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Neurosurg Focus 31 (5):E10, 2011

Axillary injury associated with sports

Sangkook Lee, M.D.,1 Kriangsak Saetia, M.D.,2 Suparna Saha, M.D.,1 David G. Kline, M.D.,3 and Daniel H. Kim, M.D.1 1Department of Neurosurgery, Baylor College of Medicine, Houston, Texas; 2Division of Neurosurgery, Department of Surgery, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; and 3Department of Neurosurgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana

Object. The aim of this retrospective study was to present and investigate injuries associated with sports. Methods. This study retrospectively reviewed 26 axillary nerve injuries associated with sports between the years 1985 and 2010. Preoperative status of the axillary nerve was evaluated by using the Louisiana State University Health Science Center (LSUHSC) grading system published by the senior authors. Intraoperative nerve action potential recordings were performed to check nerve conduction and assess the possibility of resection. Neurolysis, suture, and nerve grafts were used for the surgical repair of the injured . In 9 patients with partial loss of function and 3 with complete loss, neurolysis based on nerve action potential recordings was the primary treatment. Two patients with complete loss of function were treated with resection and suturing and 12 with resection and nerve grafting. The minimum follow-up period was 16 months (mean 20 months). Results. The injuries were associated with the following sports: skiing (12 cases), football (5), rugby (2), base- ball (2), ice hockey (2), soccer (1), weightlifting (1), and wrestling (1). Functional recovery was excellent. Neurolysis was performed in 9 cases, resulting in an average functional recovery of LSUHSC Grade 4.2. Recovery with graft repairs averaged LSUHSC Grade 3 or better in 11 of 12 cases Conclusions. Surgical repair can restore useful deltoid function in patients with sports-associated axillary nerve injuries, even in cases of severe stretch–contusion injury. (DOI: 10.3171/2011.8.FOCUS11183)

Key Words • axillary nerve • stretch–contusion injury • sports •

ontact and low-intensity sports can result in ax- Methods illary nerve injury,16 resulting in loss of deltoid function. This muscle is the major abductor of Patient Population Cthe . The axillary nerve arises from the posterior Sports-related isolated axillary nerve injuries in our cord of the and contains fibers derived patient population were associated with the following from C-5 and C-6 spinal nerve roots via the posterior di- sports: skiing (12 cases), football (5), rugby (2), baseball vision of the . It passes through the quadrilat- (2), ice hockey (2), soccer (1), weightlifting (1), and wres- eral space along with the posterior circumflex artery just tling (1) (Table 1). Each patient’s function was evaluated distal to the . The nerve then curves around using the grading scale established by the senior authors the posterolateral surface of the deep to the del- (D.G.K. and D.H.K.) for axillary nerve palsy and deltoid toid and divides into anterior and posterior branches, both muscle weakness (the LSUHSC grading scale; Table 2). of which innervate that muscle. The nerve is tethered pos- Seventeen patients had complete loss of axillary activity teriorly as a result of the overlying muscle, making it sus- (Grade 0); 9 had incomplete but severe functional loss ceptible to stretch. Etiologies include not only fracture (Grade 1–2), without significant spontaneous recovery. and dislocation of the humerus, but less frequently com- Patients who did not recover after 6–8 months of conser- pensation due to prolonged pressure arising from com- vative therapy were treated surgically. mon sports-related activities. The purpose of this paper Electromyography was performed in all patients dur- is to analyze indications for surgical repair and to access ing their baseline evaluation. This study was repeated af- outcomes in patients with solitary axillary nerve injury ter an interval of several months of conservative therapy. associated with sports. Surgery was performed only in cases in which poor re- covery of deltoid function was evidenced by both clinical Abbreviation used in this paper: LSUHSC = Louisiana State and electromyographic examination. Patients selected for University Health Science Center. surgery had undergone radiographic studies and some-

