Axillary Nerve Injury: Diagnosis and Treatment

Scott P. Steinmann, MD, and Elizabeth A. Moran, MD

Abstract

Axillary nerve injury is infrequently diagnosed but is not a rare occurrence. superior border of the quadrilateral
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Injury to the nerve may result from a traction force or blunt trauma applied to space. The nerve lies in intimate
the shoulder. The most common zone of injury is just proximal to the quadri- contact with the inferior joint cap-
lateral space. Atraumatic causes of neuropathy include brachial neuritis and sule as it passes through the quadri-
quadrilateral space syndrome. The vast majority of patients recover with non- lateral space (Fig. 1). When the
operative treatment. Baseline electromyographic and nerve conduction studies nerve exits the space, it continues to
should be obtained within 4 weeks after injury, with a follow-up evaluation at the posterior aspect of the humeral
12 weeks. If no clinical or electromyographic improvement is noted, surgery neck and divides into anterior and
may be appropriate. The results of operative repair are best if surgery is per- posterior branches.
formed within 3 to 6 months from the injury. Surgical options include neuroly- The anterior portion of the nerve
sis, nerve grafting, and neurotization. The results of repair of axillary nerve continues to circle around the surgi-
injuries have been good compared with treatment of other peripheral nerve cal neck of the humerus, traveling
lesions, due to the monofascicular composition of the nerve and the relatively deep to the deltoid toward the ante-
short distance between the zone of injury and the motor end-plate. rior border of the muscle. Along
J Am Acad Orthop Surg 2001;9:328-335 the way, the nerve sends branches
to innervate the middle and ante-
rior portions of the deltoid. The
position of the anterior trunk is
Axillary nerve lesions are not com- Anatomy commonly reported to lie 4 to 7 cm
monly diagnosed. Although most inferior to the anterolateral corner
such injuries respond to nonopera- The axillary nerve is a terminal of the acromion.5
tive measures, surgical treatment is branch of the posterior cord of the The posterior trunk innervates
warranted in selected cases. With ad- brachial plexus and derives from the both the teres minor and the poste-
vances in microsurgery, increased ventral rami of the fifth and sixth rior portion of the deltoid. A branch
awareness of the potential for treat- cranial nerves. The first portion of to the teres minor usually arises
ment of brachial plexus injuries, and the axillary nerve lies lateral to the within or just distal to the quadrilat-
the greater focus on shoulder disor- radial nerve, posterior to the axil- eral space and enters the posterior
ders in the past decade, complex lary artery, and anterior to the sub- or inferior aspect of the teres minor
reconstructive procedures on the scapularis muscle. It runs obliquely muscle. A terminal branch of the
shoulder are now more common. across the inferolateral border of the
Accurate knowledge of axillary nerve subscapularis, crossing 3 to 5 mm
anatomy and function is paramount from its musculotendinous junction.
to avoid complications after such The axillary nerve then enters the Dr. Steinmann is Assistant Professor, De-
procedures. Several reports on the quadrilateral space accompanied by partment of Orthopaedic Surgery, Mayo Clinic,
results of surgical treatment of axil- the posterior humeral circumflex ar- Rochester, Minn. Dr. Moran is Chief Resident,
lary nerve lesions have been pub- tery. The boundaries of the quadri- Department of Orthopaedic Surgery, National
Naval Medical Center, Bethesda, Md.
lished.1-4 A thorough understanding lateral space are the subscapularis
of the etiology, diagnosis, and treat- anteriorly, the teres major and latis-
Reprint requests: Dr. Steinmann, Mayo Clinic,
ment of axillary nerve lesions not simus dorsi inferiorly, the long head 200 First Street SW, Rochester MN 55905.
only aids in the avoidance of injury to of the triceps medially, and the
the nerve during surgical procedures humerus laterally. When the shoul- Copyright 2001 by the American Academy of
but also promotes early recognition der is viewed from its posterior Orthopaedic Surgeons.
and treatment. aspect, the teres minor forms the

