What is the appropriate management for a patient presenting with shoulder and hand pain along with fever?

Management of Shoulder and Hand Pain with Fever

When a patient presents with combined shoulder and hand pain plus fever, immediately suspect Complex Regional Pain Syndrome (CRPS, also known as Shoulder-Hand Syndrome) and initiate treatment promptly, as this condition can significantly impair rehabilitation and quality of life if left untreated. 1

Immediate Diagnostic Considerations

The combination of shoulder pain, hand pain, and fever should trigger evaluation for:

• CRPS/Shoulder-Hand Syndrome: Look specifically for pain and tenderness of the metacarpophalangeal and proximal interphalangeal joints, edema over the dorsum of the fingers, trophic skin changes, hyperaesthesia, and limited range of motion in both shoulder and hand 2, 1
• Infectious causes: If fever is prominent with systemic signs, consider septic arthritis or other infectious etiologies requiring urgent evaluation 2
• Inflammatory conditions: Assess for signs of systemic inflammatory response that may require broad-spectrum antibiotics 2

Key Clinical Findings to Assess

Perform a focused examination evaluating:

• Tone, strength, soft tissue length changes, and joint alignment of the shoulder girdle 2, 3
• Specific hand involvement: metacarpophalangeal and proximal interphalangeal joint tenderness distinguishes CRPS from isolated shoulder pathology 1
• Presence of edema over the dorsum of fingers, which is characteristic of CRPS 1
• Skin changes including hyperaesthesia and trophic changes 1

Diagnostic Testing

• Triple-phase bone scan can assist in CRPS diagnosis, demonstrating increased periarticular uptake in distal upper extremity joints 1
• Imaging: If trauma history or concern for structural pathology, obtain shoulder radiographs (anteroposterior views in internal and external rotation plus axillary or scapula-Y view) 3
• Laboratory evaluation: If systemic infection suspected, obtain inflammatory markers and cultures as appropriate 2

Treatment Algorithm

First-Line Management (Initiate Immediately)

Pharmacological:

• Analgesics: Start acetaminophen or ibuprofen if no contraindications 2, 1, 4
• Topical NSAIDs should be considered as first pharmacological treatment for mild to moderate pain 1
• Topical capsaicin may be effective specifically for hand involvement 1

Non-Pharmacological:

• Range of motion exercises: Active, active-assisted, or passive ROM exercises focusing on external rotation and abduction 2, 1, 3
• Avoid overhead pulleys, which encourage uncontrolled abduction and dramatically increase risk of worsening shoulder pain 1, 3
• Active ROM should be increased gradually while restoring alignment and strengthening weak shoulder girdle muscles 2, 3
• Local heat application before exercise can provide symptomatic relief 1
• Splints and orthoses should be considered for thumb base involvement 1

Second-Line Management (If Inadequate Response to First-Line)

For CRPS with significant swelling and pain:

• Oral corticosteroids: Start 30-50 mg daily for 3-5 days, then taper over 1-2 weeks to reduce swelling and pain 1

For shoulder pain related to spasticity:

• Botulinum toxin injections into the subscapularis and pectoralis muscles 2, 1, 3

For pain related to subacromial inflammation:

• Subacromial corticosteroid injections when pain is thought related to rotator cuff or bursa injury 2, 1, 3

Additional modalities:

• Functional electrical stimulation (FES) or neuromuscular electrical stimulation (NMES) may be considered 3
• Suprascapular nerve blocks as adjunctive treatment for persistent pain 3

Critical Pitfalls to Avoid

• Do not use overhead pulley exercises: These encourage uncontrolled abduction and dramatically increase hemiplegic shoulder pain incidence 1, 3
• Protect the limb from trauma: Failure to protect the affected limb from trauma is a critical error that can worsen CRPS 1
• Do not delay treatment: Shoulder pain can delay rehabilitation and mask improvement of motor function, contributing to depression, sleeplessness, and reduced quality of life 1, 3
• Monitor for NSAID complications: If using ibuprofen, remain alert for GI ulceration/bleeding, renal toxicity, cardiovascular events, and serious skin reactions 4

Special Considerations for Fever

If fever persists or systemic signs of infection are present:

• Consider empirical broad-spectrum antibiotics (e.g., ceftriaxone plus metronidazole) until infectious etiology is ruled out 2
• Reassess for alternative diagnoses including septic arthritis, osteomyelitis, or systemic infection 2

Monitoring and Reassessment

• Patients should be reassessed periodically to evaluate response to treatment 1
• Most patients with CRPS should respond within 72-96 hours to appropriate treatment 2
• If no improvement or worsening occurs, escalate to second-line therapies and consider alternative diagnoses 1, 3