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TABLE 1: Sports associated with axillary nerve injury in 26 cases TABLE 2: The LSUHSC grading scale for axillary nerve palsy and deltoid muscle weakness* Sport No. of Cases (%) Grade Definition skiing 12 (46) football 5 (19) 0 no deltoid contraction rugby 2 (8) 1 trace of deltoid contraction baseball 2 (8) 2 some abduction of shoulder beyond 30° w/ gravity eliminated ice hockey 2 (8) 3 abduction of shoulder against gravity & mild pressure; lateral soccer 1 (4) abduction usually 60°–90° weightlifting 1 (4) 4 abduction of shoulder against gravity & moderate pressure; lateral abduction usually >90° wrestling 1 (4) 5 abduction of shoulder against gravity & great amount of pres- sure; lateral abduction usually >110° times MR imaging of the shoulder. In addition, these patients were often evaluated by orthopedists to rule out * Reproduced with permission from Kline DG, Kim DH: J Neurosurg conditions resulting in comparable functional impair- 99:630–636, 2003. ments, such as injury. In this way, a definitive diagnosis of axillary nerve injury could be established. alization of the (Fig. 1). The thoracodorsal branch extends from the posterior aspect of the posterior Surgical Procedure cord and was usually found at right angles to the cord, An anterior infraclavicular surgical approach was coursing toward the . Distally, used in all of our patients. In those cases in which the subscapularis branches were usually seen leaving the lesion was determined to extend significantly distally, a posterior cord close to its bifurcation into the axillary and posterior approach was added to the anterior approach so radial nerves. By retracting the more distal that adequate exposure could be achieved. The patients medially, and by displacing the were positioned supine and anesthetized with general superiorly and either medially or laterally, access to the endotracheal anesthesia. The table was then inclined to deeper axillary nerve, including that in the quadrilateral place the patient in an approximately 20° reverse Tren- space, could be gained. delenburg position. The patient’s arm was abducted ap- On occasion, posterior circumflex vessels were en- proximately 10°–20°. countered and had to be ligated and divided. At this level, The mildly curvilinear incision extended from the lev- the axillary nerve passes lateral to the profundus branch el of the clavicle to the . At the deltopectoral groove, of the axillary artery, whereas the is located the pectoralis major muscle was incised and split in the on its medial side (Fig. 2). direction of its fibers. A self-retaining retractor was used to To reach the quadrilateral space, the axillary nerve hold the muscle edges apart. Laterally and medially, bun- follows a slightly oblique course laterally and posteriorly. dles of split pectoralis major were set aside for subsequent Exposure of the nerve down to the level of the quadrilateral repair. space was sometimes assisted by deep placement of 1 or The deltopectoral vein and associated vascular 2 small self-retaining retractors. Just distal to the inferior branches were ligated at the superior aspect of the wound, shoulder joint capsule, the nerve passes through the quad- and the underlying pectoralis minor muscle was divided rilateral space along with the posterior circumflex humeral transversely. The self-retaining retractor was then repo- artery. The quadrilateral space is bounded by the teres mi- sitioned to a deeper level and placed along both edges of nor above, the long head of the medially, the teres the pectoralis minor. major and latissimus dorsi muscles below, and the humeral After the was identified and dissected neck laterally. Posteriorly, the axillary nerve divides into free from adipose and scar tissue, it was traced distally anterior and posterior branches. The posterior branch sup- to and through its contribution to the . Next, plies the posterior portions of the deltoid muscles, and a the cord was followed past its branches to the coracobra- small branch from this posterior division innervates the chialis, and finally, on to its continuation as the musculo- teres minor. The posterior branch of the axillary nerve also cutaneous nerve. The latter was freed up several inches supplies sensation to the skin overlying the deltoid muscle. distal to the coracobrachialis branches by splitting the The anterior branch curls around the surgical neck of the overlying biceps and brachialis muscles. The axillary humerus under the deltoid muscle and branches as it ex- artery was dissected out and traced distally along with tends to the anterior border of the deltoid. The branches the overlying median nerve. Often, a large venous branch further divide to innervate this muscle (Fig. 3). The deltoid crossing the median nerve was encountered. This branch is composed of 3 bundles of muscle fibers that contract in was usually isolated and divided. concert to raise the arm laterally. Contraction of the an- The posterior cord was then exposed by gently re- terior bundles, however, provides a more significant con- tracting the lateral cord; on some occasions, the more tribution to anterior or forward abduction. This motion is proximal portion of the axillary artery, and even the me- aided by the pectoralis major muscle and sometimes by the dial portion of the , required gentle retraction long head of the biceps, depending on its relationship to the by means of application of a Penrose drain to allow visu- glenohumeral joint.