328 Journal of the American Academy of Orthopaedic Surgeons

 Scott P. Steinmann, MD, and Elizabeth A. Moran, MD

plexus injury. In reported studies,

Suprascapular nerve anastomosis infraclavicular isolated axillary nerve
between suprascapular and injury occurred in only 0.3% to 6% of
circumflex scapular arteries brachial plexus injuries.3,7 Such infra-
clavicular injuries have been found
Infraspinatus to have a greater likelihood of spon-
taneous recovery of function than
Fibrous capsule supraclavicular lesions.8
Humerus Injury to the axillary nerve most
commonly follows closed trauma
Axillary nerve
involving a traction injury to the
shoulder, usually with associated
dislocation or fracture (Table 1).
Branch to Some patients may have an occult,
teres minor
subclinical axillary nerve lesion that
is evidenced by the findings from
Deltoid the electromyographic and nerve
conduction study (EMG/NCS) but
Upper lateral that is masked by overlying dis-
cutaneous comfort from an associated fracture
nerve of arm or dislocation.9 Blunt trauma to the
anterior lateral aspect of the shoul-
der has also been noted to cause ax-
illary neuropathy. The mechanism of
Triangular space injury in such cases is considered to
be a compressive force to the nerve
Quadrilateral space as it travels on the deep surface of the
deltoid muscle.10 Occasionally, the
patient presents after an injury with
Triangular interval
a mixed brachial plexus palsy affect-
ing primarily the proximal shoul-
der girdle muscles with partial arm
Figure 1 Posterior view of quadrilateral space. (Adapted with permission from Anderson
JE [ed]: Grant’s Atlas of Anatomy, 7th ed. Baltimore: Williams & Wilkins, 1978, p 6-39.) or hand palsy. With observation and
nonoperative treatment, sponta-
neous recovery of the forearm neu-
ropathy usually occurs. When there
posterior trunk forms the superior the nerve enters the quadrilateral is incomplete recovery, the deltoid
lateral cutaneous nerve. space there are three distinct groups and rotator cuff muscles are most
There are several common ana- of fascicles: the motor groups to the commonly affected.1
tomic variations of the course of the deltoid and teres minor and the sen- Incomplete paralysis can occur
axillary nerve. In as many as 20% sory group of the superior lateral with sparing of either the anterior or
of persons, the axillary nerve origi- cutaneous nerve. These fascicles are the posterior portion of the deltoid.
nates from the posterior division of discrete entities within the posterior In such cases, atrophy may not be
the upper trunk of the plexus. Oc- cord. The deltoid fascicles are al- obvious and, if rotator cuff function
casionally, the seventh cervical root ways found in a superolateral posi- is preserved, shoulder range of mo-
contributes to the axillary nerve. tion; those of the teres minor and tion may be normal. 1 However,
The axillary nerve may also give superior lateral cutaneous nerve are when affected individuals exercise,
rise to the inferior subscapular located inferomedially. they quickly fatigue, and their ab-
nerve, which innervates both the duction strength is much less than
subscapularis and the teres major. normal. Young athletic patients may
The internal topography of the Etiology be able to compensate for complete
fascicular groups has been studied deltoid paralysis and can often per-
by Aszmann and Dellon.6 The nerve Most axillary nerve injuries present form activities of daily living with
in the axilla is monofascicular, but as as part of a combined brachial only limited disability. However, in

