axillary nerve palsy and deltoid muscle atony · 2019. 12. 19. · treatment, and prevention of...

Axillary Nerve Palsy and DeltoidMuscle Atony

Justin J. Mitchell, MD

Christopher Chen, MD

Daniel J. Liechti, MD

Austin Heare, MD

Jorge Chahla, MD

Jonathan T. Bravman, MD

Investigation performed at theDepartment of Orthopaedic Surgery,Division of Sports Medicine andShoulder Surgery, University ofColorado, Aurora, Colorado, andUniversity of Colorado School ofMedicine, Aurora, Colorado

COPYRIGHT © 2017 BY THEJOURNALOF BONE AND JOINTSURGERY, INCORPORATED

Abstract» Axillary nerve palsy presents in a variety of ways and can be asubstantial source of dysfunction about the shoulder. It is important forthe orthopaedic surgeon to recognize axillary nerve injuries in thesetting of acute trauma. The surgeon should also be aware that suchinjuries are part of the complication profile of both open andarthroscopic surgery involving the shoulder.

» Early recognition and treatment is important as full recoverybecomes less likely in association with chronic axillary nerve injuries.However, diagnosis is often difficult and can be masked by compen-satory mechanisms of the adjacent shoulder muscles.

» Several treatment options are available, depending on the extent andtype of injury, including neurolysis, neurorrhaphy, nerve-grafting, andnerve transfer. This article highlights the etiology, diagnostic pathways,and treatment of both traumatic and iatrogenic axillary nerve injuries.

Peripheral nerve injuries aboutthe shoulder are a cause of painand dysfunction and have avariety of etiologies and pre-

sentations. Among these, axillary nerveinjury is one of the most common1,2,representing.50% of all infraclavicularbrachial plexus injuries in a recent studyof 101 patients3. Axillary nerve injury canoccur in cases of trauma, with 1 studydemonstrating a rate of 16% (38 of 240)among patients with anterior shoulderdislocation4. It is also an increasinglywell-known and devastating iatrogeniccomplication of shoulder surgery, with thediagnosis being frequently delayed ormissed5,6. A delay in diagnosis may beattributable to absent or delayed symp-tomatology due to compensation by themuscles of the rotator cuff or due to anoccult presentation in the setting of severeassociated injuries, such as proximal hu-meral fracture or shoulder dislocation7.

Axillary nerve injury also may occurduring other forms of glenohumeral

trauma, with or without associated sub-luxation of the humeral head, resulting incompression, traction, or contusion of thenerve along the deep surface of the deltoidmuscle. Such mechanisms of injury fre-quently have been reported in associationwith motor-vehicle accidents and contactsports (e.g., skiing, football, and rugby)8,9.Additionally, atraumatic and chronic formsof injury may occur secondary to repetitivemicrotrauma (e.g., in overhead throwingathletes such as baseball pitchers), brachialneuritis, quadrilateral space syndrome,blunt trauma, and neural entrapmentsecondary to space-occupying lesions7.

A delay in diagnosis is concerning asclinical outcome is strongly dependent onthe time from the injury to treatment7,witha worse prognosis for injuries that remainundiagnosed for more than 6 to 12months7,8. Therefore, it is critical to rec-ognize the clinical settings that demand ahigh index of suspicion for axillary nerveinjury and to understand correspondingevidence-based treatment options. To this

Disclosure: The authors indicated that no external funding was received for any aspect of this work.

The Disclosure of Potential Conflicts of Interest forms are provided with the online version

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end, we present an updated review of theanatomy, pathophysiology, diagnosis,treatment, and prevention of axillarynerve injury and dysfunction.

AnatomyThe axillary nerve, also known as thecircumflex nerve, is a mixed motor andsensory nerve that originates from theventral rami of the fifth and sixth cervicalnerve roots5. Most commonly, the axil-lary nerve arises from fibers of the pos-terior cord of the posterior division ofthe brachial plexus10; however, variantshave been reported in as many as 20%of patients, in whom the nerve arisesfrom the posterior division of the uppertrunk11. The axillary nerve travelsobliquely along the anterior surface ofthe subscapularis muscle and posteriorto the axillary artery before diving infe-riorly into the quadrilateral spacealongside the posterior humeral cir-cumflex artery, in close proximity tothe inferomedial capsule (Fig. 1)5,12.

The quadrilateral space is boundby the long head of the triceps musclemedially, the humeral shaft laterally, theteres major and latissimus dorsi musclesinferiorly, and the subscapularis muscleanteriorly. After passing through thequadrilateral space, the nerve travelsaround the posterolateral aspect of thehumeral neck, where it divides into an-terior and posterior branches. The an-terior branch courses around the surgical

neck of the humerus, approximately 4 to7 cm inferior to the anterolateral cornerof the acromion, and terminates in theanterior portion of the deltoid12,13,supplying collateral sensory and motorbranches to the anterior and lateralsegments of this muscle (Fig. 2). Theposterior branch provides motor inner-vation to the posterior portion of thedeltoid muscle and teres minor muscleand provides sensory cutaneousbranches to the skin overlying the pos-terior portion of the deltoid muscle be-fore terminating as the superior lateralbrachial cutaneous nerve14. During ar-throscopic surgery, Yoo et al.15 foundthat the axillary nerve typically lies ator near the most inferior position of theglenoid (6 o’clock position), approxi-mately 10 to 25 mm from the inferiorglenoid rim, and is farther away fromthe operative field when the arm is inabduction and neutral rotation.

Pathophysiology of Nerve InjuryThe severity of peripheral nerve injuriesis graded primarily on the basis of theamount of axonal discontinuity ob-served. The 2 most commonly refer-enced systems that are used to describenerve injury are the Seddon classifica-tion system16 and the Sunderlandclassification system17 (Table I). Firstdescribed in 1943, the Seddon classifi-cation system involves 3 categories thatcorrespond to the degree of axonal

discontinuity: neurapraxia, axonotme-sis, and neurotmesis. Neurapraxia is themildest of the 3 categories and typicallyis caused by excessive compression ortraction of the nerve. It is characterizedby conduction abnormality in the ab-sence of structural deformity; that is,there is no axonal loss or interruption ofthe epineurium, perineurium, or endo-neurium. Axillary nerve injury causedby glenohumeral dislocation or blunttrauma is commonly neurapraxic in na-ture18. These injuries carry an excellentprognosis, with complete resolution ofsymptoms typically occurring withindays to weeks without surgical inter-vention. In contrast, axonotmesis ischaracterized by an injury to the epi-neurium and perineurium. Unlikeneurapraxia, axonotmesis involvesdamage to the axon and the myelinsheathbut spares Schwanncells involvedin initiating the process of Walleriandegeneration. Although operative treat-ment is usually not required, axonot-metic injuriesmay takeweeks tomonthsto heal as governed by the rate ofWallerian degeneration (maximum rate,;1 mm per day), and nerve recoverymay be incomplete. Neurotmesis com-prises the most severe form of injury,representing a complete transection ofall 3 neural layers. Neurotmesis typicallyrequires surgical nerve-grafting forthe restoration of nerve functionality(as described in later sections).

