Patients after stroke often have shoulder pain 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 during hospitalization, accusing doctors of poor standards, which is actually a complication after stroke, called shoulder-hand syndrome, and is 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 function of the affected movement.
Shoulder-hand syndrome is one of the common comorbidities of stroke, mostly occurring 1 to 3 months after stroke, and may occur as early as the third day after the onset of stroke, 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 pump action
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 theory
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 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.
–With the wrist in posterior palmar flexion, the contrast flow to 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.
–It is inferred that the wrist flexion mechanism, which impedes venous circulation, may be the most basic cause of shoulder-hand syndrome in hemiplegic patients.
Considering the process concerning the shoulder-hand syndrome in hemiplegic patients, the above tests have practical implications.
1. why 66-74.1% of the patients occurred 1 to 3 months after stroke?
–Because it is difficult to get the same care as in the acute phase as well as monitoring during this period, the patient’s hand may be in an obligatory palmar flexion position for a considerable period of time and not detected or ignored in time.
2. When the muscle tone of the upper extremity is relatively low, there is already wrist as well as shoulder flexion of the affected hand, while the wrist extensor group is indeed hypotonic, resulting in an inability to counteract wrist flexion.
3, Some patients with left-sided hemiplegia have neglect syndrome or severe sensory dysfunction and cannot notice the presence of poor good limb position.
4.The reason for the predominance of early edema in the back of the hand?
–because the veins and lymphatic vessels of the hand are almost all related to the back of the hand from anatomical view.
5.What is the reason for the limitation of swelling in the patient, mostly terminating at the proximal end of the wrist joint?
– because the patient’s wrist joint is always in some degree of palmar flexion, day or 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.
– Sudden swelling of the affected hand, and significant limitation of the range of motion on the affected side occurs soon.
–Oedema mainly appears on the dorsum of the affected hand, including the metacarpophalangeal joint, thumb and 2 to 5 fingers, with loss of skin folds, especially in the proximal and distal interphalangeal joints.
–The edema is tender and swollen to touch 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 turns orange or purple, especially when the hand is in a downward position; the hand has a slightly warm and moist feeling, 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 more severe when the wrist is palmarly flexed.
–Interphalangeal joint movement is significantly limited, and the protruding phalanges are completely invisible due to edema.
– Severely restricted finger abduction, the proximal interphalangeal joint can only be slightly flexed, completely unable to extend, and painful when passively flexed; the distal interphalangeal joint can be extended, but flexion is almost impossible, and painful when flexed.
Stage 2.
Characterized by marked atrophy or contracture of the skin and the small muscles of the hand.
–An increase in pressure pain in the hand and fingers that is clearly unbearable.
– Decrease in shoulder pain, dyskinesia and edema of the hand.
–Vasomotor changes, such as increased skin moisture and redness.
–Significant atrophy of the skin and muscles of the affected hand, often seen as 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.
— Wrist flexion deviates to the ulnar side, dorsiflexion is limited, and the dorsal bulge of the metacarpal bone is fixed without edema.
–Limited external rotation of the forearm.
–Partial atrophy of the interphalangeal joints of the thumb and index finger with no elasticity.
–The interphalangeal joints are in a mildly flexed position, and if flexion is possible, it is within a small range.
–Palm is flattened, with significant atrophy of the thumb and little finger
–Pressure 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 soak warm water for 10 minutes, in the immersion of 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 exercise method.
Passive joint range of motion training for the affected shoulder, wrist and fingers.
7.Lymphatic program, qi hands, 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.