Patients after stroke often have shoulder pain accompanied or accompanied by hand swelling and pain, which is often mistaken for frozen shoulder, rheumatism, deep vein thrombosis and other diseases, and is often mistaken by patients for poor treatment when it occurs during hospitalization, which is actually a post-stroke complication called shoulder-hand syndrome, briefly described as follows.
I. Concept.
It refers to the sudden swelling and pain in the affected hand and pain in the affected shoulder of patients with cerebrovascular disease during the recovery period, and limits the affected motor function. Shoulder-hand syndrome is one of the common comorbidities of stroke disease, mostly occurring 1 to 3 months after stroke, and may occur as early as the third day after onset, or as late as 6 months.
If left untreated, it can lead to deformation of the hand and fingers and total loss of hand function, which should be treated early.
II. Etiology and pathogenesis
The exact mechanism is not known.
(A) External factors.
1, prolonged inactivity of the affected limb
2, poor limb position
3.Mechanical action directly causes swelling
4.Secondary trauma
5, muscle weakness loss of the pump role
6.Compulsory palmar flexion of the wrist joint
7.Inflammatory-like swelling and pain caused by excessive wrist extension of the treated person.
8.Prolonged infusion of fluids into the affected hand.
9.Prolonged and repeated use of the affected hand.
10.Compulsory palmar flexion of the wrist joint for a long time
In short, edema, pain, and restricted ROM lead to a vicious cycle, which eventually leads to the occurrence of the sign.
(ii) Intrinsic factors.
Cervical sympathetic nerve stimulation doctrine.
The acute cerebrovascular attack stimulates the cervical sympathetic nervous system, reinforces the centripetal impulses from the lesion to the cervical medulla, and forms pathological reflex loops in the posterior horn of the cervical segment of the spinal cord.
Experimental evidence shows that.
1. mandatory excessive carpal palmar flexion, the venous circulation of the hand will be severely blocked.
When the wrist joint is in intermediate position, the contrast agent is injected into the vein of the dorsum of the hand, and the flow of the contrast agent is observed to be unobstructed under X-ray. When the wrist is palmarly flexed, the contrast flow is not smooth.
2. In stroke patients with descending shoulder, increased muscle tone of the upper extremity adductor group, and obvious spasticity of the hemiplegic patients, the flow of contrast agent is further obstructed by further compression of the wrist joint.
Inference.
The wrist flexion mechanism that impedes venous circulation may be the most basic cause of shoulder-hand syndrome in hemiplegic patients.
Considering the course of the shoulder-hand syndrome in patients with hemiplegia, the above tests are of practical interest.
Why 66-74.1% of the patients occurred 1 to 3 months after stroke?
Because it is difficult to provide the same care and monitoring as in the acute phase, the patient’s hand may be in an obligatory palmar flexion position for a considerable period of time, which is not detected or ignored in time.
When the muscle tone of the upper extremity is relatively low, there is already wrist as well as shoulder flexion of the affected hand, and the wrist extensor group is indeed hypotonic, resulting in an inability to counteract the wrist flexion.
Some patients with left-sided hemiplegia have neglect syndrome or severe sensory dysfunction and are unable to notice the presence of poor good limb position.
The reason for the predominance of the dorsal aspect of the hand in early edema?
Because the veins and lymphatic vessels of the hand are anatomically almost all related to the dorsum of the hand.
What are the limitations of the patient’s edema, mostly terminating at the proximal end of the wrist joint?
Because the patient’s wrist joint is always in some degree of palmar flexion, both day and night, especially when no monitoring or correction is given for this incorrect posture.
III. Clinical manifestations.
Shoulder-hand syndrome is divided into three phases
Phase 1.
It is characterized by wrist joint pain, restricted movement, swelling, and severe pain after passive activity.
The affected hand is suddenly swollen, and significant limitation of the range of motion of the affected side occurs soon.
