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Acute traumatic rotator-cuff tear after anterior shoulder dislocation — MSRA MCQ

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ModerateShoulder InjuriesAcute traumatic rotator-cuff tear after anterior shoulder dislocationMSRA

A 55-year-old self-employed landscape gardener is reviewed 9 days after a first traumatic anterior dislocation of his dominant shoulder following a fall. The shoulder was reduced in the emergency department. Pre- and post-reduction radiographs showed no fracture and concentric reduction. His resting pain is improving, but he remains unable to lift the arm to place objects on a shelf. Active abduction is limited to 35 degrees and active external rotation is markedly weak. Passive abduction is 155 degrees and passive external rotation is near full. Deltoid contraction is palpable, sensation over the lateral upper arm and throughout the hand is normal, and there is no neck pain or recurrent deformity. What is the most appropriate management now?

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Correct answer: C — Arrange urgent shoulder ultrasound and urgent orthopaedic referral

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

This presentation is most consistent with an acute traumatic rotator-cuff tear, likely involving supraspinatus with possible infraspinatus involvement. The discriminating features are persistent marked weakness of abduction and external rotation after trauma, with substantially preserved passive movement. A normal lateral upper-arm sensory examination and palpable deltoid contraction make a clinically significant axillary nerve palsy less likely. In a patient under 70 with a traumatic cuff tear, UK NHS referral guidance advises urgent orthopaedic opinion, shoulder radiographs to exclude fracture or avulsion, and urgent ultrasound. The emergency radiographs have already excluded bony injury, so urgent ultrasound and orthopaedic referral are appropriate. A is appropriate for uncomplicated post-dislocation rehabilitation or degenerative cuff disease, but risks delaying assessment of a potentially repairable acute tear. C may have a role in non-traumatic cuff-related pain after exclusion of a tear requiring escalation, but is not appropriate first-line management here. D delays referral unnecessarily; ultrasound is an appropriate initial soft-tissue investigation in this pathway. E is unsuitable because prolonged immobilisation does not address profound cuff weakness and may worsen stiffness.

Reference: Rotator Cuff Tear | NHS Tayside RefGuide (Next review date: 4 July 2027; checked 15 August 2026) — https://www.rightdecisions.scot.nhs.uk/nhs-tayside-refguide/surgery-and-orthopaedics/orthopaedic-and-trauma-surgery/shoulder-and-elbow/rotator-cuff-tear/?UNLID=22638775202621594927