Ultrasound of the posterior circumflex humeral artery

Quadrangular Space Syndrome: A Narrative Overview

OBJECTIVE

The purpose of this narrative review of the literature is to provide an overview of quadrangular space syndrome with special attention to its clinical presentation, differential diagnosis, and treatment.

METHODS

A narrative review of the English-language, peer-reviewed literature was performed using the key words "axillary nerve," "quadrangular space," "quadrilateral space," and "posterior humeral circumflex artery." Databases searched were Medline Complete, Cumulative Index to Nursing and Allied Health Literatures, and Index to Chiropractic Literature. The search period was from 1983 through January 2020.

RESULTS

There were 85 articles selected for this review. A summary and overview are provided.

CONCLUSION

Quadrangular space syndrome is an uncommon cause of shoulder pain. Clinicians should consider it as a diagnosis after ruling out more common shoulder conditions and examining other concurrent diseases.

Posterior circumflex humeral artery pathology and digital ischemia in elite volleyball: Symptoms, risk factors & suggestions for clinical management

OBJECTIVES

To assess the association between posterior circumflex humeral artery (PCHA) pathology (PCHAP), symptoms and associated risk factors, in elite volleyball players, and to suggest profiles for clinical management and monitoring.

DESIGN

Cross-sectional study.

METHODS

A questionnaire assessed symptoms of digital ischemia (DI) in the dominant hand and risk factors among 278 elite indoor and beach volleyball players of whom 6.1% (17/278) was diagnosed with PCHAP using ultrasound. Odds Ratios (OR) including 95% confidence intervals (95%CI) were calculated using binary logistic regression.

RESULTS

All 278 players completed the questionnaire. Three participants with PCHAP were symptomatic (18%). Ninety-three of 96 symptomatic participants had no PCHAP (OR=0.39; 95% CI 0.13-1.13). Total years playing volleyball (OR 1.14; 95% CI 1.03-1.25) and age (OR 1.17; 95% CI 1.00-1.29) were dose-response related risk factors: a volleyball career of ≥17 years and age of ≥27 years were associated with a 9-fold and 14-fold increased risk of PCHAP, respectively.

CONCLUSIONS

The volleyball career duration and age are dose-response related risk factors for PCHAP among elite indoor and beach volleyball players. DI symptoms are prevalent in a minority of athletes with PCHAP (3/17; 18%). To enable worldwide standardized care for these athletes at risk, four profiles for clinical management and monitoring have been suggested based on questionnaire and ultrasound outcomes.

Vascular Quadrilateral Space Syndrome in 3 Overhead Throwing Athletes: An Underdiagnosed Cause of Digital Ischemia

Vascular quadrilateral space syndrome (vQSS) is an underdiagnosed cause of extremity ischemia, pain, and paresthesia in overhand throwing athletes. The mechanism of vQSS is thought to result from repeated abduction and external rotation of the arm leading to a distraction injury of the posterior circumflex humoral artery (PCHA) as this courses through the quadrilateral space. This trauma may cause dissection and dissecting aneurysm formation. Thrombus from this arterial injury then embolizes down the arm resulting in the symptomatic presentation. Patients were often presented after multiple embolic events, which have resulted in obliteration of digital arteries. Later stages of presentation may include ischemic ulceration and gangrene. We report 3 cases of vQSS in overhand throwing athletes. All 3 underwent surgical correction and have returned to competition. We discuss presentation, diagnosis, imaging findings, management, outcomes, and review of the literature. Prompt recognition of this syndrome is essential to optimal treatment, which includes PCHA ligation and division with or without thrombolytic therapy. Increased awareness of vQSS is needed among coaches and athletic trainers who often identify the symptoms and initiate the treatment. When treated promptly, these athletes return to baseline functional status.

Ultrasound assessment of the posterior circumflex humeral artery in elite volleyball players: Aneurysm prevalence, anatomy, branching pattern and vessel characteristics

Objectives

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.

Methods

Two-hundred and eighty players underwent standardized ultrasound assessment of the dominant arm by a vascular technologist. Assessment included determination of PCHA aneurysms (defined as segmental vessel dilatation ≥150 %), PCHA and DBA anatomy, branching pattern, vessel course and diameter.

Results

The PCHA and DBA were identified in 100 % and 93 % (260/280) of cases, respectively. The prevalence of PCHA aneurysms was 4.6 % (13/280). All aneurysms were detected in proximal PCHA originating from the axillary artery (AA). The PCHA originated from the AA in 81 % of cases (228/280), and showed a curved course dorsally towards the humeral head in 93 % (211/228). The DBA originated from the AA in 73 % of cases (190/260), and showed a straight course parallel to the AA in 93 % (177/190).

