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A 35-year-old woman with a 2-year history of right shoulder pain
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The patient is a 35-year-old right-hand dominant woman with 2 years of chronic right shoulder pain. She previously sustained a cerebral hemorrhage related to postpartum hypertension, which resulted in right-sided hemiparesis 2 years prior to presentation. At baseline, she had right upper extremity paresis that was worse than her right lower extremity paresis. She was able to walk short distances around the house, but her shoulder pain impaired her ability to take care of her three children. Her complaints were centered around shoulder pain that occurred while trying to use her arm. She currently uses her right hand as a helping hand to post objects that she then lifts with her left hand, but she cannot grasp or lift independently with the right upper extremity.
Prior to presentation to orthopedic surgery, she tried physical therapy and steroid injections to improve motion and help with pain control. She takes oral narcotics regularly to help manage her shoulder pain.
On physical examination, she is a well-appearing woman for her stated age with normal mentation. She denies pain with palpation of the acromioclavicular joint or glenohumeral joint. There is painful shoulder range of motion. Her motion includes minimal active forward elevation (FE) at the glenohumeral joint with 160° passive FE, 25° passive external rotation with the arm at the side and 90° passive internal rotation (IR) with the shoulder at 90°. The patient can flex the elbow to 90°. She is distally neurologically intact to sensation but is only able to wiggle her fingers and weakly fire her wrist flexors and extensors.
Initial imaging of her right shoulder included radiographs and an MRI. An anteroposterior (AP) and a scapular Y-view radiograph (Figure 1) demonstrated posterior and inferior subluxation of the proximal humerus. An MRI with T2-weighted sequences (Figure 2) demonstrated an intact rotator cuff with posterior subluxation of the proximal humerus.
Source: Frank A. Petrigliano, MD
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Post-stroke shoulder pain
The patient’s history and physical are consistent with a painful shoulder due to central neurologic dysfunction from her peripartum cerebrovascular accident. Initial imaging demonstrates a posteriorly and inferiorly subluxed proximal humerus.
Debilitating shoulder pain after a hemiplegic stroke can lead to disability and decreased function. Post-stroke shoulder pain has been reported to occur as soon as 2 weeks after the initial stroke diagnosis. Post-stroke shoulder pain has been reported in the literature to be variable, with a prevalence of 9% to 73%.
The exact cause of post-stroke shoulder pain is not well understood. Many studies have attempted to better elucidate the cause-effect relationship between hemiplegic stroke and shoulder pain, but there has not been universal agreement among researchers. Current theories about this include subluxation, adhesive capsulitis, complex regional pain syndrome, rotator cuff injury and/or imbalance of rotator cuff musculature.
Given the difficulty and lack of agreement about the cause of post-stroke shoulder pain, the treatment for post-stroke shoulder pain is variable and is often based on assumptions about the underlying causes of pain. Often the cause of post-stroke shoulder pain is multifactorial in nature. Therefore, treatment should include multiple modalities including physical therapy, anti-inflammatory medication and, in some cases, surgical intervention.
Treatment
Our patient was a young mother with functional demands that included caring for her three children, and her shoulder pain and instability were limiting. After a discussion of treatment options, the patient elected to proceed with glenohumeral arthrodesis.
The patient was positioned in the beach chair position and an S-type incision was made over the lateral acromial spine extending into a deltoid split incision. The supraspinatus was resected en bloc, and the proximal humerus, undersurface of the acromion and glenoid were denuded of cartilage using a burr, curettes and osteotomes (Figure 3a). The glenohumeral joint was positioned in 30° abduction, FE and IR. The patient’s hand was positioned in a place where she was able to reach her mouth, which was checked intraoperatively. A 10-hole, 4.5-mm locking-compression reconstruction plate was contoured and used with cancellous and cortical screws to compress the proximal humerus to the glenoid and acromion (Figure 3b). Demineralized bone matrix was added after fixation to augment fusion. A postoperative AP lateral and oblique view of the shoulder (Figure 4) demonstrated good compression and hardware position.
Postoperatively, the patient was admitted for pain control. She was fitted with a quadrant shoulder brace for continuous immobilization. She was seen for follow-up for a wound check. The patient was placed in a gunslinger orthosis for 10 weeks until radiographic evidence of fusion was seen. She performed occupational therapy for hand and elbow range of motion and reported good pain relief at her most recent follow-up.
Discussion
Treatment for painful flail shoulder includes nonoperative management modalities, like physical therapy, bracing and corticosteroid injections. Glenohumeral arthrodesis is a satisfactory option for patients who fail nonoperative management.
Glenohumeral arthrodesis has specific indications, including brachial plexus injuries, paralysis or severe paresis of the deltoid and rotator cuff, chronic infection, failed glenohumeral arthroplasty, severe refractory instability, and bony deficiency following tumor or bony resection. A painful flail shoulder may be the best indication for arthrodesis due to the limited functional goals associated with the surgery and the preserved glenohumeral bony anatomy.
Shoulder fusion has a few contraindications. Active infection is an absolute contraindication to fusion. Glenohumeral arthrodesis relies on residual scapular motion for additional mobility at the shoulder girdle, therefore paresis or paralysis of the trapezius and serratus anterior musculature are also relative contraindications for shoulder arthrodesis.
The incidence of shoulder fusion has decreased over time as the success of total and reverse total shoulder arthroplasty has improved. However, in the aforementioned clinical scenarios, arthrodesis continues to be an option for pain relief. In a large series of 71 fused shoulders by Cofield and Briggs, pain relief was adequate in 75% of patients and 70% of patients were able to lift moderate weight. Additionally, activities of daily living, such as dressing, personal hygiene and feeding, were possible in 70% of patients. Richards and colleagues reported outcomes in a smaller series of 33 patients. Almost all patients could perform necessary activities at waist level, and 21 patients could work at shoulder level. The authors noted a correlation between the ability to perform activities of daily living and the function of the hand in patients with brachial plexus injuries.
Potential complications of shoulder fusion include standard post-surgical complications, including infections, wound complications, periprosthetic fractures about the implants and pseudarthrosis. The most functionally limiting complication involves shoulder malpositioning including excess abduction or FE. Sousa and colleagues recommend fusion in no more than 35° abduction, no more than 30° FE and IR no more than 45°. This is the recommended position to be able to reach one’s mouth and perineal region.
- References:
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- Cotoi, A et al. Chapter 11: Painful Hemiplegic Shoulder. Evidence Based Review of Stroke Rehabilitation. www.ebrsr.com/evidence-review/11-hemiplegic-shoulder-pain-complex-regional-pain-syndrome. Accessed on March 12, 2018.
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- For more information:
- Edward C. Cheung, MD, and Frank A. Petrigliano, MD, can be reached at David Geffen School of Medicine at UCLA, Department of Orthopaedic Surgery, 10833 Le Conte Ave., #12138, Los Angeles, CA 90095; Cheung’s email: echeung@mednet.ucla.edu. Petrigliano’s email: fpetrigliano@mednet.ucla.edu.
- Edited by Gregory L. Cvetanovich, MD; and Benedict U. Nwachukwu, MD, MBA. Cvetanovich is in the division of sports medicine at Rush University Medical Center. Nwachukwu is an orthopedic surgery chief resident at Hospital for Special Surgery. For information on submitting Orthopedics Today Grand Rounds cases, please email: orthopedics@healio.com.
Disclosures: Petrigliano reports he is a paid presenter or speaker for Zimmer Biomet and Stryker. Cheung reports no relevant financial disclosures.