The edema mainly appears on the dorsum of the affected hand, including the metacarpophalangeal joint, thumb and 2-5 fingers, with loss of skin folds, especially in the proximal and distal interphalangeal joints.
The edema is tender and swollen to palpation and often terminates at the wrist joint and proximal end.
The muscle keys of the hand are masked and not visible; the color of the hand changes to orange or purple, especially when the hand is in a downward position; there is a slight feeling of heat and humidity in the hand, and the nails are pale or opaque.
There is pain in the affected shoulder and wrist joints, and ROM is limited, especially when the forearm is passively externally rotated and when the wrist joint is palmarly flexed.
Interphalangeal joint movement is significantly limited, and the protruding phalanges are completely invisible due to edema.
The proximal interphalangeal joint can only be slightly flexed and cannot be extended at all, and it is painful when it is passively flexed; the distal interphalangeal joint can be extended, but flexion is almost impossible, and it is painful when it is flexed.
Stage 2.
Characterized by marked atrophy or contracture of the skin and the small muscles of the hand.
There is a markedly unbearable increase in pressure pain in the hand and fingers.
Shoulder pain, dyskinesia and edema of the hand are reduced.
Vasomotor changes, such as increased skin moisture and redness.
Significant atrophy of the skin and muscles of the affected hand is often seen with thickening of the palmar tendon membrane and claw-shaped fingers and finger contractures.
X-ray fluoroscopy reveals osteoporotic changes in the affected hand, with hard bulges visible to the naked eye in the dorsal center of the intercarpal region and at the union of the metacarpal and carpal bones.
Stage 3.
Complete loss of edema and pain, permanent loss of hand mobility, and a fixed, characteristic deformed hand.
The wrist flexion is biased to the ulnar side, dorsiflexion is limited, and the dorsal bulge of the metacarpal bone is fixed without edema.
External rotation of the forearm is limited.
The interphalangeal thumb and index finger are partially atrophied and inflexible.
The interphalangeal joints are in a mildly flexed position, and if flexion is possible, it is within a small range.
The palm of the hand is flattened, with significant atrophy of the thumb and little finger
Compression pain as well as vasomotor changes disappear.
Stage 1: lasts 1 to 6 months, immediate treatment often controls progression and cures spontaneously.
Stage 2: lasts for an average of 3 to 6 months and has a poor prognosis.
Stage 3: irreversible, the affected hand is completely useless.
IV. Prevention.
Factors that produce swelling should be avoided as much as possible.
1. Maintain correct posture in bed and wheelchair, especially the position of the affected upper limb: good limb position in bed, wheelchair placement shelf
2. Pay attention to the intensity and duration of weight-bearing training of the affected limb.
3. Do not rehydrate the affected hand as much as possible.
4, prevent any trauma to the affected hand.
V. Treatment.
Treatment principles.
Early detection, early treatment, especially the onset of 3 months is the best treatment period, once the chronicity is not yet any effective treatment program.
1.Extend the metacarpophalangeal joint and prevent palmar flexion of the wrist joint to promote venous return.
2.Compression of the fingers by centripetal winding.
3.Ice water immersion: the ratio of ice to water is 2:1, and the time is as long as the patient can tolerate.
4.Cold water – warm water alternate immersion method: this method is easier to accept than the above method, cold water temperature is 10 degrees, hot water is 40 degrees, first immersion in warm water for 10 minutes, in the immersion in cold water for 20 minutes.
5, active movement method: supine position of the healthy hand to assist the affected hand to lift, or the healthy hand to hold the affected hand to lift the upper limb, swing back and forth, etc.
6.Passive movement method: passive joint range of motion training of the affected shoulder, wrist and fingers.
7.Lymphatic program, air hand, herbal infusion, herbal fumigation, acupuncture, etc.
8.Other: 1% cocaine 7ml+cortisone 2mg affected stellate ganglion block 2-3 times a week; oral corticosteroid 30mg/day.