The Clinical Syndrome

Avascular necrosis, which is also known as osteonecrosis, of the glenohumeral joint is an often missed diagnosis. Like the scaphoid, the glenohumeral joint is extremely susceptible to this disease because of the tenuous blood supply of the articular cartilage, which is only 1.0 to 1.2 mm thick at the center of the humeral head. This blood supply is easily disrupted, often leaving the proximal portion of the bone without nutrition leading to osteonecrosis ( Fig. 29.1 ). Avascular necrosis of the glenohumeral joint is a disease of the fourth and fifth decades, except when it is secondary to collagen vascular disease. Avascular necrosis of the glenohumeral joint is more common in men. The disease is bilateral in 50% to 55% of cases.

The pain of avascular necrosis of the glenohumeral joint is worsened by passive and active range of motion.

Factors predisposing to avascular necrosis of the glenohumeral joint are listed in Box 29.1 . They include trauma to the joint; corticosteroid use; Cushing’s disease; alcohol abuse; and connective tissue diseases, especially systemic lupus erythematosus, osteomyelitis, human immunodeficiency virus infection, organ transplantation, hemoglobinopathies including sickle cell disease, hyperlipidemia, gout, renal failure, pregnancy, and radiation therapy involving the femoral head.

The patient with avascular necrosis of the glenohumeral joint complains of pain over the affected glenohumeral joint or glenohumeral joints that may radiate into the proximal upper extremity and shoulder. The pain is deep and aching, and patients often complain of a catching sensation with range of motion of the affected glenohumeral joint or glenohumeral joints. Range of motion decreases as the disease progresses.

Signs and Symptoms

Physical examination of patients suffering from avascular necrosis of the glenohumeral joint reveals pain to deep palpation of the glenohumeral joint. The pain can be worsened by passive and active range of motion. A click or crepitus may also be appreciated by the examiner during range of motion of the glenohumeral joint. Range of motion is invariably decreased.