Fig. 1Posterior-view photograph of a cadavericright shoulder, demonstrating the quad-rilateral space. The quadrilateral space isbounded by the long head of the tricepsmuscle medially, the humeral shaft later-ally, the teres major and latissimus dorsimuscles inferiorly, and the subscapularismuscle anteriorly. The axillary nervetravels through this space and around theposterolateral part of the humeral neck,where it divides into anterior and poste-rior branches.

| Ax i l l a r y Ne r v e Pa l s y a n d D e l t o i d Mu s c l e A t o n y

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Unfortunately, iatrogenic axillary nerveinjuries often involve axonotmesis orneurotmesis18.

Patient EvaluationThediagnosis of axillary nerve injury canbe challenging as a result of asymptom-atic or subclinical presentation. Whilea complete and thorough physicalexamination shoulddetect the identifyingpatterns of nerve injury, deltoid dysfunc-tion initially may be masked in youngpatients with excellent compensatorymechanisms or those with difficultycomplying with the examination11. In-juries resulting in incomplete paralysismay not be obvious when only the ante-rior or posterior portion of the deltoidmuscle is affected. Additionally, in somecases, the patient may retain nearly fullabduction of the shoulder secondaryto supraspinatus compensation.

Clinical ExaminationEvaluation begins with a thoroughhistory. A recent history of blunt traumaor shoulder dislocationmakes an axillaryneurapraxia more likely, whereaspenetrating trauma or recent surgerymay point toward laceration of thenerve. It is important to note that apatient age of.50 years and a lack ofconcentric glenohumeral reductionfor.12 hours are known risk factors foraxillary nerve injury following shoulderdislocation5,18.

A focused but comprehensivephysical examination of the shouldershould be performed bilaterally. Fol-lowing inspection and palpation of theshoulder, sensory examination of theterminal branch of the axillary nerve(the superior lateral brachial cutaneousnerve), which supplies sensory innerva-tion to the lateral aspect of the arm near

the distal two-thirds of the deltoidmuscle, can reveal sensory changes thatare suggestive of axillary nerve damage.Despite its utility, this sensory testingdoes not reliably exclude mixed brachialplexus injuries that may be associatedwith axillary nerve injury. Because ofthe incompleteness of sensory testing,a thorough distal strength examinationis paramount as brachial plexus injuriesmay prolong or limit the resolution ofsymptoms, require intensive physio-therapy, or require additional or separatesurgical interventions2,19.

While the testing of deltoidmuscle strength can be used to deter-mine axillary nerve function, patientswho have had a recent operation ortraumatic episode may have difficultyperforming such testing, which maypresent a challenge when pain pre-vents a comprehensive physical

Fig. 2Photograph of a cadaveric right humeruswith the deltoid muscle belly reflected,revealing the axillary nerve as it branchesto the deltoid muscle.

TABLE I Seddon and Sunderland Classification Systems for Peripheral Nerve Injuries16,17

Seddon Sunderland Injury Type Neurological Deficits

Neurapraxia I Intrafascicular edema with conductionblock, possible segmental demyelination

Neuritis, paresthesias

Axonotmesis II Severed axon, intact endoneurium Paresthesia, episodic dysesthesias

III Severed axon, disruption of endoneurium Paresthesia, dysesthesia

IV Disruption of endoneurium andperineurium

Hypoesthesia, dysesthesia, neuroma

Neurotmesis V Complete nerve discontinuity Anesthesia, intractable pain, neuroma

VI Combination of above Mixed presentation

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examination. Special physical exami-nation techniques have been describedto aid in the identification of isolateddeltoid muscle dysfunction. Theswallow-tail test (Fig. 3) is performedby having the patient bend forward atthe waist and maximally extend theshoulders, first with elbows extendedand then with elbows flexed. A dif-ference in shoulder extension betweenthe normal and affected sides of.20°indicates a positive test20. The deltoidextension lag test involves the exam-inermaximally extending the shoulderand elbows of the patient and thenasking the patient to hold that posi-tion. A lag in shoulder extension onthe affected side as compared withthe contralateral side is considereda positive test21.

The abduction in internal rotationtest22 (Fig. 4) is our preferredmethod forevaluating deltoid muscle function as ithas been shown to be superior to boththe deltoid muscle extension lag test andswallow-tail test21. It is performed byplacing the patient’s shoulder in fullinternal rotation with the elbow flexed

and asking the patient to abduct theshoulder. If the patient is unable to fullyabduct the shoulder in this position,the examiner assists with abduction andasks the patient to maintain this posi-tion. Any abduction lag indicates apositive test. The internal rotation ofthe shoulder in this maneuver displacesthe supraspinatus tendon insertionanteriorly, decreasing its ability to aidin shoulder abduction and increasingthe sensitivity of the examination.

Further clinical examination fol-lowing the identification of axillarynerve injury often allows for determi-nation of the location of the lesion asit relates to the quadrilateral space. Ifthe axillary lesion spares the posteriorportion of the deltoid and teres minormuscles, the lesion is distal to thequadrilateral space8.

Imaging and Other TestingStandard shoulder radiographs shouldbe made for patients with suspecteddeltoid muscle atony. Conventional ra-diographs often will be normal outsidethe setting of dislocation or fracture.

However, slight inferior displacement,or pseudosubluxation, of the humeralhead may be evident, indicating deltoidmuscle dysfunction. Advanced cervicalspine imaging may assist in ruling outa more proximal lesion23,24. Advancedimaging studies, including computedtomography (CT) and magnetic reso-nance imaging (MRI), also can be per-formed, depending on the mechanismand clinical suspicion of the underlyinginjury. As in other regions of the body,MRI typically is superior for the evalu-ation of soft-tissue lesions such as nerveinjuries. MRI scans traditionally havebeen useful when space-occupying le-sions or fibrotic scars are compressingthe nerve; however, recent advances inMRI have allowed for detailed evalua-tion of nerve injuries resulting frombothtraumatic and surgical causes. Magneticresonance neurography also has beenproposed as a method for visualizingthe axillary nerve.

When clinical presentation and/orimaging studies are concerning for an ax-illary nerve injury, electromyography andnerve conduction studies (EMG/NCS)

Fig. 3Photographs illustrating the swallow-tail test. In a normal test (Fig. 3-A), both shoulders are fully extended to the same level.However, in an abnormal test (Fig. 3-B), the posterior fibers of the deltoid muscle fail to fire, thus limiting full extension of theaffected shoulder.



can be used to confirm the diagnosis.One to 4 weeks typically are requiredfor changes to manifest on EMG/NCSfollowing an axial nerve injury24.Therefore, delaying EMG/NCS untilapproximately 4 weeks can be helpfulfor establishing a post-injury baselinefor the patient and can help to betterdelineate the full extent of the injury.

EtiologiesNon-Surgical InjuriesUnderstanding the etiology or mecha-nism of injury is of paramount impor-tance as the treatment of an axillarynerve injury is based on the severity andtype of injury that has been sustained. Adetailed clinical history is vital for treat-ment decision-making as each mecha-nism has a characteristic injury pattern.Operative treatment typically is not in-dicated for low-energy, non-penetratingtraumatic injuries. Such injuries areusually traction, torsion, or compressionneurapraxias in which the axon is notdisrupted. Rather, neurological symp-toms occur following trauma as a resultof a conduction block due to transientdemyelination or intrafascicular edemain the nerve.

