# Situation: A 68-year-old man is on the medical ward on day 4 after an ischemic stroke in the right cerebral hemisphere. He did not receive reperfusion therapy. He has left-sided weakness, is alert, and has hypertension. He passed a bedside swallow screen yesterday. He now sits in a wheelchair for 2 hours each afternoon. His left arm is flaccid. Which action protects his left shoulder?

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> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 68-year-old man is on the medical ward on day 4 after an ischemic stroke in the right cerebral hemisphere. He did not receive reperfusion therapy. He has left-sided weakness, is alert, and has hypertension. He passed a bedside swallow screen yesterday.

He now sits in a wheelchair for 2 hours each afternoon. His left arm is flaccid. Which action protects his left shoulder?

## 보기

1. Support the left arm on a lap tray or a pillow **✔ 정답**
2. Move him up in the chair by lifting under both arms
3. Let the left arm hang down to stretch the tight muscles
4. Keep the left elbow bent across his chest, hand fisted

**정답: 1**

## 해설

The weight of a flaccid arm pulls the humeral head down and causes shoulder subluxation and pain. The arm is supported on a pillow or lap tray, positioned with the elbow extended and palm up, and never pulled on during transfers or repositioning.

## 심화 해설

Why the left shoulder is at risk

After a right hemispheric ischemic stroke, the contralateral left arm is often flaccid during the early phase. In the flaccid stage, the rotator cuff muscles and other shoulder stabilizers lose tone, so they can no longer hold the humeral head snugly in the glenoid fossa. Gravity then pulls the humerus downward, widening the acromion-humeral gap and producing glenohumeral subluxation [2]. This downward displacement is the main mechanical cause of shoulder pain and secondary injury in hemiplegic patients [1][4].

The weight of a flaccid arm hanging unsupported from a wheelchair is enough to stretch the joint capsule and surrounding soft tissue, causing subluxation and pain. Therefore, the priority is to eliminate the downward pull of gravity on the humerus.

Why option 1 is correct

Supporting the left arm on a lap tray or pillow lifts the humerus back toward the glenoid and keeps the shoulder in a neutral, protected position. The forearm should rest with the elbow extended and the palm up to avoid internal rotation and elbow flexion contracture. Positioning the arm this way reduces traction on the joint capsule and helps prevent subluxation during prolonged sitting [1][3].

Why the other options are harmful

| Action | Problem |
| --- | --- |
| Lifting under both arms | Pulling upward under the axilla directly stresses the unsupported shoulder joint and can worsen subluxation or injure the brachial plexus. Transfers must never use the affected arm as a handle [1]. |
| Letting the arm hang down | Gravity pulls the humeral head downward, increasing the acromion-humeral gap and stretching the capsule. This is the exact mechanism that causes subluxation [2]. |
| Elbow bent, hand fisted | This flexed, internally rotated posture promotes spasticity and contracture. It does not support the humerus and can increase shoulder pain over time [1][3]. |

Clinical application for nursing care

Positioning management is a core nursing intervention after stroke. When the patient sits in a wheelchair, the affected arm should be supported so the shoulder is not pulled downward. During repositioning or transfer, the arm must be moved gently and never pulled. Proper positioning and transfer technique are the most important nursing actions for reducing shoulder injury in hemiplegic patients. Gentle range of motion and functional electrical stimulation may also help reduce subluxation, but these are usually performed with physiotherapy involvement and do not replace basic protective positioning [1][4].

Key point! The flaccid shoulder subluxates because gravity overcomes absent muscle tone. Support the humerus, keep the elbow extended with the palm up, and never pull on the affected arm.

Watch out! Lifting under the arms during transfers is a common mistake that can directly injure the shoulder and brachial plexus. Use a transfer belt or support the trunk instead.References (research sources)

- [1]Post-stroke shoulder subluxation: a concern for neuroscience nurses.Research articleSeneviratne C, Then KL, Reimer M (2005)

- [2]Effect of Sling Suspension-Based Active Shoulder Joint Exercises on Shoulder Subluxation in Subacute Stroke Patients.Research articleKilledar MT, Kanase SB. (2026) · DOI: 10.7759/cureus.109397

- [3]Best evidence summary on positioning management in stroke patients.Research articleXiong Y, Pan M, Chai W, Lei H, Peng H, Hu Z, Li N, Liang Y, Kuang L, Liu H. (2025) · DOI: 10.3389/fneur.2025.1648841

- [4]Comparison of efficacy and safety of different types of electrical stimulation for shoulder subluxation after acute stroke: protocol for a systematic review and network meta-analysis of randomised controlled trials.Meta-analysis/systematic reviewKan M, Chen Q, Dan Y, Li L, Li W, Zhang L, Lu Y, Feng Z. (2025) · DOI: 10.1136/bmjopen-2024-090121

## 임상 시나리오

Protecting the Hemiplegic ShoulderPositioning and Transfer Safety After Stroke
In the flaccid stage after stroke, loss of rotator cuff tone allows gravity to pull the humeral head downward, causing glenohumeral subluxation. The primary preventive action is to eliminate downward traction on the unsupported arm during sitting.

Support the affected arm on a lap tray or pillow with the elbow extended and palm up. This neutral position reduces joint capsule stretch and prevents internal rotation or elbow flexion contractures during prolonged wheelchair sitting.

CautionNever lift or reposition the patient by pulling under the axilla or using the affected arm as a handle. This stresses the unsupported joint and risks worsening subluxation or causing brachial plexus injury.

## 핵심 개념

- **Glenohumeral subluxation** — Downward displacement of the humeral head from the glenoid fossa due to loss of rotator cuff tone in a flaccid arm
- **Flaccid stage** — Early post-stroke phase characterized by loss of muscle tone and absent voluntary movement
- **Lap tray** — A wheelchair-attached surface used to support the affected arm and reduce gravitational pull on the shoulder
- **Rotator cuff** — Muscle group that stabilizes the humeral head within the glenoid fossa
- **Brachial plexus injury** — Nerve damage that can occur from pulling or stretching the arm during transfers

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