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Fig. 1. Illustration of an anterior view of the posterior cord and its major branch relationships between the radial nerve, axillary nerve, and , and the anterior and posterior circumflex arteries.

Intraoperative nerve action potential recordings then examined. If a portion of that nerve on cross-section guided the method of surgical repair of the nerve. If a appeared worse than the rest, that specific portion was nerve action potential was recorded through and distal to resected across the lesion. The nerve was subsequently the stretch–contusion injury, then the epineurial scar was repaired, usually with grafts, leaving the rest of the nerve removed, but the lesion in continuity was not resected. If intact. If there was no action potential conducted across the lesion was irregular, neurolysis was performed along the lesion, the lesion was resected and the gap was usually the full extent of the lesion. The skeletonized nerve was repaired by means of grafts—either sural or antebrachial cutaneous nerves—using a technique similar to that de- scribed by Millesi.19 If a lesion in continuity was not sig- nificantly long, then suture repair was performed. Follow-Up Postoperatively deltoid function was again assessed by means of both clinical examination and electromyog- raphy. All patients were evaluated at least once during the follow-up period (range 16 months–6 years, mean 20 months).

Results Twenty-six cases were surgically explored via an infraclavicular approach. After a mean follow-up of 20 months, functional recovery appraised by means of the Fig. 2. Intraoperative photograph of the infraclavicular plexus at the LSUHSC grading system was quite satisfactory. Nine level where the axillary nerve branches off the posterior cord. LC = patients with partial nerve loss Grade 1 or 2 preopera- lateral cord; MC = medial cord; MT = middle trunk; PC = posterior cord; tively, underwent exploratory surgery. In this subset of pa- UT = upper trunk. tients, neurolysis was performed on the axillary nerves.

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Fig. 3. Intraoperative photographs (A and B) of the posterior approach to the axillary nerve and artist’s illustration of the pos- terior view of the shoulder joint (C). The axillary nerve courses around the humerus with the posterior circumflex artery to branch into the deep aspect of deltoid muscle. The black arrows in A and B indicate the axillary nerve branches to the deltoid muscle. The white arrow in B indicates the posterior circumflex artery.