Shoulder dislocation is one of theleading causes of traction injury of theaxillary nerve, with the reported rates ofnerve injury following dislocation rang-ing between 5% and 54%5,23. Injuriesto the nerve occur in association withanteroinferior shoulder subluxation,frank dislocation, and Bankart lesions25.When nerve damage occurs in

association with acute shoulder disloca-tions, complete spontaneous recoveryusually occurs, with reported rates in theliterature ranging from 87.5% to 100%of cases3,24. In the study by Visseret al.24, 4 of 32patients inwhoma severeaxillary nerve injury was confirmed onthe basis of both clinical examinationand EMG findings failed to recover fullfunction. However, only minor residualsymptomatology remained. Interest-ingly, those authors did not find an in-creasing severity of nerve injury, but theydid find that the risk of nerve injury inassociation with dislocation increasedwith age (p, 0.007). Results have beensimilarly favorable in patients with low-energy torsional and compression-typeinjuries. Guerra and Schroeder26

reported on 5 patients with torsionalnerve injury, all of whom had good orexcellent restoration of motor functionafter a mean duration of follow-upof 33 months.

Compression of the axillary nervecanoccur in associationwith blunt, non-penetrating trauma in the absence offracture or dislocation11. These mecha-nisms typically involve a direct blow tothe anterolateral aspect of the deltoidmuscle. If compression occurs at the sitewhere the nerve exits the quadrilateralspace, isolated posterior deltoid muscleparalysis and sensory loss along the su-perior lateral brachial cutaneous distri-bution are observed. This presentationalso can occur in cases of quadrilateralspace syndrome, in which the axillarynerve and circumflex humeral artery

exiting the quadrilateral space are com-pressed by surgical adhesions, glenoidparalabral cysts, ganglion cysts, musclehypertrophy, or displaced scapularfractures14,27. Quadrilateral space syn-drome also can occur after prolongedlying in the lateral decubitus position28.Patients who have sustained blunttrauma to the axillary nerve distal to thequadrilateral space often present withsoft-tissue swelling throughout the an-terolateral aspect of the shoulder associ-ated with full or partial deltoid muscleparalysis and variable sensory loss. Insome cases, sensation may be normalin the presence of complete deltoidmuscle paralysis.

In cases of blunt trauma, outcomeshave been less favorable. Perlmutteret al.29 reported on 11 athletes whosustained axillary nerve injury as a resultof direct blunt trauma. At the time of thelatest follow-up (mean, 73.8months) allpatients were still experiencing clinicallyapparent motor and sensory deficits ofthe axillary nerve.However, 10 of the 11patients returned to the preinjury levelof athletics. Similarly, Berry and Bril30

reported on 13 patients who experi-enced axillary nerve injury as a result ofblunt trauma without fracture or dislo-cation. Only 6 patients had completeor nearly complete resolution of neuro-logical symptoms. Certainly, morestudies are needed to determine thenatural history of, and best treatmentfor, these types of injuries.

Torsional peripheral nerve injuriesare exceedingly rare and involve rotation

Fig. 4Figs. 4-A and 4-B Photographs illustrating the abduction in internal rotation test. Fig. 4-A The patient is instructed to abduct andinternally rotate the shoulder actively with both elbows flexed. Fig. 4-B If any discrepancies are noted, the examiner repeats themaneuver (passively) and the patient is instructed to maintain the position. If the patient is not able to do so, the test is positive.



or twisting of the axillary nerve on itself,resulting in a so-called hourglass-likedeformity. While the underlying etiol-ogy of these injuries remains unclear, it isgenerally accepted that posttraumaticcases of axillary nerve injury occur sec-ondary to inflammation and fibrosisof epineurial and perineurial tissuewhilespontaneous cases of nerve injury occursecondary to forceful movements thatcause stretching of the axillary nerve overthe scapulohumeral joint of the medialaspect of the shoulder. A clinical hall-mark of axillary nerve torsion injury isthe abrupt onset of pain, often associatedwith pronounced motor deficits. Clini-cal and electrophysiological recoveryoften do not occur evenmonths after theinitial injury. Ultimately, persistent is-chemia of the axillary nerve may resultin exudation of proteins into the epi-neurium and subsequent fibrosis thatmay be detectable on MRI scans23.

Other comorbidities or medicalconditions also can confound the diag-nosis of axillary nerve injury. Diabetesmellitus, thyroid disease, renal disease,autoimmune disorders, or chronic liverdisease may lead to peripheral neuropa-thies that can symptomatically mimicisolated injury to the axillary nerve31,32.Furthermore, cervical compression ofeither the C5 or C6 nerve roots maycause isolated axillary symptomatologyor may contribute to a so-called double-crush phenomenon in cases of bothcervical compression and distal axillarynerve injury30. A thorough history andphysical examination are required toappreciate these comorbidities and toavoid misdiagnosis.

Surgical InjuriesIatrogenic injury is a frequent and pre-ventable cause of axillary nerve palsy.Open injuries are more likely to resultin axonotmesis or neurotmesis of thenerve, which require operative repair.Mechanisms of intraoperative nerveinjury include limb malpositioning,inadvertent suturing, heat penetration,aggressive retractor placement, and ex-cessive inferior dissection of the shouldercapsule15,33-37. Attention also should be

paid to factors that increase the predis-position to iatrogenic injury, includingcurrent or previous use of methotrexate,a history of shoulder surgery, a historyof radiation treatment, a preoperativepassive external rotation range ofmotionof,10°, and decreased operativetime38,39.

Several surgical procedures havebeen implicated in axillary nerve injuryas well. Among these, the Latarjet pro-cedure, which is a means of glenohu-meral joint stabilization that includestransfer of the coracoid process to theanterior aspect of the glenoid, has be-come increasingly popular34. While theLatarjet procedure is effective, a recentsystematic review of 1,904 such proce-dures demonstrated a relatively highrate of neurovascular injury (1.8%),including 6 axillary nerve injuries40.The cadaveric study by Freehill et al.demonstrated consistent postoperativeoverlap between the musculocutaneousand axillary nerves as well as medialdisplacement of both nerves relative totheir preoperative positions during theLatarjet procedure41.Delaney et al. usedintraoperative neuromonitoring duringthe procedure and found the nerve tobe most at risk during glenoid exposureand graft insertion42. Additionally,79.4%of the nerve alerts occurred whenthe arm was in external rotation, indi-cating that while the axillary nerve isunder the least amount of tension inexternal rotation, that position alsomaybring the axillarynerve closest to thesurgical field42. In order to avoid injury,those authors advised against excessiveretraction and a more superior place-ment of the coracoid graft.

