In an unprecedented case of acute traumatic quadrilateral space syndrome (QSS) related to a scapula fracture, the Tunis Trauma Center has documented a breakthrough surgical intervention leading to a complete recovery of the axillary nerve function within ten weeks. This extraordinary case signifies a step forward in understanding and treating what has previously been considered a rare and diagnosis-challenging condition.

The clinical narrative, featured in the “Journal of Clinical Orthopaedics and Trauma,” details the experience of a patient who sustained a burst fracture of the right scapula with significant displacement of the lateral border, resulting in a total isolated paralysis of the right axillary nerve due to nerve compression. The patient underwent a successful lateral scapula border fracture reduction and stabilized with neurolysis of the axillary nerve through a posterior surgical approach.

DOI: 10.1016/j.jcot.2018.05.016


1. Quadrilateral Space Syndrome
2. Scapula Fracture Treatment
3. Axillary Nerve Injury
4. Shoulder Trauma Recovery
5. Neurolysis Surgical Technique

A recent publication in the “Journal of Clinical Orthopaedics and Trauma” has brought to light a rare yet significant case of acute traumatic quadrilateral space syndrome (QSS), shedding new light on its management and underscoring the need for heightened clinical awareness. The report documents the novel treatment of QSS following an extensive fracture of the scapula, usually a consequence of shoulder trauma.

Quadrilateral space syndrome, a condition resulting from the compression of the axillary nerve and the posterior humeral circumflex artery, manifests as shoulder pain, numbness, and motor deficiency, particularly within the deltoid muscle. Although cases of QSS have been documented in clinical literature, they remain infrequent, and their association with scapula fractures without concomitant shoulder dislocation is exceedingly rare.

The case, presented by a team of orthopedic specialists at the Tunis Trauma Center, involves a patient who suffered from a scapula fracture leading to a brutal compression of the axillary nerve. What makes this case both original and critical is that, unlike most reported instances of axillary nerve injury, there was no accompanying shoulder dislocation. This element alone could have posed a significant diagnostic challenge, potentially leading to compromised patient prognosis.

On examination, it was determined that the scapula fracture had resulted in significant displacement of the lateral border, occasioning a complete and isolated paralysis of the right axillary nerve – a condition that required immediate surgical intervention to prevent lasting nerve damage.

Under the guidance of the lead surgeon and first author, Dr. Mahjoub Sabri, the patient underwent surgery which involved the use of a posterior approach to reduce and stabilize the lateral scapula border fracture, as well as neurolysis—an intricate procedure where the nerve is freed from restrictive tissues—to decompress the axillary nerve.

The postoperative recovery was groundbreaking; within an astounding ten weeks, the patient demonstrated full recovery of axillary nerve function, which was corroborated by electromyographic studies.

This success story is particularly significant in the realm of orthopedic trauma care for multiple reasons. Firstly, it accentuates the importance of timely and accurate diagnosis of axillary nerve injury associated with scapula fractures. It also highlights the potential of surgical treatment that extends beyond the traditional fixation of the fracture to include neurolysis to alleviate nerve compression.

References supporting the novelty and gravity of this case are the backbone of the study. Pioneering research by Cahill and Palmer described the condition of QSS as early as 1983 (Cahill B.R., Palmer R.E. Quadrilateral space syndrome. J Hand Surg. 1983;8(January (1)):65–69. DOI: 6827057). Further understanding of QSS’s anatomy was provided by McClelland and Paxinos in 2008 (McClelland D., Paxinos A. The anatomy of the quadrilateral space with reference to quadrilateral space syndrome. J Shoulder Elbow Surg. 2008;17(January-February (1)):162–164. DOI: 17993281), which expanded the clinical awareness of the syndrome.