Postoperatively, the nerves recovered satisfactorily, and literature have been part of a combined brachial plexus a mean grade of 4.2 was attained. Another subset of 3 injury. In 1999, however, Oberle et al.22 presented a case patients with stretch injuries in continuity were found to of axillary nerve paralysis after excessive squash play- have complete nerve loss preoperatively. Intraoperatively, ing. In 2003, repair of axillary nerve–associated shoul- nerve action potentials were able to be conducted across der injury either with or without fracture/dislocation was the lesion. These nerves were treated with neurolysis reported by the senior authors in our group (D.G.K. and alone and eventually a grade of 3–4 was attained in each D.H.K).16 For the first time, isolated axillary nerve palsy of these cases (Table 3). In 2 patients, resection and suture was credited with a dominant role in shoulder dysfunc- repairs were performed for relatively focal lesions. Nerve tion. Previously, our senior authors showed that tailoring action potentials could be conducted across the lesions. the surgical repair to restore the axillary nerve yielded The mean outcome grade in these cases was 3–4. In 12 satisfactory results. This current paper takes the repair patients, graft repairs were made for lengthier lesions of the axillary nerve one step further by categorizing the in continuity that required resection; the mean outcome nuances of the surgical repair and assigning them to be grade was 3 in 3 patients, 3.5 in 8 patients, and 4 in 1 applied to specific subsets of patients, as determined from patient. Specifically, outcomes of neurolysis from partial nerve action potential measurements across the lesion. loss (1 case) and resection with graft from complete loss In our series, skiing and football were the sports most (1 case) revealed extraordinarily good results with post- often associated with axillary nerve injury—involved, re- operative grades of 4.2 and 4, respectively. spectively, in 46% and 19% of the injuries in our case series. Krivickas and Wilbourn17 reported a very large se- ries of over 200 sports-related nerve injuries. Wrestling, Discussion football, rugby, and weightlifting were the 4 sports in Incidence in Various Sports which the highest numbers of peripheral nerve injuries were identified. The absolute number of injuries seen as Most axillary nerve injuries described to date in the a result of participation in a particular sport suggests that TABLE 3: Outcome of axillary nerve repair in 26 cases* the risk of nerve injury is higher in certain sports and that the risk is also influenced by a specific referral base Condition & Treatment No. of Cases Mean Postop Grade for a particular patient population. The most common up- per-extremity injuries were cervical radiculopathies and partial loss & positive NAP† brachial plexopathies, usually the result of severe burn- neurolysis 9 4.2 ers (also referred to as stingers) sustained while wrestling 17 12 complete loss & positive NAP‡ or playing football. A related study by Hirasawa also reported some cases of nerve palsies, but the causes were neurolysis 3 3–4 limited to injuries sustained during mountain climb- resection & suture 2 3–4 ing, gymnastics, and baseball. The reported prevalence resection & graft 3 3 of nerve injury after anterior dislocation of the shoulder 8 3.5 ranges from 5% to 25%,6 and it tends to increase with 1 4 advancing age. In adolescents and young adults who have already had one shoulder dislocation, the prevalence of * NAP = nerve action potential. recurrent shoulder dislocation is about 40%.13–15 † The mean preoperative grade was in the range of 1–2. Another sport deserving of attention is ice hockey. ‡ The preoperative grade in each case was 0. The peripheral nerves of the upper extremity are exposed