Axillary nerve injury is also a well-documented complication of totalshoulder arthroplasty. Neurologicalinjuries occur in associationwith about1% of total shoulder arthroplasty pro-cedures, with the axillary nerve beingmost commonly affected43-47. In asystematic review, Bohsali et al.43

found that 10 (77%) of 13 axillarynerve injuries resolved spontaneouslywithout surgery while 1 patient witha transected axillary nerve required

trapezius tendon transfer to restoredeltoid functionality. Nagda et al.38

found that 57% of 30 patients dem-onstrated EMG findings consistentwith impending intraoperative com-promise of nerve function duringpositioning of the involved extremity atthe time of total shoulder arthroplasty.Fifty percent of the nerve events oc-curred while the extremity was placedin abduction, external rotation, andextension, and the other 50% occurredduring preparation of the glenoid.While these changes may have beenrelated to retractor tension on thenerve, repositioning of the arm into amore neutral position, rather than re-tractor removal alone, was more likelyto return EMG readings to baseline.Limb lengthening associated withreverse total shoulder arthroplastyincreases the native tension across theentire brachial plexus, placing thesestructures at risk of peripheral nervepalsies and other neurological compli-cations48. A recent cadaveric studyquantified the proximity of the axillarynerve to the implant after reverseshoulder arthroplasty49. The principalfinding of that study was that the mainanterior branch of the axillary nervewasapproximately 5 mm away from thehumeral prosthetic implant. Addition-ally, the nerve was never closer than15 mm to the glenosphere, whichconstituted a safer implant with respectto the nerve.

The open inferior capsular shift,which reduces capsular redundancy andrestores anterior, inferior, and posteriorstability, is another procedure in whichdamage to the axillary nerve can occur50.During the procedure, excessive inferiordissection or thermal injury resultingfrom electrocauterization can causedamage to the axillary nerve as it coursesacross the operative field beneath theglenohumeral ligament. This type ofinjury also can occur in association witharthroscopic or open Bankart lesionrepair51. Neer and Foster reportedpostoperative axillary neurapraxia in 3(8%) of 40 patients undergoing openinferior capsular shift procedures52.



A limited body of literature hasdescribed cases of axillary nerve com-promise after proximal humeral fixa-tion. One cadaveric study showed thatthe axillary nerve could be elevatedalmost 14 mm from the bone withoutbecoming taut53. Nonetheless, thenerve could be exposed to greatertension forces during manipulationof the fracture fragments, fibrosis, orosteosynthesis materials. Park andJeong, in a consecutive series of 21patients with proximal humeral frac-tures that were treated with minimallyinvasive percutaneous plating,reported 1 case of axillary nerve pare-sis54. Additionally, humeral nailfixation is not without risks. A ca-daveric study demonstrated that theaxillary nerve can be damaged duringthe insertion of the locking screwsdespite the use of protection sleevesand trocars55.

Given our understanding of thecomplications related to open surgicalprocedures about the shoulder, the ma-jority of primary stabilization proce-dures are currently being performedarthroscopically. As a result, it is im-portant for surgeons to consider theclose proximity of the axillary nerve evenduring arthroscopic procedures. Severalreports have described the close prox-imity of the axillary nerve to the inferioraxillary pouch during the placement ofarthroscopic capsular plication suturesfor the treatment of multidirectionalinstability, for anteroinferior capsulola-bral repair, or for complex arthroscopicreconstruction15,33-37. However, recentreports also have shown that the nervemaybe as close as 7mmduringbicorticaldrilling at the time of biceps tenodesisprocedures or during the placement ofstandard or accessory anterior or poste-rior portals or posteroinferior (7 o’clock)arthroscopic portals56-59. While axillarynerve injuries resulting from arthro-scopic procedures remain rare, thereporting on such complications is lim-ited and therefore these injuries may bemore frequent than presently recog-nized. Surgeons must maintain a highlevel of attention to anatomic landmarks

and surgical precision in order to avoidpossible iatrogenic injury.

Reverse shoulder arthroplasty isbecoming more common, and limblengthening associated with this proce-dure may increase the native tensionacross the entire brachial plexus and theaxillary nerve, thus posing a risk of pe-ripheral nerve palsies and other neuro-logical complications48. A recentcadaveric study also quantified the lo-cation of the axillary nerve in relation tothe implant following reverse shoulderarthroplasty and suggested that nervedamage can occur secondary to theproximity of the axillary nerve duringthe placement of a reverse prosthesis.The principal finding of that study wasthat the main anterior branch of theaxillary nerve was approximately 5 mmaway from the humeral prosthetic im-plant, placing it at risk for irritation,abutment, or injury.However, the nervewas never closer than 15 mm to theconvex hemispherical glenoid prosthesis(glenosphere)49.

Injury involving the axillary nervealso may occur in association withproximal humeral fractures or duringthe reduction and fixation of such frac-tures. A limited body of literature,however, has described cases of axillarynerve compromise following proximalhumeral fixation. As noted above, ca-daveric laboratory dissection has dem-onstrated that the axillary nerve can beelevated nearly 14 mm from the bonewithout being placed under tension53.Tensionmay, however, be placed on thenerve during reduction or manipulationof fracture fragments if the nerve istethered by fibrosis or if the nerve isabutting fixation implants. Park andJeong, in a consecutive series of 21 pa-tients with proximal humeral fracturesthat were treated with minimally inva-sive percutaneous plating, reported1 case of axillary nerve paresis54. In ad-dition, humeral nail fixation is notwithout risks. A cadaveric study dem-onstrated that the axillary nerve can bedamaged during the insertion of thelocking screws despite the use of pro-tection sleeves and trocars55.

Natural HistoryThe vast majority of axillary nerve in-juries are temporary neurapraxias, whichtypically resolve within 6 to 12 monthsafter the index injury. Nevertheless,permanent axillary nerve deficit alsohas been reported30,60. Regardless of thefact that nerve damage can be devastat-ing for the patient, previous reportshave described nearly normal shoulderfunction after closed axillary nerveinjury (although none of thosereports documented permanent nervedamage)29,61-64. It also has been estab-lished that a delay in diagnosis is stronglycorrelated with the final outcome andthat a less-than-optimal prognosis canbe expected if the diagnosis is made.6months after the index injury.

Nonoperative TreatmentWith the exception of certain cases ofquadrilateral space syndrome, neu-rapraxic injuries usually are treatednonoperatively. Several case series in-volving patients who have had compli-cations after shoulder surgery haveshown high rates of spontaneousrecovery following axillary nerveneurapraxia18,39,43; however, compara-tive studies with operative treatment arelacking. Nonoperative treatment shouldinclude a rehabilitation program em-phasizing passive and active range ofmotion as well as strengthening of therotator cuff, deltoid muscle, and peri-scapular musculature7,65. Shouldercontracture typically is not associatedwith axillary nerve injury unless an ex-tensive ligamentous or osseous injuryis present30. If no apparent clinical im-provement is evident at 3 months fol-lowing the initial insult, repeat EMG/NCS should be performed, and serialEMG studies may be performed tomonitor the progression of recovery39. Ifthere is no improvement in terms of theclinical and/or electrophysiological re-covery status within 3 to 4 months afterthe injury, operative treatment shouldbe considered18. Operative treatmenttypically is recommended between 3and 6 months after the injury forpatients lacking evidence of clinical or



electrophysiological improvement11,18.We support surgical exploration of theaxillary nerve within 3 to 4 months afterthe injury if testing shows a lack ofelectrophysiological recovery; thesespecific interventions will be discussedin later sections. The strength of thisrecommendation is graded as weak onthe basis of the limited available litera-ture, and comparative studies betweenexpectant management and operativerepair are needed.

