome. Additionally, it can be a useful surgical technique to alleviate major negative symptoms, such as in renal denervation. Denervation can have many harmful side effects such as increased risk of infection and tissue dysfunction.

The axillary nerve or the circumflex nerve is a nerve of the human body, that originates from the brachial plexus at the level of the axilla (armpit) and carries nerve fibers from C5 and C6. The axillary nerve travels through the quadrangular space with the posterior circumflex humeral artery and vein.

Cause

Diagnosis

Diagnosis is usually suspected by clinical history and confirmed by MRI, in which edema of the teres minor is seen, with variable involvement of the deltoid. The circumflex humeral artery may also be compressed. Before the advent of MRI, compression of this vessel on angiography used to be the mechanism of diagnosis, although this is no longer done as it is an invasive procedure.

Edema abnormal accumulation of fluid in the interstitium

Edema, also spelled oedema or œdema, is an abnormal accumulation of fluid in the interstitium, located beneath the skin and in the cavities of the body, which can cause severe pain. Clinically, hyperaldosteronism, edema manifests as swelling. The amount of interstitial fluid is determined by the balance of fluid homeostasis and the increased secretion of fluid into the interstitium. The word is from Greek οἴδημα oídēma meaning "swelling". The condition is also known as dropsy.

The deltoid muscle is the muscle forming the rounded contour of the human shoulder. It is also known as the 'common shoulder muscle', particularly in other animals such as the domestic cat. Anatomically, it appears to be made up of three distinct sets of fibers though electromyography suggests that it consists of at least seven groups that can be independently coordinated by the nervous system.

Angiography or arteriography is a medical imaging technique used to visualize the inside, or lumen, of blood vessels and organs of the body, with particular interest in the arteries, veins, and the heart chambers. This is traditionally done by injecting a radio-opaque contrast agent into the blood vessel and imaging using X-ray based techniques such as fluoroscopy.

Atrophy can occur in cases of chronic nerve impingement.^[1]^[2] It can be associated with a glenoid labral cyst, with the cyst also reflecting injury of the glenoid labrum.^[3]

Atrophy is the partial or complete wasting away of a part of the body. Causes of atrophy include mutations, poor nourishment, poor circulation, loss of hormonal support, loss of nerve supply to the target organ, excessive amount of apoptosis of cells, and disuse or lack of exercise or disease intrinsic to the tissue itself. In medical practice, hormonal and nerve inputs that maintain an organ or body part are said to have trophic effects. A diminished muscular trophic condition is designated as atrophy. Atrophy is reduction in size of cell, organ or tissue, after attaining its normal mature growth. In contrast, hypoplasia is the reduction in size of a cell, organ, or tissue that has not attained normal maturity.

The glenoid labrum is a fibrocartilaginous structure rim attached around the margin of the glenoid cavity in the shoulder blade. The shoulder joint is considered a ball and socket joint. However, in bony terms the 'socket' is quite shallow and small, covering at most only a third of the 'ball'. The socket is deepened by the glenoid labrum.

Differential diagnosis

Differential considerations include similar rotator cuff denervation syndromes such as Parsonage–Turner syndrome, and compression of the suprascapular nerve at the spinoglenoid notch in which the infraspinatus, and to a lesser degree supraspinatus is involved.

Parsonage–Turner syndrome, also known as acute brachial neuropathy and neuralgic amyotrophy, is a syndrome of unknown cause; although many specific risk factors have been identified, the cause is still unknown. The condition manifests as a rare set of symptoms most likely resulting from autoimmune inflammation of unknown cause of the brachial plexus.

The suprascapular nerve is a nerve that arises from the brachial plexus. It is responsible for the innervation of some of the muscles that attach on the scapula, namely the supraspinatus and infraspinatus muscles.

Treatment

Treatment is decompression of the quadrilateral space, with supportive therapy in recalcitrant cases.^[1]

Related Research Articles

The humerus is a long bone in the arm that runs from the shoulder to the elbow. It connects the scapula and the two bones of the lower arm, the radius and ulna, and consists of three sections. The humeral upper extremity consists of a rounded head, a narrow neck, and two short processes. The body is cylindrical in its upper portion, and more prismatic below. The lower extremity consists of 2 epicondyles, 2 processes, and 3 fossae. As well as its true anatomical neck, the constriction below the greater and lesser tubercles of the humerus is referred to as its surgical neck due to its tendency to fracture, thus often becoming the focus of surgeons.

The human shoulder is made up of three bones: the clavicle (collarbone), the scapula, and the humerus as well as associated muscles, ligaments and tendons. The articulations between the bones of the shoulder make up the shoulder joints. The shoulder joint, also known as the glenohumeral joint, is the major joint of the shoulder, but can more broadly include the acromioclavicular joint. In human anatomy, the shoulder joint comprises the part of the body where the humerus attaches to the scapula, and the head sits in the glenoid cavity. The shoulder is the group of structures in the region of the joint.

A rotator cuff tear is an injury of one or more of the tendons or muscles of the rotator cuff of the shoulder. Symptoms may include shoulder pain, which is often worse with movement, or weakness. This may limit peoples’ ability to brush their hair or put on clothing. Clicking may also occur with movement of the arm.

The teres minor is a narrow, elongated muscle of the rotator cuff. The muscle originates from the lateral border and adjacent posterior surface of the corresponding right or left scapula and inserts at both the greater tubercle of the humerus and the posterior surface of the joint capsule.