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to acute and chronic mechanical injuries in ice hockey peatedly, leading to overuse of particular muscles or mus- players. This is due to frequent repetitive motions, large cle groups and adverse effects on the associated nerves. muscular forces, and extreme shoulder positions. Colak Many proposed mechanisms of injury are described in et al.8 evaluated the effect of ice hockey playing on the the literature in regard to blunt trauma to both the shoulder axillary, musculocutaneous, and radial nerves crossing and the deltoid muscle. Perlmutter and colleagues described the upper arm region. In this study, the values of distal compression of the axillary nerve by a helmeted head blow motor latency of the axillary, musculocutaneous, and ra- as it travels on the deep surface of the deltoid.24–26 Direct dial nerves were found to be significantly prolonged in blunt trauma to the anterolateral aspect of the shoulder via ice hockey players compared with controls. Hence, ice the same mechanism has also been noted to cause axillary hockey and similar sports can repetitively stress the upper nerve injury. There may also be a traction component as- extremity through repeated hard throwing motions sociated with this injury, as scarring of the axillary nerve distal to the quadrilateral space, as well as scarring to the Mechanism of Injury intramuscular portion of the nerve, has been identified. Axillary nerve injuries occur both with and without A direct blow to the anterior lateral deltoid muscle is another main cause of the injury for athletes playing shoulder dislocation. When the shoulder is not dislocated, 3 blunt trauma to the anterior aspect of the shoulder has contact sports. The proximity and route of the axillary been implicated in causing axillary nerve injury. This oc- nerve along the deltoid muscles make it vulnerable to the curs in sports such as football, wrestling, and ice hockey injuries sustained from contact sports. Furthermore, the short length of the axillary nerve renders it vulnerable to as a result of blows from helmeted heads of other play- 11 ers to the shoulder.3,11,16 A more frequent athletic injury, stretch injuries, especially during shoulder dislocation. however, is nerve injury resulting from anterior shoulder Quadrilateral space syndrome represents a chronic dislocation (Fig. 4).4,11 The incidence of nerve palsy af- compression syndrome of the axillary nerve in athletes whose sports of choice require repetitive throwing mo- ter acute dislocations of the shoulder ranges from 9% to 11,18,28 18%.4,23 The prevalence of electrophysiologically docu- tions. Teres minor is the superior margin of the quad- mented nerve damage associated with closed shoulder rilateral space. If fibrous bands develop at the inferior edge trauma is reported to be up to 62% and most frequently of the teres minor, they can compress both the axillary involves the axillary nerve.10 Occasionally, the axillary nerve and the posterior humeral circumflex artery. Quad- nerve is damaged during reduction of a shoulder dislo- rilateral space syndrome can cause complete denervation cation. After glenohumeral dislocation, transient axillary of the deltoid and teres minor muscles by compressing the numbness is often noted. This usually reflects neuraprax- axillary nerve. Compression could be more severe in the abducted, externally rotated (throwing) position.28 Cheung ia rather than a more severe nerve injury. 7 Initially, the mechanism of axillary nerve injury in et al. described the effects of shoulder position on axillary sports was described by Bateman,2 in 1967, as being the nerve positions during the split lateral deltoid approach. result of an upward driving force directly into the armpit. A traumatic insult such as this has the ability to crush the Clinical Presentation and Examination posterior cord against the inferior aspect of the glenohu- Surprisingly, many patients with axillary nerve inju- meral joint, resulting in axillary nerve palsy. An alterna- ry may be asymptomatic even though they have sustained tive mechanism was also described that attributed falling complete or incomplete lesions.29 Pain is not a prominent backward to result in traumatization of the axillary nerve. complaint, and deltoid weakness is often masked by com- As far as sports such as baseball, skiing, ice hockey, and pensation from surrounding muscle groups.1 In the acute football are concerned, stretch injuries of the nerve rank setting, the athlete classically presents with weakness in highest on the list of causes of axillary nerve injury. This abduction, decreased sensation along the deltoid muscle is mainly due to the repetitive motions specific to indi- insertion, progressive atrophy of the deltoid muscle, and vidual sports, which engage the same, distinct muscles re- subluxation of the glenohumeral joint. When affected athletes exercise, however, they may fatigue quickly. This is especially noted with overhead ac- tivity and heavy lifting. Affected persons may also notice reduced strength with abduction or an inability to raise the arm. Furthermore, numbness of the lateral arm may be noted. The presence of trauma, dislocation, or fracture should be documented. The physical examination of ath- letes with axillary nerve injury should include evaluation for range of motion (passive and active) and strength in all planes. External rotation strength is important to as- sess, because 45% of external rotation strength is from the teres minor. This is an important distinction, because global strength, especially abduction and forward eleva- Fig. 4. Schematic illustration of the axillary nerve being stretched across the humeral head following shoulder dislocation. The capsule is tion, is predominantly provided by the deltoid, the prime represented as completely disrupted or greatly elongated. A: Intact mover of the shoulder. When a patient is seen late in the shoulder joint and axillary nerve. B: Shoulder joint dislocation and course of the affliction, muscular atrophy, particularly of stretched axillary nerve. the deltoid and teres minor, should be noted, as it is of