Operative TreatmentThe results of operative treatment ofaxillary nerve injuries are optimal whensurgery is performed within 3 to 6months after the injury7. Outcomes ofsurgical treatment for axillary nerve in-jury are worse beyond this time frame,with only marginal benefits seen whensurgery is performed$12 months afterthe injury66-68.These recommendationsare based on case series, and furthercomparative studies are needed to opti-mize the timing of surgery. Four stan-dard modalities of operative treatmentare generally utilized: neurolysis, neu-rorrhaphy, nerve-grafting, and neuroti-zation8. The choice between treatmentmodalities is contingent on the findingsobserved during operative exploration.

NeurolysisNeurolysis is a procedure that involvesexcision and debridement of scar tissuearound the nerve (external neurolysis)or removal of scarred or fibrosed nervetissue within the perineurium (internalneurolysis). In cases of axillary nervepalsy, external neurolysis is indicatedif the nerve is found to be intact butentrapped69,70. This type of entrapmentis seen in patients with a history ofshoulder surgery as well as overheadathletes in whom fibrosis develops asa result of repetitive microtrauma69.

An anterior approach with the pa-tient in a modified beach-chair positionor the lateral decubitus position canbe used to achieve direct access to thenerve71. If the area of fibrosis is sus-pected to be in the quadrilateral space,visualization can be attained through a

posterior approach between the longhead of the triceps and teres majormuscles. However, both anterior andposterior approaches may be required toachieve adequate debridement ordecompression69,71,72. For this reason,preoperative MRI is extremely helpfulfor determining the etiology and loca-tion of neurological symptoms.

Outcomes following neurolysis forthe treatment of stretch or contusioninjuries have been favorable. Kline andKim found that, even in patients withcomplete clinical nerve loss, axillarynerve recovery was possible with isolatedneurolysis as long as intraoperative nerveaction potentials were observed71.However, clinical and patient-reportedoutcomes are poorer when concomitantdistal peripheral nerve injury in the armor hand, or associated mixed brachialplexus injuries, are present73.

NeurorrhaphyPrimary repair of the axillary nerve withsuture, also known as neurorrhaphy, isindicated for the treatment of acutetransections or lacerations of the nerveand in cases in which the nerve is foundto be cleanly bisected with minimalscarring. Primary repair is particularlyadvantageous for the treatment of theaxillary nerve (as compared with otherperipheral nerves) because of its simplefascicular structure and close proximityto effector muscles73. For this reason,primary repair is preferred to nerve-grafting or neurotization. In patientswith acute injuries, it is important toperform the repair as soon as possibleas fibrosis will lead to increased dissec-tion and blunted or distorted repairends, which may negatively impactoutcomes71,73. If the nerve cannotbe mobilized intraoperatively, or ifa tension-free anastomosis cannot beachieved, nerve-grafting may benecessary.

Focal, isolated transection lesionsof the axillary nerve are rare, andmobilization is often difficult becauseof retraction of the nerve ends or sur-rounding musculature. As a result, thereis a scarcity of literature on the outcomes

of direct repair. Kline and Kim reportedon3patientswhounderwent direct end-to-end suture repair of the axillary nervethat resulted in clinical recovery of del-toid muscle strength71. Terzis andBarmpitsioti also performed direct re-pair of the axillary nerve in a larger studybut did not report on outcomes specificto those patients74.

Nerve-Grafting and NeurotizationIn some cases of axillary nerve injury ortransection, scarring and retraction haveoccurred, making repair or other less-invasive procedures difficult. In suchcases, nerve reconstruction by nerve-grafting or nerve transfer, known asneurotization, is recommended. Al-though typically recommended inchronic settings, neurotization also maybe recommended in cases of severe orsegmental traumatic axillary injuries,especially those associated with a root orcord avulsion, because of the need forrapid regeneration of nerve fibers75-77.

Neurotization involves the transferof autologous nerves from redundant orless-used areas of the body. Commonharvest sites include the thoracodorsal,phrenic, spinal accessory, and intercostalnerves, with promising results for thecorrection of axillary nerve palsy75,76.Reports of transferring the medial tri-ceps branch of the radial nerve to theaxillary nerve (triceps-to-axillary trans-fer) have demonstrated reasonableoutcomes77,78. Triceps-to-axillarytransfers have been particularly success-ful for the treatment of acute axillarynerve palsy77,78. However, other studieshave shown that outcomes following thetransfer of the medial triceps branchof the radial nerve are less predictable,and negative prognostic factors includedelayed time to surgery, increased age,and increased bodymass index (BMI)72.

Nerve-grafting also is an option forthe treatment of large, traumatic nervelesions or in cases in which considerableneuroma resection is required. Shortnerve grafts have been associated withbetter outcomes than long grafts23,which initially showed disappointingresults79. However, a recent study by



Wolfe et al. showed no difference be-tween long nerve grafts and triceps-to-axillary nerve transfers in adult patientswith axillary nerve palsy80.

PreventionSeveral measures can be routinely fol-lowed to prevent iatrogenic axillarynerve injury. Proper understanding oflocal anatomy is crucial for the avoid-ance of injury to the axillary nerve,particularly when planning surgical in-cisions over the lateral portion of thedeltoid muscle, placing arthroscopicportals, or performing capsular plica-tions or releases, as previously discussed.In addition, arm positioning during theoperation is vital. A cephalad-directedforce on the flexed elbow helps toeliminate inferior translation of thehumerus and decreases the risk ofcompression or traction injury of theaxillary nerve81,82. We recommend amobile arm positioner with the patientin the beach-chair position. The useof shoulder-specific operating tablesshould be considered in order to im-prove patient comfort, body alignment,and safety.

In order to preserve the functionof the deltoid muscle, the location andcourse of the axillary nerve should becarefully identified, particularly duringopen capsular releases, arthroplasty, orarthroscopic procedures near the infe-rior capsule. In procedures involvingopen anterior approaches to the shoul-der, the axillary nerve courses across theoperative field, and the course of thenerve can be delineated with use of the“tug” test81. This test is performed bysimultaneously palpating the axillarynerve both medial and lateral to thehumeral shaft with both index fingers.Once the surgeon has located the nervemedially as it courses inferiorly on thesubscapularis and laterally on the un-dersurface of the deltoidmuscle, a gentle“tug” is applied by either finger and canbe felt by the contralateral index finger.This maneuver allows for direct palpa-tion of the axillary nerve in order to as-sess its continuity and to identify itslocation for protection throughout the

procedure. However, this tactile ma-neuver does not provide direct infor-mation regarding compressive orconductive injuries to a nerve in conti-nuity. Alternatively, deltoid muscle at-rophy can be minimized by using anextended deltopectoral approach, whichpreserves both the origin and the inser-tion of the deltoid muscle.

