Age and Ageing (1975), 4, 16 SUBLUXATION OF THE SHOULDER IN HEMIPLEGIA O. P. FITZGERALD-FINCH AND IRIS I. J. M. GIBSON Southern General Hospital, Glasgow Summary This is a study of 100 hemiplegic patients of whom 17 had downward subluxation of the shoulder joint. The mechanism of this complication is described and appropriate preventative treatment Downloaded from ageing.oxfordjournals.org by guest on January 24, 2011 suggested. INTRODUCTION Painful shoulder has long been recognized as a sequel of hemiplegia. Tobis (1957) suggested that a common cause of shoulder pain in hemiplegic patients was downward subluxation due to weakness of the muscular support, leading to distension of the joint capsule and stretching of the muscle cuff. Najenson & Pikielny (1965) in a review of 500 patients found 88 subluxations of the shoulder joint among 280 hemiplegic patients, and pointed out that the deformity may not be diagnosed in supine films and that erect films should be taken. Moskowitz et al. (1969) made the same point and suggested that appropriate physio- therapy was necessary to avoid this complication. This paper describes the result of a survey carried out in our own hospital to assess the incidence of this complication. Methods One hundred hemiplegic patients were studied on admission to a Geriatric and a Young Disabled Unit or during their stay within the units. There were 38 men and 62 women between the ages of 22 and 94. Women on average were 10 years older than men. The number and ages of men and women conformed to the pattern of all admissions (Table I). Table I. Age and subluxation Males Age 20-30 30-40 40-50 50-60 60-70 70-80 80-90 90 + Number 1 2 19 10 6 Subluxation 1 2 1 Females Age 20-30 30-40 40-50 50-60 60-70 70-80 80-90 90 + Number 2 17 35 6 2 Subluxation 2 4 6 1 An antero-posterior radiograph of both shoulders was taken with the patient erect. Since patients had to be able to stand, no patients were radiographed immediately after infarction and the interval varied between three weeks and 31 years. Three patients had more than one infarct so that Subluxation of the Shoulder in Hemiplegia 17 a total of 55 cases of left-sided hemiplegia and 48 right-sided were obtained for 100 patients (Table II). Table //. Time interval (years) between infarct and radiograph Time o-i * - • 1 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 9+ Patients 17 11 10 10 16 9 11 7 3 3 6 Subluxa- 2 3 1 0 4 2 2 0 0 1 2 tion One hundred patients of matched age and sex without hemiplegia were similarly studied. All radiographs of both groups of patients were reported without prior knowledge of the clinical history. RESULTS Downloaded from ageing.oxfordjournals.org by guest on January 24, 2011 Four men and 13 women from the hemiplegic population were found to have subluxation of the shoulder joint (see Table I). Ten subluxations were on the right side and seven on the left. No patient had bilateral subluxation. All subluxations were found on the side of the hemiplegia and none discovered among the control population. This, of course, shows the time of discovery of the problem and not the time when it occurred. The majority were discovered in the first six years after cerebral infarct but six were discovered in the first year, so that it was not a late phenomenon (Table II). The occur- rence and prevention of the problem must therefore be considered as soon as hemiplegia has developed. DISCUSSION The stability of the shoulder depends entirely upon the support of the surrounding muscle cuff. In order to allow freedom of movement the joint capsule is very lax, parti- cularly inferiorly and anteriorly where it is least supported and subject to the greatest strain when the arm is abducted. This movement requires external rotation of the humerus if it is to be carried beyond a right angle. Following cerebral infarction, patients go through a period of flaccidity, and it is during this period that, if unsupported, the weight of the arm will stretch the surrounding muscle cuff and distend the joint capsule, resulting in inferior subluxation of the humerus. Early subluxation may be encouraged by lifting methods. Unless nurses have been trained in correct lifting, they will tend to lift hemiplegic patients by abducting and externally rotating the arm. A nurse working alone does this even more markedly since she tends to go behind patients and pull both arms up and out in order to lift the patient. Relatives are still more likely to do so since they tend to pull at the hemiplegic limb. PREVENTION Previous authors have emphasized that inferior subluxation of the shoulder joint is a preventable complication with appropriate nursing care and physiotherapy (Tobis, 1957; Moskowitz, 1969). In view of the shortage of physiotherapists, the prevention of subluxation will depend on the nursing staff and how they are taught. When the patient is ambulant he should have a sling on his hemiplegic arm so that the weight does not press on the weakest part 18 O. P. Fitzgerald-Finch and Iris I. J. M. Gibson of the joint. This will also keep the shoulder in the safest position of adduction and internal rotation. However, if the patient is sitting he should not wear a sling since this is then taken by junior nurses and patients as a signal that the arm should not be touched. When the patient is in bed a supporting throne should be made with pillows and when in a chair an arm rest must be provided to ensure shoulder support. Junior nurses should be shown how to put the shoulder joint through a complete range of passive movements several times daily. Nurses should be taught to use the 'Australian lift', where the weight of the patient is taken on the shoulders of the assistants and in addition the patients' shoulders are protected. One person should never attempt to lift a hemiplegic patient. Prevention of subluxation will not only spare the patient pain, but allow a degree of rehabilitation which could not otherwise be achieved. Downloaded from ageing.oxfordjournals.org by guest on January 24, 2011 REFERENCES MOSKOWITZ, H. et al. (1969). Hemiplegic shoulder. New York State J. Med. 69, 548-50. NAJENSON, T. & PIKIELNY, S. S. (1965). Malalignment of the glenohumeral joint following hemiplegia. A review of 500 cases. Aim. phys. Med. 8, 96. TOBIS, J. S. (1957). Posthemiplegic shoulder pain. New York State J. Med. 57, 1377.