Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

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Management-Operative Management

For axillary nerve injury resulting from penetrating trauma or iatrogenic causes, management is immediate repair. When axillary nerve injury results from causes other than penetrating trauma or surgery (i.e., those with closed trauma), surgery is indicated for symptomatic patients with no clinical or EMG/NCV evidence of recovery 3 to 6 months following injury.

The best functional results occur when surgery is performed within 6 months of injury; patients can expect excellent return of strength and function. Surgery after 6 months results in more modest gains. Functional improvement can be expected with surgery up to 1 year after injury.

Surgery performed more than 1 year after the injury in symptomatic patients has an even poorer prognosis for functional recovery. Surgical approaches include neurolysis, neurorrhaphy, nerve grafting, nerve transfer, and neurotization. After 1 year, tendon transfers may be undertaken, but these are salvage procedures and are not designed for return to sports.

Reviewing the literature does not help in determining the outcome for athletes. Most series do not report their results of athletes independently from the general population. Furthermore, most series combine the results of surgery in patients with axillary nerve injury from many different etiologies.

The symptoms of quadrilateral space syndrome are thought to result from intermittent compression of the axillary nerve at the quadrilateral space, but EMG/NCV studies are almost uniformly negative. No studies have determined the natural history, but many suggest that this syndrome may resolve with nonoperative management provided the patient has no space-occupying lesion, such as a cyst, or bony abnormality causing this syndrome. One investigator has suggested that only 30% of patients experience symptoms warranting surgical intervention.

The indication for decompression of the quadrilateral space for quadrilateral space syndrome is persistent symptoms beyond 6 months despite nonoperative management. Cahill and Palmer recommend surgery only if the diagnosis is confirmed by angiography, the patient is point tender at the quadrilateral space of the posterior shoulder, and the patient has failed 6 months of conservative management.

The surgical approach requires splitting the deltoid in line with its fibers posteriorly but some advocate detaching part of the origin of the deltoid. The axillary nerve and posterior circumflex artery are readily identified and isolated. Often, fibrous bands are identified, and if so, they are sectioned or excised.

Some surgeons also recommend releasing part of the teres major to further relieve pressure on the nerve; however, the senior author has not found this to be necessary.Once the nerve and artery have been released, digital palpation of the arterial pulse with the arm in abduction and external rotation will confirm adequate decompression.

Looking to the literature, no large series of quadrilateral space syndrome have appeared since the initial report of 18 patients by Cahill and Palmer. Of these 18 patients, eight had dramatic relief of symptoms, eight were improved (with some persistence of night pain), and two were no better following surgery. In the experience of the senior author as well as that of others, however, patients with arteriogram-proven quadrilateral space syndrome usually have immediate relief of symptoms after release of fibrous bands.

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