Several studies have demon-strated that the position of the axil-lary nerve varies as a function ofabduction, extension, and rotation ofthe humerus12,82. Adduction of thehumerus moves the axillary nerve closerto the operative field and glenohumeraljoint, whereas external rotation at 45° ofhorizontal glenohumeral flexion movesthe axillary nerve away from the field.The arm should be in the latter positionduring deep dissection and retractorplacement near the insertion of inferiorcapsule10. During arthroscopic surgery,the axillary nerve is farther away from thefield with the arm in abduction andneutral rotation15. Additional studiesare required to determine how the po-sition of the axillary nerve variesaccording to surgical approach, typeof procedure, and stage of procedure.Extreme ranges of arm positioning,particularly external rotation, shouldnot be maintained for extended periodsof time42.

Because the optimal balance be-tween visualization and safety of theaxillary nerve is difficult to assess, intra-operative neuromonitoring may behelpful for identifying impending orsubclinical nerve damage secondary toretractor placement or limb malposi-tioning. While multiple studies havefound that this technique may preventiatrogenic nerve damage, cost-benefitanalyses are needed to assess the effec-tiveness of this practice33,83. Currently,intraoperative neuromonitoring is bestconsidered for patients with anticipatedrisk factors for nerve injury, as previouslydiscussed.

OverviewAxillary nerve injuries may presentas sensory deficits, deltoid muscle

dysfunction, motor weakness, or acombination of these symptoms. Anunderstanding of the pathophysiologyof nerve injury aids in clinical decision-making, which may result in earlyoperative intervention before irreversi-ble nerve damage occurs. In addition,an understanding of axillary nerveanatomy is important for diagnosis andtreatment as well as for reducing the riskof intraoperative iatrogenic injury.Additional studies are needed to provideboth guidelines for treatment and futuredirections as the indications and typesof shoulder procedures continueto expand.

NOTE:The authors thank VivekChadayammuri, BS, for his criticalreview of the manuscript.

Justin J. Mitchell, MD1,Christopher Chen, MD2,Daniel J. Liechti, MD3,Austin Heare, MD2,Jorge Chahla, MD3,Jonathan T. Bravman, MD2,4

1Division of Orthopaedic SportsMedicine, Gundersen Health System,La Crosse, Wisconsin

2Department of Orthopaedic Surgery,Division of Sports Medicine and ShoulderSurgery, University of Colorado,Aurora, Colorado

3Steadman Philippon Research Institute,Vail, Colorado

4University of Colorado School ofMedicine, Aurora, Colorado

E-mail address for J.T. Bravman:[email protected]

References1. Apaydin N, Uz A, Bozkurt M, Elhan A. Theanatomic relationships of the axillary nerve andsurgical landmarks for its localization from theanterior aspect of the shoulder. Clin Anat. 2007Apr;20(3):273-7.

2. Friedman AH, Nunley JA 2nd, Urbaniak JR,Goldner RD. Repair of isolated axillary nervelesions after infraclavicular brachial plexusinjuries: case reports. Neurosurgery. 1990 Sep;27(3):403-7.

3.HemsTE,MahmoodF. Injuries of the terminalbranches of the infraclavicular brachial plexus:patterns of injury, management and outcome.J Bone Joint Surg Br. 2012 Jun;94(6):799-804.



mailto:[email protected]

4. Atef A, El-Tantawy A, Gad H, Hefeda M.Prevalence of associated injuries after anteriorshoulder dislocation: a prospective study. IntOrthop. 2016 Mar;40(3):519-24. Epub 2015Jul 02.

5. Perlmutter GS. Axillary nerve injury. ClinOrthop Relat Res. 1999 Nov;(368):28-36.

6. Richards RR, Hudson AR, Bertoia JT, UrbaniakJR, Waddell JP. Injury to the brachial plexusduring Putti-Platt and Bristow procedures. Areport of eight cases. Am J Sports Med. 1987Jul-Aug;15(4):374-80.

7. Boardman ND 3rd, Cofield RH. Neurologiccomplications of shoulder surgery. Clin OrthopRelat Res. 1999 Nov;(368):44-53.

8. Ho E, Cofield RH, Balm MR, Hattrup SJ,Rowland CM. Neurologic complications ofsurgery for anterior shoulder instability.J Shoulder Elbow Surg. 1999 May-Jun;8(3):266-70.

9. Burge P, Rushworth G, Watson N. Patterns ofinjury to the terminal branches of the brachialplexus. The place for early exploration. J BoneJoint Surg Br. 1985 Aug;67(4):630-4.

10. Loomer R, Graham B. Anatomy of theaxillarynerve and its relation to inferior capsularshift. Clin Orthop Relat Res. 1989 Jun;(243):100-5.

11. Steinmann SP, Moran EA. Axillary nerveinjury: diagnosis and treatment. J Am AcadOrthop Surg. 2001 Sep-Oct;9(5):328-35.

12. Burkhead WZ Jr, Scheinberg RR, Box G.Surgical anatomy of the axillary nerve. JShoulder Elbow Surg. 1992 Jan;1(1):31-6. Epub2009 Feb 02.

13. Stecco C, Gagliano G, Lancerotto L, TiengoC, Macchi V, Porzionato A, De Caro R, AldegheriR. Surgical anatomy of the axillary nerve and itsimplication in the transdeltoid approaches tothe shoulder. J Shoulder Elbow Surg. 2010 Dec;19(8):1166-74. Epub 2010 Aug 25.

14. McClelland D, Paxinos A. The anatomy ofthe quadrilateral space with reference toquadrilateral space syndrome. J ShoulderElbow Surg. 2008 Jan-Feb;17(1):162-4. Epub2007 Nov 12.

15.YooJC, KimJH,Ahn JH, LeeSH.Arthroscopicperspective of the axillary nerve in relation totheglenoid andarmposition: a cadaveric study.Arthroscopy. 2007 Dec;23(12):1271-7.

16. Seddon HJ. Three types of nerve injury.Brain. 1943;66(4):237-87.

17. Sunderland S. A classification of peripheralnerve injuries producing loss of function. Brain.1951 Dec;74(4):491-516.

18. Perlmutter GS, Apruzzese W. Axillary nerveinjuries in contact sports: recommendations fortreatment and rehabilitation. Sports Med. 1998Nov;26(5):351-61.

19. Gabriel EM, Villavicencio AT, Friedman AH.Evaluation and surgical repair of brachial plexusinjuries. Semin Neurosurg. 2001;12(1):29-48.

20. Nishijma N, Yamamuro T, Fujio K, Ohba M.The swallow-tail sign: a test of deltoid function.J Bone Joint Surg Br. 1995 Jan;77(1):152-3.

21. Hertel R, Lambert SM, Ballmer FT. Thedeltoid extension lag sign for diagnosis andgradingof axillarynervepalsy. J ShoulderElbowSurg. 1998 Mar-Apr;7(2):97-9.

22. Bertelli JA, Ghizoni MF. Abduction ininternal rotation: a test for the diagnosis ofaxillary nerve palsy. J Hand Surg Am. 2011 Dec;36(12):2017-23. Epub 2011 Nov 03.

