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Acute traumatic rotator-cuff tear — MSRA MCQ

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HardShoulder InjuriesAcute traumatic rotator-cuff tearMSRA

A 52-year-old self-employed plumber presents 4 days after falling onto his outstretched right arm from a step ladder. Shoulder radiographs obtained in the emergency department showed no fracture or dislocation. Despite analgesia, he cannot actively abduct the arm beyond 30 degrees or hold it abducted against gravity. Passive abduction is 165 degrees. External rotation is markedly weak, but sensation over the lateral deltoid and throughout the hand is normal and distal pulses are present. There is no neck pain or cervical neurological deficit. What is the most appropriate management today?

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Reveal the answer and explanation

Correct answer: B — Make an urgent orthopaedic referral for suspected acute traumatic rotator-cuff tear

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

This presentation is most consistent with an acute traumatic rotator-cuff tear. The key discriminator is the marked discrepancy between severely impaired active elevation and near-preserved passive abduction, accompanied by objective external-rotation weakness. This is not explained by an unreduced dislocation, fracture, axillary nerve injury or cervical radiculopathy: radiographs exclude fracture/dislocation, and neurovascular examination is normal. In UK referral guidance, acute traumatic cuff injury with loss of active movement or disabling weakness in a person younger than 60 years warrants urgent orthopaedic assessment. Early specialist review is important because a repairable traumatic tear may require time-sensitive investigation and operative consideration. Ultrasound may subsequently help define tendon pathology, but should not delay the urgent referral decision in this clinical context. A is appropriate for uncomplicated rotator-cuff tendinopathy or after specialist assessment, but not for a suspected acute full-thickness traumatic tear. B may be reasonable for subacromial pain syndrome after exclusion of a tear, but steroid injection is not the priority here. D risks delaying escalation. E is inappropriate because adhesive capsulitis causes restriction of both active and passive movement, particularly passive external rotation, rather than isolated active weakness after trauma.

Reference: Shoulder — DGRefHelp, NHS Dumfries and Galloway Right Decisions (Reviewed 5 July 2024) — https://www.rightdecisions.scot.nhs.uk/dg-refhelp/musculoskeletal-system/shoulder/