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Concept: Posterior humeral circumflex artery

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Quadrilateral space syndrome (QSS) is a rare disorder characterized by axillary nerve and posterior humeral circumflex artery (PHCA) compression within the quadrilateral space. Impingement is most frequently due to trauma, fibrous bands, or hypertrophy of one of the muscular borders. Diagnosis can be complicated by the presence of concurrent traumatic injuries, particularly in athletes. Since many other conditions can mimic QSS, it is often a diagnosis of exclusion. Conservative treatment is often first trialed, including physical exercise modification, physical therapy, and therapeutic massage. In patients unrelieved by conservative measures, surgical decompression of the quadrilateral space may be indicated.

Concepts: Muscle, Exercise, Physical therapy, Exercise physiology, Massage, Axillary nerve, Posterior humeral circumflex artery, Quadrangular space

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Quadrilateral space syndrome (QSS) is a rare orthopedic condition caused by compression, entrapment, or injury to the axillary nerve or posterior humeral circumflex artery as they arise from the quadrilateral space. QSS can present with point tenderness over the quadrilateral space and weakness and paresthesia in the axillary nerve distribution. It is commonly associated with repetitive overhead activities and is seen in athletes engaging in such activities. Here we report a case of QSS in a 42-year-old male weight lifter who presented with pain and soreness in the posterior aspect of his right shoulder radiating around his arm as well as slight weakness of his right shoulder of a few weeks duration. MRI results of his shoulder demonstrated moderate atrophy and fatty infiltration of the teres minor. His diagnosis of QSS was confirmed with electro diagnostic testing which showed axillary neuropathy. He was treated with ultrasound guided corticosteroid injections and gained relief from this treatment. His axillary neuropathy was shown to be resolving on repeat electro diagnostic testing at six-months follow-up. Here we report a case of QSS and provide a brief review of the literature.

Concepts: Neurology, Pain, Rotator cuff, Teres minor muscle, Deltoid muscle, Axillary nerve, Posterior humeral circumflex artery, Quadrangular space

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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.].

Concepts: Humerus, Elbow, Latissimus dorsi muscle, Deltoid muscle, Axillary nerve, Glenohumeral joint, Posterior humeral circumflex artery, Quadrangular space

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Ultrasound-guided infraclavicular block in the costoclavicular space located between the clavicle and the first rib, reaches the secondary trunks when they are clustered together and lateral to the axillary artery. This block is most often performed through a lateral approach, the difficulty being finding the coracoid process an obstacle and guiding the needle towards the vessels and pleura. A medial approach, meaning from inside to outside, will avoid these structures. Traditionally the assessment of a successful block is through motor or sensitive responses but a sympathetic fibre block can also be evaluated measuring the changes in humeral artery blood flow, skin temperature and/or perfusion index.

Concepts: Blood, Scapula, Posterior humeral circumflex artery

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Anatomic variations of axillary artery branches are commonly encountered during radiological investigation and surgical operations. Their existence can confuse interpretation of radiological results and lead to undesired complications during surgery. In this report authors describe a rare case of a subscapular arterial trunk that gave origin to thoracodorsal, circumflex scapular, posterior humeral circumflex, and lateral thoracic artery. Such a variation might cause undesired sequelae during trauma management and a variety of common flap harvesting operations including latissimus dorsi, scapular and parascapular flaps. Furthermore it presents embryological interest as it gives insight to embryologic development of axillary area.

Concepts: Medicine, Surgery, Latissimus dorsi muscle, Axillary artery, Subscapular artery, Arteries of the upper limb, Lateral thoracic artery, Posterior humeral circumflex artery

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To determine the prevalence of posterior circumflex humeral artery (PCHA) aneurysms and vessel characteristics of the PCHA and deep brachial artery (DBA) in elite volleyball players.

Concepts: Brachial artery, Posterior humeral circumflex artery

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A 70-year-old man presented to accident and emergency with an isolated anteriorly dislocated shoulder, in the absence of a concomitant fracture. There was no neurovascular deficit at presentation, and the shoulder was reduced under sedation, using the Kocher’s technique. Following this, the patient developed signs of hypovolaemic shock. Clinical examination revealed an expanding fullness in the deltopectoral area, with compromise of the limb neurovascular status. CT imaging confirmed an expanding haematoma from the axillary vessels, restricting left lung expansion. Once resuscitated, the patient was transferred to theatre for exploration of the bleeding vessels. Intraoperative findings included an avulsed anterior circumflex humeral artery that was subsequently ligated. Postoperatively, the patient developed axillary, radial, median and ulnar nerve neuropraxia, which improved clinically prior to discharge. The patient was ultimately discharged home after a lengthy inpatient stay.

Concepts: Shoulder, Ulnar nerve, Brachial plexus, Joint dislocation, Radial nerve, Dislocated shoulder, Posterior humeral circumflex artery, Anterior humeral circumflex artery

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Elite overhead athletes are at risk of posterior circumflex humeral artery (PCHA) degeneration, aneurysm formation and thrombosis. Identification of the proximal PCHA and the nearby originating deep brachial artery (DBA) can be a challenge, even among experienced sonographers. The aim of this study was to assess the accuracy and precision of a newly designed standardized ultrasound (US) protocol (SPI-US) for assessment of the PCHA and DBA.

Concepts: Evaluation, Blood pressure, Psychometrics, Reliability, Accuracy and precision, Brachial artery, Profunda brachii, Posterior humeral circumflex artery

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Quadrilateral space syndrome (QSS) is a rare neurovascular compression syndrome that results from the compression of the axillary nerve and posterior circumflex humeral artery in the quadrilateral space. Electromyography (EMG) is often used to evaluate for the presence of neuropathic changes in the deltoid and teres minor in cases of suspected QSS. Needle examination of the teres minor may be challenging due to the muscle’s small size and proximity to the infraspinatus. In cases where patients are overweight or have significant teres minor atrophy, localization of the muscle through conventional methods may be extremely difficult. We present a case of an overweight man with posterior shoulder pain who was diagnosed with QSS using a combination of ultrasound and EMG.

Concepts: Muscle, Shoulder, Rotator cuff, Teres minor muscle, Supraspinatus muscle, Deltoid muscle, Axillary nerve, Posterior humeral circumflex artery

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Anatomic variations in branching pattern of axillary artery (AxA) are common and typically involve subscapular artery (SsA) and posterior circumflex humeral artery (PCHA). Several skin and muscle flaps are based on the branches of AxA. Furthermore, these branches are frequently used as recipient vessels in functioning free muscle transfers for upper extremity reconstruction and in breast reconstruction. Accurate knowledge of the normal anatomy and variations in branching pattern of AxA is of significant clinical importance for the reconstructive microsurgeon. The purpose of this article is to report the variable branching pattern of AxA based on multidetector-row computed tomography angiography study of 62 upper extremities. The thoracoacromial artery consistently originated from the first or second part of AxA. The classic origin and branching patterns of SsA and PCHA were observed in 21 cases (33.9%). Anatomic variations of SsA and PCHA were observed in 41 upper extremities (66.1%). In addition to the classic pattern, five distinct variations were noted.

Concepts: Medical imaging, Human anatomy, Upper limb, Axillary artery, Subscapular artery, Arteries of the upper limb, Thoracoacromial artery, Posterior humeral circumflex artery