23. Robinson CM, Shur N, Sharpe T, Ray A,Murray IR. Injuries associated with traumaticanterior glenohumeral dislocations. J BoneJoint Surg Am. 2012 Jan 04;94(1):18-26.

24. Visser CP, Coene LN, Brand R, Tavy DL. Theincidence of nerve injury in anterior dislocationof the shoulder and its influence on functionalrecovery. A prospective clinical and EMG study.J Bone Joint Surg Br. 1999 Jul;81(4):679-85.

25. Bankart ASB. Recurrent or habitualdislocation of the shoulder-joint. BMJ. 1923Dec15;2(3285):1132-3.

26.GuerraWK, SchroederHW. Peripheral nervepalsy by torsional nerve injury. Neurosurgery.2011 Apr;68(4):1018-24, discussion :1024.

27. Sanders TG, Tirman PF. Paralabral cyst: anunusual cause of quadrilateral space syndrome.Arthroscopy. 1999 Sep;15(6):632-7.

28. NishimuraM, Kobayashi M, Hamagashira K,Noumi S, Ito K, Kato D, Shimada J. Quadrilateralspace syndrome: a rare complicationof thoracicsurgery. Ann Thorac Surg. 2008 Oct;86(4):1350-1.

29. Perlmutter GS, Leffert RD, Zarins B. Directinjury to the axillary nerve in athletes playingcontact sports. Am J Sports Med. 1997 Jan-Feb;25(1):65-8.

30. Berry H, Bril V. Axillary nerve palsy followingblunt trauma to the shoulder region: a clinicaland electrophysiological review. J NeurolNeurosurg Psychiatry. 1982 Nov;45(11):1027-32.

31. Azhary H, Farooq MU, Bhanushali M,Majid A, Kassab MY. Peripheral neuropathy:differential diagnosis and management. AmFam Physician. 2010 Apr 01;81(7):887-92.

32. Dimachkie MM, Saperstein DS. Acquiredimmune demyelinating neuropathies.Continuum (Minneap Minn). 2014 Oct;20(5Peripheral Nervous System Disorders):1241-60.

33. Esmail AN, Getz CL, Schwartz DM,Wierzbowski L, Ramsey ML, Williams GR Jr.Axillary nerve monitoring during arthroscopicshoulder stabilization. Arthroscopy. 2005 Jun;21(6):665-71.

34. Reinares F, Werthel JD, Moraiti C, Valenti P.Effect of scapular external rotation on theaxillary nerve during the arthroscopic Latarjetprocedure: an anatomical investigation. KneeSurg Sports Traumatol Arthrosc. 2016 Jun 24;24(Jun):•••. Epub 2016 Jun 24.

35. Uno A, Bain GI, Mehta JA. Arthroscopicrelationship of the axillary nerve to the shoulderjoint capsule: an anatomic study. J ShoulderElbow Surg. 1999 May-Jun;8(3):226-30.

36. Jerosch J, Filler TJ, Peuker ET. Which jointposition puts the axillary nerve at lowest riskwhenperforming arthroscopic capsular releasein patients with adhesive capsulitis of theshoulder? Knee Surg Sports TraumatolArthrosc. 2002 Mar;10(2):126-9. Epub 2002Jan 29.

37. Price MR, Tillett ED, Acland RD, NettletonGS. Determining the relationship of the axillarynerve to the shoulder joint capsule from anarthroscopic perspective. J Bone Joint Surg Am.2004 Oct;86-A(10):2135-42.

38. Nagda SH, Rogers KJ, Sestokas AK, GetzCL, RamseyML, Glaser DL,WilliamsGR Jr. NeerAward 2005: Peripheral nerve function duringshoulder arthroplasty using intraoperativenerve monitoring. J Shoulder Elbow Surg.2007 May-Jun;16(3)(Suppl):S2-8. Epub 2006Jul 26.

39. Lynch NM, Cofield RH, Silbert PL, HermannRC. Neurologic complications after totalshoulder arthroplasty. J Shoulder Elbow Surg.1996 Jan-Feb;5(1):53-61.

40. Griesser MJ, Harris JD, McCoy BW, HussainWM, Jones MH, Bishop JY, Miniaci A.Complications and re-operations afterBristow-Latarjet shoulder stabilization: asystematic review. J Shoulder Elbow Surg.2013 Feb;22(2):286-92.

41. Freehill MT, Srikumaran U, Archer KR,McFarland EG, Petersen SA. The Latarjetcoracoid process transfer procedure:alterations in the neurovascular structures. JShoulder Elbow Surg. 2013 May;22(5):695-700.Epub 2012 Sep 01.

42. Delaney RA, Freehill MT, Janfaza DR,Vlassakov KV, Higgins LD, Warner JJ. 2014 NeerAward paper: neuromonitoring the Latarjetprocedure. J Shoulder Elbow Surg. 2014 Oct;23(10):1473-80. Epub 2014 Jun 18.

43. Bohsali KI, Wirth MA, Rockwood CA Jr.Complications of total shoulder arthroplasty. JBone Joint Surg Am. 2006 Oct;88(10):2279-92.

44. Bufquin T, Hersan A, Hubert L, Massin P.Reverse shoulder arthroplasty for the treatmentof three- and four-part fractures of the proximalhumerus in the elderly: a prospective review of43 cases with a short-term follow-up. J BoneJoint Surg Br. 2007 Apr;89(4):516-20.

45. TorchiaME, Cofield RH, Settergren CR. Totalshoulder arthroplasty with the Neer prosthesis:long-term results. J Shoulder Elbow Surg. 1997Nov-Dec;6(6):495-505.

46. Frankle M, Siegal S, Pupello D, Saleem A,Mighell M, Vasey M. The Reverse ShoulderProsthesis forglenohumeral arthritis associatedwith severe rotator cuff deficiency. A minimumtwo-year follow-up study of sixty patients. JBone Joint Surg Am. 2005 Aug;87(8):1697-705.

47. Chin PY, Sperling JW, Cofield RH, Schleck C.Complications of total shoulder arthroplasty:are they fewer or different? J Shoulder ElbowSurg. 2006 Jan-Feb;15(1):19-22.

48.Wingert NC, Beck JD, Harter GD. Avulsiveaxillary artery injury in reverse total shoulderarthroplasty. Orthopedics. 2014 Jan;37(1):e92-7.

49. Ladermann A, Stimec BV, Denard PJ,CunninghamG, Collin P, Fasel JHD. Injury to theaxillary nerve after reverse shoulderarthroplasty: an anatomical study. OrthopTraumatol Surg Res. 2014 Feb;100(1):105-8.Epub 2013 Dec 04.

50. Cooper RA, Brems JJ. The inferior capsular-shift procedure for multidirectional instabilityof the shoulder. J Bone Joint SurgAm. 1992Dec;74(10):1516-21.

51. Yoneda M, Hayashida K, Wakitani S,Nakagawa S, Fukushima S. Bankart procedureaugmented by coracoid transfer for contactathletes with traumatic anterior shoulderinstability. Am J Sports Med. 1999 Jan-Feb;27(1):21-6.