Vol 9, No 5, September/October 2001 329

Axillary Nerve Injury

The findings on physical exami- nerve injury, this has not been re-
Table 1 nation are usually limited to tender- ported in the literature.
Etiology of Axillary Nerve Lesions
ness posteriorly along the shoulder The initial physical evaluation
joint. Deltoid atrophy and lateral should include standard testing for
Closed blunt trauma sensory changes are uncommon, active and passive range of motion of
Traction injury to the shoulder and the EMG findings are usually the shoulder, as well as for strength
Penetrating trauma (sharp or normal. If quadrilateral space syn- of abduction, external rotation, and
blunt) drome is suspected, a subclavicular internal rotation. In chronic cases,
Nerve compression due to mass arteriogram may be appropriate. muscle atrophy should be assessed,
effect (aneurysm, tumor) This study is considered positive if remembering that if the posterior del-
Parsonage-Turner syndrome posterior humeral circumflex artery toid and teres minor are spared, the
(brachial neuritis) occlusion occurs with less than 60 lesion must be distal to the quadrilat-
Quadrilateral space syndrome degrees of abduction. On magnetic eral space.
resonance (MR) imaging, signal A complete neurologic examina-
changes in the deltoid and teres tion of the extremity should be per-
minor muscles have been noted to formed, specifically checking the
represent denervation patterns con- function of the spinal accessory,
a work environment, they will easily sistent with quadrilateral space syn- suprascapular, long thoracic, radial,
fatigue with overhead activities or drome.12 and musculocutaneous nerves. In-
heavy lifting. Because this syndrome is diffi- volvement of the superior lateral
The origin of deltoid paralysis cult to diagnose accurately, obser- cutaneous nerve of the arm may
sometimes appears to be atraumat- vation is the usual treatment, as the lead to sensory loss over the lateral
ic. This condition has been referred vast majority of patients will im- aspect of the shoulder. However, it
to as acute brachial neuritis or prove over time. Some patients is important to remember that even
Parsonage-Turner syndrome. Pa- benefit from surgical exploration of patients with a complete deltoid
tients typically relate a history of the quadrilateral space and decom- motor deficit can present with only
severe shoulder pain that may radi- pression of the axillary nerve by re- mild loss of sensation over the later-
ate down the arm and may last lease of scar or tight fibrous bands.13 al aspect of the shoulder. Therefore,
from a few days to several weeks. the diagnosis of axillary neuropathy
The pain is soon followed by loss should not rest on the presence or
of motor function in the affected Evaluation absence of sensation over the area of
muscles. Several nerves may be in- the deltoid.
volved (typically, the axillary, long The clinical history is important in Standard radiographic examina-
thoracic, and suprascapular nerves), planning the treatment of patients tions of the shoulder and cervical
but occasionally only one nerve is in- who may have an axillary nerve spine are helpful in determining
volved. When brachial neuritis or injury. Patients without a distinct whether a fracture, dislocation, or
a mixed lesion is suspected, EMG episode of trauma may have a com- other pathologic process is associated
evaluation can be helpful in delin- pressive neuropathy due to an en- with the nerve injury. An EMG/NCS
eating the problem. Treatment larging mass or aneurysm. Quad- evaluation is important in confirm-
with oral corticosteroids has been rilateral space syndrome may also ing the diagnosis and establishing a
used empirically, although it has occur with minimal or no trauma. If reference point for subsequent as-
not yet been established that these pain precedes the loss of motor func- sessment and potential recovery.
drugs provide any clear benefit. tion, the diagnosis may be brachial These studies may also reveal lesions
The prognosis in atraumatic cases neuritis. A recent event of pene- in other nerves or in the proximal
is quite good, with most patients trating trauma or surgical trauma brachial plexus, which may affect
achieving normal function.11 makes axillary nerve injury likely. the overall treatment plan.
The quadrilateral space syn- Clinicians should also carefully eval- In chronic cases with established
drome is another potential cause of uate the axillary nerve function of muscle atrophy, an MR imaging
axillary neuropathy. Symptoms any patient with a shoulder disloca- study of the shoulder can demon-
typically include a chronic, dull, tion or proximal humerus fracture strate increased signal on spin-echo
aching pain in the dominant prior to reduction. However, al- sequences due to muscle replace-
extremity, which can awaken the though it is theoretically possible to ment by fat.14 This can be helpful
patient at night. Patients infre- reduce a dislocation or fracture when examining for a combined
quently report a history of trauma. forcefully enough to cause axillary nerve injury; attempting to delineate

