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Acute traumatic rotator cuff tear — MSRA MCQ

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ModerateShoulder InjuriesAcute traumatic rotator cuff tearMSRA

A 52-year-old right-handed carpenter presents 4 days after falling onto his outstretched left hand from a ladder. He had immediate shoulder pain and has since been unable to lift his arm above waist height. Anteroposterior and axial shoulder radiographs obtained in the emergency department show no fracture or dislocation. Despite regular ibuprofen and paracetamol, active abduction is limited to 25 degrees and active external rotation is markedly weak. Passive abduction is 160 degrees and passive external rotation is full. Deltoid contraction is present, sensation over the lateral upper arm is normal, and distal neurovascular examination is normal. There is no cervical pain, fever, or recurrent shoulder deformity. What is the most appropriate management now?

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Correct answer: D — Arrange urgent shoulder ultrasound and urgent orthopaedic assessment

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

This presentation is most consistent with an acute traumatic rotator cuff tear. The key discriminators are a clear traumatic mechanism, profound loss of active abduction and external rotation, preserved passive range of movement, and objective weakness despite analgesia. Normal deltoid function and preserved sensation over the lateral upper arm make axillary nerve palsy less likely; normal radiographs exclude an obvious fracture or persistent dislocation. In a patient under 60 years with acute traumatic shoulder injury, loss of active movement and inability to sustain movement against resistance warrant urgent orthopaedic referral. UK NHS referral guidance also advises urgent ultrasound in younger patients with a traumatic cuff tear after appropriate radiographs have excluded fracture-avulsion. Early specialist assessment is important because an acute full-thickness tear may be amenable to repair. A is appropriate for uncomplicated rotator cuff tendinopathy or degenerative cuff disease, not suspected acute traumatic rupture. C introduces an inappropriate delay and selects MRI rather than the recommended urgent initial ultrasound pathway. D may be considered for non-traumatic subacromial pain but can delay assessment of a potentially repairable tear. E would be appropriate if there were an unreduced dislocation, fracture, neurovascular compromise, or suspected infection; none is present.

Reference: Shoulder — Rotator cuff injury (Last reviewed 5 July 2024) — https://www.rightdecisions.scot.nhs.uk/dg-refhelp/musculoskeletal-system/shoulder/ Rotator Cuff Tear (Next review date 4 July 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