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Unauthenticated | Downloaded 10/02/21 12:54 PM UTC S. Lee et al. great importance in localizing the lesion. If the posterior but despite this, the results of surgery are generally good, deltoid and teres minor are spared, then the lesion is dis- with restoration of 3–4/5 strength in the deltoid in more tal to the quadrilateral space. A complete neurovascular than 90% of patients.27 Chronic axillary nerve compres- examination should be performed to assess sensation over sion in quadrilateral space syndrome generally responds the upper lateral arm and to rule out other lesions such as to conservative management, including changing pitching thoracic outlet syndrome and brachial plexus and cervical mechanics, which has been reported to be successful in spine lesions. It is also important to note that complete 75%–90% of patients.9,11 Surgical intervention for quadri- deltoid muscle deficit may occur in the presence of nor- lateral space syndrome is indicated if conservative man- mal sensation to the upper lateral arm and shoulder. Sev- agement fails and involves release of fibrous bands of the eral reports have documented the unreliability of sensory and any aberrant bands crossing the changes after injury.4 quadrilateral space.9,28 Timing of surgery, however, remains Axillary nerve injury resulting from a direct blow to controversial. In a thorough review of 146 cases, Bonnard the anterolateral shoulder, however, has a less optimistic et al.5 demonstrated a dramatic reduction in the number prognosis. Perlmutter et al.24–26 noted persistent paralysis of successful outcomes with increasing delay between the of the deltoid with such injuries in 11 athletes at 2.5–23 time of injury and intervention. By contrast, Moor et al.20 years after injury. showed the positive results in delayed axillary nerve recon- Acute axillary nerve palsy is often seen in the athletic struction with interposition of sural nerve grafts and con- setting, and careful physical examination and EMG evalu- cluded that even delayed axillary nerve grafting may lead ation are necessary to make an accurate diagnosis. Evalua- to satisfactory functional results with a low morbidity and tion of strength is typically hampered by pain. The injured should therefore be done in selected patients. athlete can often elevate the arm using the pectoralis and supraspinatus muscles, and subluxation can be prevented Preventive Measures by the supraspinatus and long head of the biceps muscles. Proper conditioning and preventive measures in Active arm elevation by compensatory muscles is seen in young athletes are important to avoid axillary nerve in- up to 60% of athletes after axillary nerve injury. juries around the shoulder. Most of these injuries occur Careful manual muscle testing is important in identi- in inexperienced athletes, and poor conditioning plays a fying gross weakness in abduction. Patients with chronic large role.21,31 Preventing these types of injuries includes compression of the axillary nerve in quadrilateral space the following: adequate preseason examination; matching syndrome typically present with tenderness in the pos- competitors for age, weight, and skill level; proper condi- terior shoulder area in the quadrilateral space, which is tioning; avoiding excessive training at too early an age; exacerbated by placing the arm in the throwing position thorough rehabilitation of the injured athlete before return and resisting internal rotation.28 Symptoms, however, are to sports; appropriate and properly maintained equipment often vague, consisting of a dull ache in the shoulder with and playing fields; adequate supervision; and rule changes progressive use, and may be difficult to differentiate from as necessary. Although in the US the highest injury rates the internal impingement also seen in the throwing ath- are noted in adolescents participating in football, basket- lete. ball, gymnastics, baseball, and roller skating, in Japan nerve injury occurs most commonly from mountain climb- Treatment ing—as a result of excessive backpack weight.2,30 Rather When electromyography reveals an axillary nerve le- than condemning certain sports as unsafe because of a high sion, the athlete should be reevaluated at monthly inter- incidence of injuries, proper training techniques should be vals for signs of nerve regeneration. Because the axillary emphasized in all sports to reduce the risk of these injuries. nerve is relatively short, in the case of a second-degree injury (axonotmesis), recovery should be seen between Conclusions the 3rd and 4th month after injury. Surgical exploration and possible nerve grafting are generally recommended Direct attacks and blows to the shoulder area are if no return of function has occurred by 4–6 months after common for athletes playing contact sports. In addition, injury.1,3,9,11,27 the axillary nerve has characteristic anatomical features In our series, all patients who were deemed to be ap- such as its short length and a specific route beneath the propriate surgical candidates did not show adequate signs deltoid muscle that predispose it to injury. As such, axil- of spontaneous recovery (greater than LSUHSC Grade lary nerve injury associated with sports has been a rela- 2) even after 6–8 months of conservative therapy. Thus, tively common occurrence, with or without humerus frac- surgical intervention was believed to be a reasonable ture and dislocation. Favorable functional outcomes in treatment option. The patients in our series were further those with axillary nerve injury are essential, especially subdivided into 3 groups: neurolysis-only group, resec- for athletes who wish to continue engaging in their sport tion-and-direct-suture-repair group, and resection-and- of choice. Therefore, surgical repair of the axillary nerve graft-repair group; after surgical intervention, patients in by means of neurolysis and nerve grafting should be con- all 3 groups showed satisfactory results. sidered in the management of these cases. In our patient The site of nerve injury is sometimes in the quadri- population, surgical intervention appropriate to the extent lateral space, requiring both anterior and posterior surgi- of nerve injury has proven to be a reliable method of re- cal approaches. Cable grafts are commonly required if the gaining deltoid function in severe cases of sports-related axillary nerve ends cannot be repaired without tension, stretch–contusion injuries.