330 Journal of the American Academy of Orthopaedic Surgeons

 Scott P. Steinmann, MD, and Elizabeth A. Moran, MD

the involvement of smaller mus- and active assisted range of motion. lesions. 9 All patients recovered
cles, such as the teres minor; or The key element of therapy sessions within 1 to 2 years, including those
seeking to identify a mass lesion should be to preserve the maximum with complete nerve lesions but no
that may be causing compressive range of motion so as to prevent objective loss of function.
neuropathy. Evaluation of the bra- joint contracture while awaiting the Leffert15 has suggested that axil-
chial plexus is often difficult to ac- return of muscle function. Electrical lary nerve injury after fracture or dis-
curately interpret and has not been stimulation of the deltoid has been location is a more common entity
found to be helpful. used to preserve muscle viability, than is usually appreciated, but be-
although it is unclear whether this lieves that most patients progress to
approach has any effect on ultimate full recovery. Perkins and Watson
Nonoperative Treatment outcome. Jones16 reviewed a series of 15 pa-
The results of nonoperative treat- tients with axillary neuropathy after
Patients with an atraumatic history ment for atraumatic lesions have dislocation and reported that 13
of axillary neuropathy should be been generally quite good. Even in recovered fully and only 2 had per-
observed over a period of at least 3 cases of closed trauma involving a manent paralysis. In one series of 108
months from the onset of symp- fracture or dislocation, satisfactory elderly patients with anterior shoul-
toms before operative treatment is recovery occurs in most patients. In der dislocation, 10 (9.3%) were noted
considered (Fig. 2). At 2 to 4 weeks, a study of 73 patients with a proxi- to have an axillary nerve injury, but
EMG/NCS should be performed to mal humerus fracture or disloca- all went on to full recovery by 12
establish baseline values. Physical tion, 24 (33%) had EMG/NCS evi- months.17 In another study,18 a high
therapy should be instituted during dence of an axillary nerve injury; rate of axillary neuropathy was
this period, emphasizing passive there were 9 complete and 15 partial noted in patients over age 40 with a

Isolated axillary
nerve lesion

Acute Chronic (>18 mo)

Atraumatic Closed trauma Penetrating trauma Salvage procedure:

• Trapezius transfer
• Pectoralis major transfer
• Functioning free muscle
transfer
• EMG/NCS • EMG/NCS Sharp (e.g., knife, Blunt (e.g.,
• Observation • Treat any associated surgical blade) gunshot)
• Repeat EMG/NCS fracture or dislocation
at 3 mo • Observation

EMG/NCS • Observation
within 1 wk • EMG/NCS at 4 wk
If no clinical Improvement No improvement
or EMG/NCS
improvement,
consider surgery
at 6 mo If severe changes Improvement No improvement
Continue Repeat EMG/ on NCS, early
observation NCS at 3 mo exploration

Repeat EMG/NCS
at 3 mo

If no clinical or EMG/NCS
improvement, consider
surgery at 3-6 mo

Figure 2 Algorithm for treatment of isolated axillary nerve lesions (EMG/NCS = electromyographic and nerve conduction study).

