Assistant Professor Baylor College of Medicine / Texas Children’s Hospital Houston, Texas, United States
Case Diagnosis: Steroid-induced avascular necrosis of the shoulder in a patient with brain tumor receiving long-term intermittent steroids
Case Description: An eighteen-year-old male with progressive complex cystic-solid optic chiasmastic-hypothalamic glioma whose care is at a tertiary pediatric hospitalpresented with acute left upper extremity weakness and shoulder pain to the emergency room. Initial work-up ruled out shunt malfunction, cyst progression, and fractures. During his PM&R appointment, severe pain was noted with range of motion of his shoulder, palpation of the shoulder joint, and provocative maneuvers for shoulder impingement and rotator cuff pathologies. Magnetic resonance imaging later showed humeral head avascular necrosis with associated subchondral fracture and articular surface collapse, likely due to long-term intermittent steroid use. The patient was referred to adult orthopedics given the potential need for an arthroplasty. Despite conservative measures, including physical therapy and left suprascapular nerve block, his pain persisted, prompting a left shoulder hemiarthroplasty, which successfully alleviated his symptoms.
Discussions: Steroid use is the leading non-traumatic cause for avascular necrosis of the humeral head. The condition often progresses slowly, with many patients presenting in advances stages because the shoulder is not a weight-bearing joint and compensatory movements of the scapulothoracic joint can mask early symptoms. Patients typically experience pain and a clicking sensation during certain shoulder movements, caused by joint incongruity or a cartilage flap. As the condition worsens, it can lead to persistent pain and reduced range of motion, impacting daily activities. While early stages may benefit from conservative management, more severe cases generally require surgical intervention, which may require referral to adult orthopedics.
Conclusions: This case highlights the importance of considering avascular necrosis of the humeral head as a potential cause of shoulder pain and weakness, particularly in patients with history of long-term steroid use. Timely and accurate diagnosis is crucial to mitigate the need for surgical intervention.
