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Suspected acute traumatic rotator cuff tear — MSRA MCQ

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HardSoft Tissue InjurySuspected acute traumatic rotator cuff tearMSRA

A 52-year-old right-hand-dominant warehouse worker attends a GP-led urgent treatment centre 5 days after falling onto his outstretched right hand from a loading step. He had immediate shoulder pain but no visible deformity. He has been unable to return to work because he cannot lift his arm to reach overhead. Shoulder radiographs obtained on the day of injury show no fracture or dislocation. There is no cervical pain or paraesthesia. Sensation over the lateral deltoid is normal and distal neurovascular examination is normal. Passive glenohumeral abduction and external rotation are nearly full but painful. He cannot actively abduct beyond 30 degrees and cannot maintain abduction when the arm is passively positioned at 90 degrees. External rotation against resistance is markedly weak and painful compared with the other side. What is the most appropriate management now?

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

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

This presentation is concerning for an acute traumatic rotator cuff tear. The decisive pattern is substantial loss of active elevation and inability to sustain abduction despite near-preserved passive movement, together with marked painful weakness of external rotation. This is not explained by adhesive capsulitis, in which passive movement would also be restricted. Normal sensation over the lateral deltoid makes a clinically significant axillary nerve injury less likely, while normal radiographs exclude the major bony injury or unreduced dislocation that would otherwise account for the deficit. In UK primary-care referral guidance, acute traumatic shoulder injury with loss of active movement, disabling weakness or inability to sustain movement against resistance warrants urgent orthopaedic referral in people younger than 60 years. This patient is 52 and has a functionally important acute deficit, so referral should not await a prolonged trial of conservative treatment or community imaging. B and E are appropriate for many uncomplicated soft-tissue shoulder injuries without profound weakness. C may identify cuff pathology but delays the urgent specialist pathway and primary-care MRI/ultrasound is not the priority here. D may have a role in selected non-traumatic subacromial pain, but is inappropriate before assessment of a suspected acute full-thickness tear.

Reference: Shoulder | DGRefHelp | NHS Dumfries and Galloway (2024) — https://www.rightdecisions.scot.nhs.uk/dg-refhelp/musculoskeletal-system/shoulder/