Vol 9, No 5, September/October 2001 331

Axillary Nerve Injury

shoulder dislocation. Six weeks after the patient may have a neurapraxia through the quadrilateral space,
injury, EMG/NCS evaluation showed or axonotmesis that will fully re- mobilization of the nerve is often
denervation patterns ranging from cover with nonoperative treatment. not possible, and nerve grafting
moderate to severe in 28 (51%) of 55 An early EMG/NCS evaluation can must be performed. When the nerve
patients. At the 3-year follow-up help define the nature of the nerve is found to be intact but encased in
examination, no patient had persis- injury in such situations. scar or trapped in the quadrilateral
tent axillary neuropathy; however, 6 For patients with a gunshot in- space by fibrous bands, neurolysis
(21%) of the 28 had symptomatic jury to the shoulder and evidence of or decompression can be success-
rotator cuff tears. axillary neuropathy, observation for ful.3,4,14 Neurotization has also been
4 to 6 weeks may be prudent. The utilized to correct axillary nerve le-
blast effect during missile penetra- sions with use of the thoracodorsal,
Operative Treatment tion may have caused neurapraxia phrenic, spinal accessory, and inter-
or axonotmesis, both of which have costal nerves.22,23
Operative treatment of axillary a good potential for spontaneous
neuropathy can be considered if no recovery. Results of Surgical Treatment
clinical or EMG/NCS evidence of Although the most favorable re- In one series of 37 patients with
recovery is present by 3 months sults of surgical treatment have axillary nerve injuries, 33 were
after injury.19-21 This is a reason- been documented to occur with treated by sural nerve grafting; 1, by
able time frame for patients who treatment initiated less than 6 direct repair; and 3, by neurolysis.19
have sustained closed trauma. months after injury, functional Of those with isolated axillary nerve
However, if the cause of the axil- improvement can occur if surgical lesions, 23 of 25 achieved M4 or M5
lary nerve dysfunction is a stab intervention is undertaken before strength postoperatively (as graded
wound or surgical insult, operative 12 months.2,3,19 Significant clinical by manual muscle testing according
exploration should be performed improvement is unlikely if surgical to the Nerve Injuries Committee of
much sooner. In such instances, treatment is initiated 12 months or the British Medical Research Coun-
EMG/NCS may be diagnostic of more after injury.20 cil24). The large number of patients
disruption of axillary nerve con- who required grafting illustrates the
duction at less than 1 week after Surgical Options difficulty of adequately mobilizing
injury, before axonal degeneration The axillary nerve is ideal for the nerve for a direct repair. The
occurs along the distal aspect of the critical evaluation of the results of small number of patients who un-
nerve. A denervation pattern on surgical treatment of motor nerve derwent neurolysis demonstrates
EMG testing will typically not be injuries. The proximal monofascic- that simple nerve compression by
present until approximately 2 to 3 ular structure of the nerve, its com- scar or fibrous bands is not common.
weeks after injury, when fibrilla- position of primarily motor fibers, In a series of 66 patients with axil-
tion potentials can be observed. and its relatively short length are lary neuropathy,20 27 patients un-
When assessing a patient with a attributes that make it highly appro- derwent surgical exploration and
stab wound to the shoulder and priate for study of the effects of sur- grafting within 6 months of injury.
limited deltoid function, the NCS gical intervention. Of these 27 patients, 9 recovered
should be obtained initially at 4 to The standard modalities of neu- M5 strength, and 9 recovered M4
7 days after injury; if the findings rolysis, neurorrhaphy, nerve graft- strength. Thirteen other patients un-
are equivocal, the clinician should ing, and neurotization have all been derwent neurolysis, with 10 achiev-
wait an additional 2 weeks before a used in the treatment of axillary ing grade M4 or M5 strength. The 6
repeat EMG evaluation. If the ini- nerve injuries. 19,22 The choice of patients who underwent surgery
tial EMG/NCS results demonstrate treatment is ultimately determined more than 1 year after injury did not
loss of conduction and a denerva- at surgery after exploration of the fare as well; only 1 patient achieved
tion pattern, early operative explo- nerve. If the nerve has been recent- a muscle grade of M4.
ration may be considered. ly lacerated, neurorrhaphy alone Petrucci et al3 presented the re-
Occasionally, axillary neuropa- can be successful. However, if the sults in 15 patients who underwent
thy may be noted after elective injury is several weeks or months sural nerve grafting an average of
surgery, presumably due to sus- old, retraction and scarring of the 5.8 months after injury. In most
tained traction or laceration injury cut ends of the nerve have occurred. cases, two sural nerve grafts were
to the nerve. Even in this setting, Due to the relative confinement of placed (length, 3 to 8 cm). All but 1
however, immediate surgical explo- the nerve and its oblique course of the patients achieved a muscle
ration is not always warranted, as over the subscapularis muscle and grade of M4 or M5.