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Disclosure shoulder. Results of a prospective study of treatment. J Bone Joint Surg Am 65:343–349, 1983 The authors report no conflict of interest concerning the mate- 15. Hovelius L, Lind B, Thorling J: Primary dislocation of the rials or methods used in this study or the findings specified in this shoulder. Factors affecting the two-year prognosis. Clin Or- paper. thop Relat Res (176):181–185, 1983 Author contributions to the study and manuscript preparation 16. Kline DG, Kim DH: Axillary nerve repair in 99 patients with include the following. Conception and design: Kim, Lee. Acquisi- 101 stretch injuries. J Neurosurg 99:630–636, 2003 tion of data: Lee, Saetia. Analysis and interpretation of data: Kim, 17. Krivickas LS, Wilbourn AJ: Peripheral nerve injuries in ath- Lee, Saetia, Saha. Drafting the article: Lee, Saetia. Critically revis- letes: a case series of over 200 injuries. Semin Neurol 20: ing the article: Kim, Saha, Kline. Reviewed submitted version of 225–232, 2000 manuscript: Lee, Saha, Kline. Approved the final version of the 18. McKowen HC, Voorhies RM: Axillary nerve entrapment in manuscript on behalf of all authors: Kim. Administrative/technical/ the quadrilateral space. Case report. J Neurosurg 66:932– material support: Kim, Saetia, Kline. Study supervision: Kline. 934, 1987 19. Millesi H: Nerve grafts: indications, techniques and progno- References sis, in Omer GE Jr, Spinner M (eds): Management of Periph- eral Nerve Problems. Philadelphia: WB Saunders, 1980, pp 1. Alnot JY: Traumatic brachial plexus palsy in the adult. Retro- 410–430 Clin Orthop Relat Res (237): and infraclavicular lesions. 9– 20. Moor BK, Haefeli M, Bouaicha S, Nagy L: Results after de- 16, 1988 layed axillary nerve reconstruction with interposition of sural 2. Bateman JE: Nerve injuries about the shoulder in sports. J nerve grafts. J Shoulder Elbow Surg 19:461–466, 2010 Bone Joint Surg Am 49:785–792, 1967 21. O’Neill DB, Micheli LJ: Overuse injuries in the young athlete. 3. Berry H, Bril V: Axillary nerve palsy following blunt trauma Clin Sports Med 7:591–610, 1988 to the shoulder region: a clinical and electrophysiological re- 22. Oberle J, Kuchelmeister K, Schachenmayr W, Richter HP: view. J Neurol Neurosurg Psychiatry 45:1027–1032, 1982 4. Blom S, Dahlbäck LO: Nerve injuries in dislocations of the [Axillary nerve paralysis after playing squash. A case report.] shoulder joint and fractures of the neck of the humerus. A clin- Nervenarzt 70:750–753, 1999 (Ger) ical and electromyographical study. Acta Chir Scand 136: 23. Pasila M, Jaroma H, Kiviluoto O, Sundholm A: Early compli- 461–466, 1970 cations of primary shoulder dislocations. Acta Orthop Scand 5. Bonnard C, Anastakis