Additionally, other scholarly works have informed the association between shoulder injuries and nerve damage. Chamata et al. in a national data bank review identified the prevalence of brachial plexus injuries in patients with scapular fractures (Chamata E., Mahabir R., Jupiter D., Weber R.A. Prevalence of brachial plexus injuries in patients with scapular fractures: a national trauma data Bank review. Plast Surg (Winter) 2014;22(4):246–248. PMC4271753 DOI: 25535462), while Fialka et al. modified the Constant-Murley shoulder score for better assessment and management of shoulder injuries (Fialka C., Oberleitner G., Stampfl P., Brannath W., Hexel M., Vecsei V. Modification of the constant-murley shoulder score – introduction of the individual relative constant score – individual shoulder assessment. Injury. 2005;36(October (10)):1159–1165. DOI: 16214462).

The expertise integrated into the management of this case owes much to the collective knowledge of nerve injuries around the shoulder area in athletes, provided by clinical observations such as those by Safran M.R. (Safran M.R. Nerve injury about the shoulder in athletes, part 1: suprascapular nerve and axillary nerve. Am J Sports Med. 2004;32(April-May (3)):803–819. DOI: 15090401) and investigations into the prognosis of nerve lesions resulting from shoulder dislocations and humeral neck fractures (de Laat E.A., Visser C.P., Coene L.N., Pahlplatz P.V., Tavy D.L. Nerve lesions in primary shoulder dislocations and humeral neck fractures. A prospective clinical and EMG study. J Bone Jt Surg Br. 1994;76(May(3)):381–383. DOI: 8175837). Additionally, literature covering the operative treatment of scapular fractures offered a basis for surgical decision-making in this case (Hardegger F.H., Simpson L.A., Weber B.G. The operative treatment of scapular fractures. J Bone Jt Surg Br. 1984;66(Nov (5)):725–731. DOI: 6501369).

Courageous surgical procedures and invaluable findings in such a complex realm of orthopedic surgery as presented by specialists, including Neuhaus V. et al., who explored the interobserver reliability of the classification and treatment of scapula fractures (Neuhaus V., Bot A.G., Guitton T.G. Scapula fractures: interobserver reliability of classification and treatment. J Orthop Trauma. 2014;28(March (3)):124–129. DOI: 23629469), as well as a systematic review of scapula fractures treatments provided by Zlowodzki M. et al. (Zlowodzki M., Bhandari M., Zelle B.A., Kregor P.J., Cole P.A. Treatment of scapula fractures: systematic review of 520 fractures in 22 case series. J Orthop Trauma. 2006;20(March (3)):230–233. DOI: 16648708), all contribute to the foundation upon which the surgical approach for this case was formulated.

The case presented by the Tunis Trauma Center team not only advances the medical community’s understanding of acute traumatic quadrilateral space syndrome following scapula fractures but also sets a successful precedent for surgical treatment of an otherwise overlooked nerve injury. It is a testament to the critical role of accurate diagnosis followed by innovative surgical techniques in restoring function and quality of life in patients with complex orthopedic injuries.

As awareness amongst clinicians increases, aided by publications such as this, the management of similar traumatic injuries will be refined and optimized, assuring improved outcomes for future patients.

The groundbreaking success of this case provides hope and direction for patients and medical professionals facing similar challenges in the diagnosis and treatment of acute traumatic QSS secondary to shoulder trauma and scapula fractures. It stands as a shining example of clinical acumen and surgical excellence in the orthopedic field, and will undoubtedly guide future research and treatment protocols for those afflicted with this complex condition.

In summary, the originality of the case lies in its rarity—the isolated axillary nerve injury following a scapula fracture without shoulder dislocation and the subsequent surgical intervention that advanced recovery in a remarkably short period. This case represents a pivotal point that signals the potential to correct axillary nerve injuries effectively, given adequate and prompt intervention alongside skilled surgical maneuvering.

The report has been a beneficial addition to understanding the intricacies of shoulder injuries and their profound implications on nerve function. It serves as a pivotal instrument for orthopedic clinicians and surgeons, presenting a treatment option that can lie beyond traditional orthopedic approaches and into the realm of intricate nerve repair. It also serves as a benchmark for the future direction of orthopedic trauma care and provides a foundation for ongoing education, research, and clinical improvement within this field.