332 Journal of the American Academy of Orthopaedic Surgeons

 Scott P. Steinmann, MD, and Elizabeth A. Moran, MD

Chuang et al22 reported on neu- through the quadrilateral space, attachments at the coracoid, the
rotization with the use of the phrenic achieving a proximal tension-free axillary nerve can be identified by
or spinal accessory nerve, which anastomosis from the anterior ap- passing a finger over the subscapu-
requires intercalary sural nerve proach. laris muscle and sweeping inferi-
grafting with either donor nerve. orly. This maneuver will usually
The results were similar with the Surgical Technique hook the axillary nerve and allow it
two nerves. The 23 patients who Under general anesthesia, the to be palpated with the posterior
underwent spinal accessory neuroti- patient is placed in the lateral decu- humeral circumflex as it travels into
zation with bridging sural nerve bitus position to facilitate both ante- the quadrilateral space (Fig. 3).26
grafts had an average of 45 degrees rior and posterior exposure of the Adequate visualization of the
of improvement in abduction. shoulder, as well as access for har- axillary nerve is usually possible
The results of quadrilateral space vesting the sural nerve. A modified only after the pectoralis minor has
decompression have not been re- deltopectoral approach is made been detached and retracted medi-
ported as frequently as the results from the clavicle to the deltoid in- ally. The axillary and musculocuta-
of surgical repair after a traumatic sertion with the skin incision placed neous nerves branch off the poste-
injury.14,25 Cahill and Palmer13 re- slightly more medial than usual (5 rior and lateral cords, respectively,
ported on 18 patients who under- mm to 1 cm). This is important be- at approximately the level of the
went decompression of the quadri- cause most of the surgical exposure coracoid and can be most easily
lateral space; 8 patients achieved will be centered more medially, identified by following the nerves
dramatic relief of symptoms, and 8 under the area of the pectoralis from distal to proximal. The mus-
had some relief. Francel et al25 re- major and pectoralis minor, rather culocutaneous nerve is identified as
ported the results in 5 patients with than over the humeral head. If there it enters the coracobrachialis and
quadrilateral space syndrome after is a prior surgical incision in the then can be traced proximally to the
a traumatic injury. All 5 had reso- area, it can often be extended to gain lateral cord. The axillary nerve can
lution of sensory deficits and sub- adequate exposure. be followed proximally from the
jective improvement of shoulder After development of the delto- quadrilateral space to the posterior
pain with surgical decompression. pectoral interval and exposure of cord. As the dissection proceeds prox-
The most commonly performed the clavipectoral fascia, the muscles imally, the much larger radial nerve
surgical procedure for persistent originating from the coracoid are can be identified and protected. If
axillary neuropathy is sural nerve sequentially released, beginning nerve identification is not certain, a
grafting. Satisfactory results can be with the short head of the biceps nerve stimulator should be used to
achieved in most cases. There are and coracobrachialis and followed establish which muscle groups are
two reasons why grafting is com- by the pectoralis minor. The mus- being innervated.
monly needed. First, because trac- cles may be taken down either by Once the axillary, radial, and
tion is a common pattern of injury, osteotomizing the tip of the cora- musculocutaneous nerves have been
the nerve may have several centime- coid or by using an electrocautery identified, the axillary nerve must be
ters of stretch injury, resulting in a device to detach them, with suture fully exposed by carefully dissecting
neuroma in continuity. Resection of reattachment at closure. If the pec- it from the adjoining brachial plexus.
the neuroma necessitates a grafting toralis, the coracobrachialis, and the The axillary artery and vein must be
procedure in most situations, as it is short head of the biceps are released identified and protected, as they are
difficult to mobilize the nerve to within 1 cm of their osseous origin, also at risk during axillary nerve
gain more length. Second, the most there is no danger of damage to the exposure. After the axillary nerve
common area for injury of the nerve musculocutaneous nerve. has been well exposed proximally,
is either proximal to or just at the The pectoralis major can then be surgical dissection proceeds distally
quadrilateral space. A direct repair either partially or completely re- until the area of the lesion is identi-
is technically difficult to perform in leased from the humerus for greater fied. Often this is located at or just
this area, because when a standard exposure. A cuff of tissue should proximal to the quadrilateral space.
anterior approach is used, the area be left on the humerus to allow If the lesion grossly appears to be a
to be reconstructed is at the bottom later repair at the end of the proce- neuroma, antegrade stimulation of
of a deep surgical exposure. It is dure. Sufficient dissection should the nerve can be performed with a
preferable and technically easier to be done to allow visualization of nerve stimulator. If muscle activity
perform a distal anastomosis with the axillary, radial, and musculocu- is detected, neurolysis of the lesion
nerve grafts through a posterior taneous nerves. Early in the proce- should be done. If no muscle activity
approach and then pass the grafts dure, before releasing the muscular is noted, intraoperative EMG/NCS

Vol 9, No 5, September/October 2001 333

Axillary Nerve Injury

is placed in a sling. Gentle passive

and active exercises of the shoulder
are begun at postoperative day 7,
which helps promote axillary nerve
gliding and prevents scarring.
Deltoid