Conclusions

PCHA aneurysm prevalence in elite volleyball players is high and associated with a specific branching type: a PCHA that originates from the axillary artery. Radiologists should have a high index of suspicion for this vascular overuse injury. For the first time vessel characteristics and reference values are described to facilitate ultrasound assessment.

Key Points

• Prevalence of PCHA aneurysms is 4.6 % among elite volleyball players.

• All aneurysms are in proximal PCHA that originates directly from AA.

• Vessel characteristics and reference values are described to facilitate US assessment.

• Mean PCHA and DBA diameters can be used as reference values.

• Radiologists need a high index of suspicion for this vascular overuse injury.

B-Mode Sonographic Assessment of the Posterior Circumflex Humeral Artery: The SPI-US Protocol-A Technical Procedure in 4 Steps

Elite overhead athletes are at risk of vascular injury due to repetitive abduction and external rotation of the dominant arm. The posterior circumflex humeral artery (PCHA) is prone to degeneration, aneurysm formation, and thrombosis in elite volleyball players and baseball pitchers. The prevalence of PCHA-related thromboembolic complications is unknown in this population. However, the prevalence of symptoms associated with digital ischemia is 31% in elite volleyball players. A standardized noninvasive imaging tool will aid in early detection of PCHA injury, prevention of thromboembolic complications, and measurement reproducibility. A standardized vascular sonographic protocol for assessment of the proximal PCHA (SPI-US protocol [Shoulder PCHA Pathology and Digital Ischemia-Ultrasound protocol]) is presented.

Reproducibility of the SPI-US protocol for ultrasound diameter measurements of the Posterior Circumflex Humeral Artery and Deep Brachial Artery: an inter-rater reliability study

OBJECTIVES

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.

METHODS

Two experienced sonographers determined diameters of the PCHA and DBA using the SPI-US protocol. Inter-observer agreement was evaluated using intra-class correlation coefficient (ICC), standard error of measurement (SEM), minimal detectable change (MDC), Bland-Altman (BA) analysis, and variance component (VARCOMP) analysis.

RESULTS

Thirty-three healthy volunteers participated. The ICC for diameter measurement of the PCHA and DBA were 0.70 (95 %CI 0.50-0.83) and 0.60 (95 %CI 0.30-0.80), respectively. The SEM for the PCHA and DBA was 0.32 mm and 0.29 mm and MDC was 0.90 mm and 0.80 mm, respectively. The BA and VARCOMP analyses showed no systematic and only marginal sonographer bias.

CONCLUSIONS

The SPI-US protocol is accurate and precise for PCHA and DBA diameter assessment in cases where they originate from the axillary artery. PCHA and DBA diameter measurements are sonographer-independent using the SPI-US-protocol.

KEY POINTS

• PCHA & DBA diameter assessment is accurate and reliable using the SPI-US protocol • PCHA & DBA diameter measurements are sonographer-independent using the SPI-US protocol • The SPI-US protocol minimal detectable change is 0.90 mm for PCHA diameter measurement • This minimal detectable change enables detection of PCHA aneurysms • First step towards international periodic surveillance of athletes at risk of PCHA-injury.

High prevalence of self-reported symptoms of digital ischemia in elite male volleyball players in the Netherlands: a cross-sectional national survey

BACKGROUND

In the past 3 years, 6 volleyball players with ischemic digits and small microemboli in the digital arteries of the dominant hand presented themselves in our hospital. These complaints were caused by an aneurysmatic dilation of the posterior circumflex humeral artery (PCHA) with distal occlusion and digital emboli in the isolateral limb. All were elite male volleyball players active in the national top league. Little is known about the exact symptoms associated with PCHA pathological lesions with digital emboli (PCHAP with DE) and its prevalence in elite volleyball players. If vascular injury can be identified at an early stage, thromboembolic complications and irreversible damage to the digits might be prevented.

PURPOSE

To assess the prevalence of symptoms that are consistent with digital ischemia and may be caused by PCHAP with DE in elite male volleyball players in the Netherlands.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A questionnaire survey was performed among elite volleyball players in the Dutch national top league and the Dutch beach volleyball team. The questionnaire was constructed using literature-based data on symptoms associated with PCHAP with DE, together with data retrieved from medical files.

RESULTS

A total of 99 of the 107 athletes participated, with a response rate of 93%. The most frequently reported symptoms associated with PCHAP with DE were cold, blue, or pale digits in the dominant hand during or immediately after practice or competition. The prevalence of these symptoms ranged from 11% to 27%. The prevalence of cold digits during practice and competition was 27%. The prevalence of cold, blue, and pale digits during or immediately after practice and competition was 12%.

CONCLUSION

An unexpectedly high percentage of elite volleyball players reported symptoms that are associated with PCHAP with DE in the dominant hand. Because these athletes are considered potentially at risk for developing critical digital ischemia, further analysis of the presence of digital ischemia and PCHA injury is warranted.