Organomegaly is the abnormal enlargement of organs. For example, clitoromegaly is the enlargement of the clitoris, and cardiomegaly is enlargement of the heart. Visceromegaly is the enlargement of abdominal organs. Examples of visceromegaly are enlarged liver (hepatomegaly), spleen (splenomegaly), stomach, kidneys, and pancreas.

An arthrogram is a series of images of a joint after injection of a contrast medium, usually done by fluoroscopy or MRI. The injection is normally done under a local anesthetic.The radiologist or radiographer performs the study using fluoroscopy or ultrasound to guide the placement of the needle into the joint and then injects an appropriate amount of contrast.

The shoulder joint is structurally classified as a synovial ball and socket joint and functionally as a diarthrosis and multiaxial joint. It involves articulation between the glenoid cavity of the scapula and the head of the humerus.

The quadratus femoris is a flat, quadrilateral skeletal muscle. Located on the posterior side of the hip joint, it is a strong external rotator and adductor of the thigh, but also acts to stabilize the femoral head in the acetabulum.

Subacromial bursitis is a condition caused by inflammation of the bursa that separates the superior surface of the supraspinatus tendon from the overlying coraco-acromial ligament, acromion, and coracoid and from the deep surface of the deltoid muscle. The subacromial bursa helps the motion of the supraspinatus tendon of the rotator cuff in activities such as overhead work.

A radiologic sign is an objective indication of some medical fact that is detected by a physician during radiologic examination with medical imaging.

Ulnar nerve entrapment is a condition where the ulnar nerve becomes physically trapped or pinched, resulting in pain, numbness, or weakness.

Shoulder replacement is a surgical procedure in which all or part of the glenohumeral joint is replaced by a prosthetic implant. Such joint replacement surgery generally is conducted to relieve arthritis pain or fix severe physical joint damage.

Carcinosis, or carcinomatosis, is disseminated cancer, forms of metastasis, whether used generally or in specific patterns of spread.

Anterior interosseous syndrome is a medical condition in which damage to the anterior interosseous nerve (AIN), a motor branch of the median nerve, causes pain in the forearm and a characteristic weakness of the pincer movement of the thumb and index finger.

Pronator teres syndrome is a compression neuropathy of the median nerve at the elbow. It is rare compared to compression at the wrist or isolated injury of the anterior interosseous branch of the median nerve.

<i>American Journal of Roentgenology</i> journal

The American Journal of Roentgenology (AJR) is a monthly peer-reviewed journal that covers topics in radiology. It is published by the American Roentgen Ray Society (ARRS) and is based in Leesburg, VA. The current editor-in-chief is Thomas H. Berquist.

The aortopulmonary space is a small space between the aortic arch and the pulmonary artery. It contains the ligamentum arteriosum, the recurrent laryngeal nerve, lymph nodes, and fatty tissue. The space is bounded anteriorly by the ascending aorta, posteriorly by the descending aorta, medially by the left main bronchus, and laterally by mediastinal pleura.

References

1 2 Cothran, R. Lee; Helms, Clyde (2005-03-01). "Quadrilateral space syndrome: incidence of imaging findings in a population referred for MRI of the shoulder". AJR. American Journal of Roentgenology. 184 (3): 989–992. doi:10.2214/ajr.184.3.01840989. ISSN 0361-803X. PMID 15728630.
↑ Brestas, Paraskevas S.; Tsouroulas, Marinos; Nikolakopoulou, Zoi; Malagari, Katerina; Drossos, Charalampos (2006-09-01). "Ultrasound findings of teres minor denervation in suspected quadrilateral space syndrome". Journal of Clinical Ultrasound. 34 (7): 343–347. doi:10.1002/jcu.20239. ISSN 0091-2751. PMID 16869012.
↑ Robinson, P.; White, L. M.; Lax, M.; Salonen, D.; Bell, R. S. (2000-10-01). "Quadrilateral space syndrome caused by glenoid labral cyst". AJR. American Journal of Roentgenology. 175 (4): 1103–1105. doi:10.2214/ajr.175.4.1751103. ISSN 0361-803X. PMID 11000173.

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[first-1] 1 2 Cothran, R. Lee; Helms, Clyde (2005-03-01). "Quadrilateral space syndrome: incidence of imaging findings in a population referred for MRI of the shoulder". AJR. American Journal of Roentgenology. 184 (3): 989–992. doi:10.2214/ajr.184.3.01840989. ISSN 0361-803X. PMID 15728630.

[2] Brestas, Paraskevas S.; Tsouroulas, Marinos; Nikolakopoulou, Zoi; Malagari, Katerina; Drossos, Charalampos (2006-09-01). "Ultrasound findings of teres minor denervation in suspected quadrilateral space syndrome". Journal of Clinical Ultrasound. 34 (7): 343–347. doi:10.1002/jcu.20239. ISSN 0091-2751. PMID 16869012.

[3] Robinson, P.; White, L. M.; Lax, M.; Salonen, D.; Bell, R. S. (2000-10-01). "Quadrilateral space syndrome caused by glenoid labral cyst". AJR. American Journal of Roentgenology. 175 (4): 1103–1105. doi:10.2214/ajr.175.4.1751103. ISSN 0361-803X. PMID 11000173.