Subscapularis Late Presentation

Pectoralis minor
Patients seen more than 24 months
after injury present a treatment
dilemma. Due to intrinsic muscle
Axillary nerve
wasting, nerve repair procedures are
unproductive. Patients should be
carefully evaluated for physical limi-
Radial nerve tations of the shoulder. Young pa-
tients often demonstrate full motion
Coracobrachialis/ of the shoulder and no limitations in
short head of activities of daily living. However,
biceps there may be work restrictions due
to early fatigue with overhead activ-
ities. Most of these patients cannot
be helped predictably by further
surgery, and workplace modifica-
tions are recommended.
In patients with poor shoulder
abduction that limits activities of
Figure 3 Technique of palpating the axillary nerve. daily living but a normal rotator
cuff, muscle transfer procedures can
be considered. If sparing of the
middle and posterior portions of the
monitoring may be performed. If no identified and separated from the deltoid occurs, the innervated por-
electrical activity is recorded over superior lateral cutaneous branch tion of the deltoid can be transposed
the deltoid, the neuroma should be and the branch to the teres minor. anteriorly on the acromion. Alter-
excised and grafted. If either form The lateral position facilitates natively, the pectoralis major can be
of stimulation demonstrates nerve sural nerve harvest. Usually, two or transposed laterally on the acromion.
conduction, neurolysis may be war- three sural nerve grafts measuring 4 Mobilization of the pectoralis major
ranted, with use of an operating to 8 cm are sutured to the distal can be limited by tethering of the
microscope for magnification. stump of the nerve, first through pectoral nerves. If the entire deltoid
If the lesion is located deep in the the posterior exposure and then is denervated, the trapezius can be
quadrilateral space, a posterior inci- passed anterior for anastomosis to detached from the acromion with a
sion will be needed to fully expose the proximal stump. If a lesion is portion of bone and inserted into the
the nerve. This is possible with the encountered very proximal in the proximal humerus. This procedure
patient in the lateral decubitus posi- axillary nerve, the proximal stump may improve motion but rarely
tion. A posterior incision is made can be carefully dissected under the restores functional abduction. Other
extending superiorly from the pos- microscope 1 to 2 cm into the poste- techniques include bipolar latissimus
terior axillary crease to the acrom- rior cord without affecting fascicles dorsi transposition and free muscle
ion. The inferior border of the del- directed to the radial nerve. Nerve transport.
toid is mobilized superiorly, and the grafts should be sutured in a man-
nerve is identified as it exits the ner to allow a tension-free repair
quadrilateral space. Detachment of and should be checked with the Summary
the deltoid is not necessary. If distal arm in abduction and external rota-
grafting is required at this point, the tion before completing the proximal Axillary neuropathy is a potential
motor fascicles to the deltoid are anastomosis. After closure, the arm complication of shoulder girdle

334 Journal of the American Academy of Orthopaedic Surgeons

 Scott P. Steinmann, MD, and Elizabeth A. Moran, MD

injury, which can result in signifi- evaluated with an EMG or nerve Most patients with an axillary
cant disability. Acute abduction conduction study 2 to 4 weeks after nerve injury have an excellent re-
and traction are common injury injury and again at 12 weeks. If no sponse to nonoperative treatment.
patterns that can produce a stretch improvement is noted on these stud- Favorable results can be expected for
lesion in the nerve often just proxi- ies or on clinical examination, surgi- the rest if surgical repair is under-
mal to the quadrilateral space. cal treatment may be considered. taken within 6 months of injury.
Many injuries are mild and may Studies have shown that the best Surgical options include neurolysis,
remain subclinical during treat- results of surgery occur when explo- nerve grafting, and neurotization. In
ment and rehabilitation of the pri- ration is performed 3 to 6 months most series, the majority of patients
mary shoulder injury. Most axil- after injury. In cases of sharp pene- who required surgery underwent a
lary nerve lesions occur in closed trating trauma or neuropathy after a nerve grafting procedure. The
injuries and are either neurapraxia surgical procedure, exploration of results of nerve grafting have been
or axonotmesis, for both of which the axillary nerve should be per- encouraging, due to the relatively
there is a good overall prognosis formed as soon as the diagnosis is short distance from the lesion to the
for recovery. made by physical examination and motor end-plate and the monofascic-
In addition to the initial clinical confirmed by nerve conduction ular nature of the proximal portion
examination, patients should be study. of the axillary nerve.

References
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JR, Goldner RD: Repair of isolated 136:461-466. the axillary nerve: Apropos of 37 cases
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