Age and Ageing (1975), 4, 16

                    O. P. FITZGERALD-FINCH AND IRIS I. J. M. GIBSON
                               Southern General Hospital, Glasgow

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

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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.

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
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
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
  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


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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.


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.

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.

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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.

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