DJ, van Melle G, Narakas AO: Isolated 49:260–263, 1978 and combined lesions of the axillary nerve. A review of 146 24. Perlmutter GS: Axillary nerve injury. Clin Orthop Relat Res cases. J Bone Joint Surg Br 81:212–217, 1999 (368):28–36, 1999 6. Brown HA, Brown BA: Treatment of peripheral nerve inju- 25. Perlmutter GS, Apruzzese W: Axillary nerve injuries in con- ries. Rev Surg 24:1–8, 1967 tact sports: recommendations for treatment and rehabilitation. 7. Cheung S, Fitzpatrick M, Lee TQ: Effects of shoulder position Sports Med 26:351–361, 1998 on axillary nerve positions during the split lateral deltoid ap- 26. Perlmutter GS, Leffert RD, Zarins B: Direct injury to the ax- proach. J Shoulder Elbow Surg 18:748–755, 2009 illary nerve in athletes playing contact sports. Am J Sports 8. Colak T, Bamaç B, Alemdar M, Macit Selekler H, Ozbek A, Med 25:65–68, 1997 Colak S, et al: Nerve conduction studies of the axillary, mus- 27. Petrucci FS, Morelli A, Raimondi PL: Axillary nerve inju- culocutaneous and radial nerves in elite ice hockey players. J ries—21 cases treated by nerve graft and neurolysis. J Hand Sports Med Phys Fitness 49:224–231, 2009 Surg Am 7:271–278, 1982 9. Cormier PJ, Matalon TA, Wolin PM: Quadrilateral space syn- 28. Redler MR, Ruland LJ III, McCue FC III: Quadrilateral space drome: a rare cause of shoulder pain. Radiology 167:797–798, syndrome in a throwing athlete. Am J Sports Med 14:511– 1988 513, 1986 10. de Laat EA, Visser CP, Coene LN, Pahlplatz PV, Tavy DL: 29. Safran MR: Nerve injury about the shoulder in athletes, part Nerve lesions in primary shoulder dislocations and humeral 1: and axillary nerve. Am J Sports Med neck fractures. A prospective clinical and EMG study. J Bone 32:803–819, 2004 Joint Surg Br 76:381–383, 1994 30. Sicuranza MJ, McCue FC III: Compressive neuropathies in 11. Duralde XA: Neurologic injuries in the athlete’s shoulder. J the upper extremity of athletes. Hand Clin 8:263–273, 1992 Athl Train 35:316–328, 2000 31. Stein CJ, Micheli LJ: Overuse injuries in youth sports. Phys 12. Hirasawa Y: [Mechanism of regeneration and repair of the pe- Sportsmed 38:102–108, 2010 ripheral nerve.] Nippon Seikeigeka Gakkai Zasshi 64:99– 111, 1990 (Jpn) 13. Hoelen MA, Burgers AM, Rozing PM: Prognosis of primary Manuscript submitted July 15, 2011. anterior shoulder dislocation in young adults. Arch Orthop Accepted August 23, 2011. Trauma Surg 110:51–54, 1990 Address correspondence to: Daniel H. Kim, M.D., Department of 14. Hovelius L, Eriksson K, Fredin H, Hagberg G, Hussenius Neurosurgery, Baylor College of Medicine, 1709 Dryden, Suite 750, A, Lind B, et al: Recurrences after initial dislocation of the Houston, Texas. email: [email protected].

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