52. Neer CS 2nd, Foster CR. Inferior capsularshift for involuntary inferior andmultidirectional instability of the shoulder.Apreliminary report. J Bone Joint SurgAm.1980Sep;62(6):897-908.

53.GardnerMJ,GriffithMH,Dines JS, Briggs SM,Weiland AJ, Lorich DG. The extendedanterolateral acromial approach allowsminimally invasive access to the proximalhumerus. ClinOrthopRelat Res. 2005May;(434):123-9.



54. Park J, Jeong SY. Complications andoutcomes of minimally invasive percutaneousplating for proximal humeral fractures. ClinOrthop Surg. 2014 Jun;6(2):146-52. Epub 2014May 16.

55. Spiegelberg BGI, Riley ND, Taylor GJ. Risk ofinjury to the axillary nerve during antegradeproximal humeral blade nail fixation - ananatomical study. Injury. 2014 Aug;45(8):1185-9. Epub 2014 May 17.

56. BryanWJ, Schauder K, TullosHS. The axillarynerve and its relationship to common sportsmedicine shoulder procedures. Am J SportsMed. 1986 Mar-Apr;14(2):113-6.

57. BrunoM, LavangaV,MaioranoE, SansoneV.Abizarre complicationof shoulder arthroscopy.Knee Surg Sports Traumatol Arthrosc. 2015May;23(5):1426-8. Epub 2013 Nov 01.

58. Burkhart SS, Nassar J, Schenck RC Jr, WirthMA. Clinical and anatomic considerations in theuse of a new anterior inferior subaxillary nervearthroscopy portal. Arthroscopy. 1996 Oct;12(5):634-7.

59. Lancaster S, Smith G, OgunleyeO, PackhamI. Proximity of the axillary nerve duringbicortical drilling for biceps tenodesis. KneeSurg Sports Traumatol Arthrosc. 2016 Jun;24(6):1925-30. Epub 2014 Aug 10.

60. de Laat EA, Visser CP, Coene LN, PahlplatzPV, Tavy DL. Nerve lesions in primary shoulderdislocations and humeral neck fractures. Aprospective clinical and EMG study. J BoneJoint Surg Br. 1994 May;76(3):381-3.

61. Bunts FE. Nerve injuries about the shoulderjoint. Trans Am Surg Assoc. 1903;21:521-62.

62.Dehne E, Hall RM. Active shouldermotion incomplete deltoid paralysis. J Bone Joint SurgAm. 1959 Jun;41-A(4):745-8.

63. Pollock LJ. Accessory muscle movementsin deltoid paralysis. J Am Med Assn. 1922;79:526-8.

64. Staples OS,Watkins A. Full active abductionin traumatic paralysis of thedeltoid. J Bone JointSurg Am. 1943;25:85-9.

65. Palmer SH, Ross AC. Case report. Recoveryof shoulder movement in patients withcomplete axillary nerve palsy. Ann R Coll SurgEngl. 1998 Nov;80(6):413-5.

66. Coene LN, Narakas AO. Operativemanagement of lesions of the axillary nerve,isolated or combined with other nervelesions. Clin Neurol Neurosurg. 1992;94(Suppl):S64-6.

67.Mikami Y, NaganoA,Ochiai N, Yamamoto S.Results of nerve grafting for injuries of theaxillary and suprascapular nerves. J Bone JointSurg Br. 1997 Jul;79(4):527-31.

68. Petrucci FS, Morelli A, Raimondi PL. Axillarynerve injuries—21 cases treated by nerve graftand neurolysis. J Hand Surg Am. 1982 May;7(3):271-8.

69. McAdams TR, Dillingham MF. Surgicaldecompression of the quadrilateral space inoverhead athletes. Am J Sports Med. 2008 Mar;36(3):528-32. Epub 2007 Nov 30.

70. McKowen HC, Voorhies RM. Axillary nerveentrapment in the quadrilateral space. Casereport. J Neurosurg. 1987 Jun;66(6):932-4.

71. KlineDG, KimDH. Axillary nerve repair in 99patients with 101 stretch injuries. J Neurosurg.2003 Oct;99(4):630-6.

72. Lee JY, Kircher MF, Spinner RJ, Bishop AT,Shin AY. Factors affecting outcome of tricepsmotor branch transfer for isolated axillary nerveinjury. JHandSurgAm.2012Nov;37(11):2350-6.Epub 2012 Oct 06.

73.Wehbe J,MaaloufG,Habanbo J, ChidiacRM,Braun E, Merle M. Surgical treatment oftraumatic lesions of the axillary nerve. Aretrospective study of 33 cases. Acta OrthopBelg. 2004 Feb;70(1):11-8.

74. Terzis JK, Barmpitsioti A. Axillary nervereconstruction in 176 posttraumaticplexopathy patients. Plast Reconstr Surg. 2010Jan;125(1):233-47.

75. Chuang DC, Lee GW, Hashem F, Wei FC.Restoration of shoulder abduction by nervetransfer in avulsed brachial plexus injury:

evaluation of 99 patients with various nervetransfers. Plast Reconstr Surg. 1995 Jul;96(1):122-8.

76. Dai SY, Lin DX, Han Z, Zhoug SZ.Transference of thoracodorsal nerve tomusculocutaneous or axillary nerve in oldtraumatic injury. J Hand Surg Am. 1990 Jan;15(1):36-7.

77. Leechavengvongs S, Witoonchart K,Uerpairojkit C, Thuvasethakul P,Malungpaishrope K. Combined nervetransfers for C5 and C6 brachial plexusavulsion injury. J Hand Surg Am. 2006 Feb;31(2):183-9.

78. Leechavengvongs S, Witoonchart K,Uerpairojkit C, Thuvasethakul P. Nervetransfer to deltoid muscle using the nerve tothe long head of the triceps, part II: a report of7 cases. J Hand Surg Am. 2003 Jul;28(4):633-8.

79. Socolovsky M, Di Masi G, Battaglia D. Use oflong autologous nerve grafts in brachial plexusreconstruction: factors that affect the outcome.Acta Neurochir (Wien). 2011 Nov;153(11):2231-40. Epub 2011 Aug 25.

80.Wolfe SW, Johnsen PH, Lee SK, Feinberg JH.Long-nerve grafts and nerve transfersdemonstrate comparable outcomes for axillarynerve injuries. J Hand Surg Am. 2014 Jul;39(7):1351-7. Epub 2014 Apr 29.

81. Flatow EL, Bigliani LU. Tips of the trade.Locating and protecting the axillary nerve inshoulder surgery: the tug test. OrthopRev. 1992Apr;21(4):503-5.

82. Cheung S, Fitzpatrick M, Lee TQ. Effects ofshoulder position on axillary nerve positionsduring the split lateral deltoid approach. JShoulder Elbow Surg. 2009 Sep-Oct;18(5):748-55. Epub 2009 Mar 17.

83. Ladermann A, Lubbeke A, Melis B, Stern R,Christofilopoulos P, Bacle G, Walch G.Prevalence of neurologic lesions after totalshoulder arthroplasty. J Bone Joint Surg Am.2011 Jul 20;93(14):1288-93.



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