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Acute traumatic rotator cuff tear — MSRA MCQ

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HardSoft Tissue InjuryAcute traumatic rotator cuff tearMSRA

A 58-year-old right-hand-dominant electrician is reviewed in general practice 3 days after falling forwards onto his outstretched right hand from a ladder step. He had immediate shoulder pain and was assessed in an urgent treatment centre. Anteroposterior and axial shoulder radiographs showed no fracture or dislocation. He now has marked difficulty lifting his arm to work overhead. He can actively abduct the shoulder to 35 degrees only, but passive abduction reaches 160 degrees, limited by pain. When the arm is placed at 90 degrees of abduction, he cannot maintain this position. External rotation strength is substantially reduced compared with the left side. Distal neurology and pulses are normal. He is afebrile, and there is no erythema or joint swelling. Before this injury, he had occasional mild shoulder discomfort but no functional limitation. What is the most appropriate next step?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: B — Arrange urgent shoulder ultrasonography and urgent orthopaedic referral

Explanation lettering: B = shown as A · C = shown as B · A = shown as C

This presentation is most consistent with an acute traumatic rotator cuff tear, likely involving a full-thickness component. The decisive features are a traumatic onset, substantial loss of active function with relatively preserved passive range, inability to sustain abduction, and objective external-rotation weakness. Normal radiographs exclude major fracture and persistent dislocation but do not exclude a tendon rupture. In a patient under 70 years with a traumatic suspected cuff tear, UK NHS specialty referral guidance advises shoulder radiographs to exclude fracture or avulsion, urgent ultrasonography, and urgent orthopaedic opinion. His previous intermittent mild discomfort may indicate pre-existing tendinopathy, but does not make this an atraumatic degenerative presentation: the abrupt functional loss after injury is the priority discriminator. A and E inappropriately delay assessment of a potentially repairable acute tear. They would be reasonable for a minor soft-tissue injury without objective weakness or major functional loss. B is plausible for rotator-cuff-related shoulder pain or impingement after conservative measures, but injection is not the initial response to suspected acute tendon rupture. D recognises the need for imaging but unnecessarily delays specialist assessment; urgent ultrasound plus referral is the appropriate UK pathway.

Reference: NHS Tayside RefGuide: Rotator Cuff Tear (Next review date 04/07/2027) — https://www.rightdecisions.scot.nhs.uk/nhs-tayside-refguide/surgery-and-orthopaedics/orthopaedic-and-trauma-surgery/shoulder-and-elbow/rotator-cuff-tear/?UNLID=22638775202621594927