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Axillary nerve injury after traumatic shoulder dislocation — MSRA MCQ

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HardShoulder InjuriesAxillary nerve injury after traumatic shoulder dislocationMSRA

A 61-year-old woman is reviewed in general practice 3 days after a first traumatic anterior dislocation of her right shoulder following a fall. The shoulder was reduced in the emergency department. Pre- and post-reduction radiographs showed no fracture and a concentrically reduced glenohumeral joint. The documented neurovascular examination immediately after reduction was normal. Since yesterday, she has noticed increasing numbness over the lateral aspect of the upper arm and cannot lift the arm away from her side despite analgesia. The shoulder contour is normal and there is no recurrent deformity. Passive abduction is limited only by pain, but there is no palpable deltoid contraction on attempted abduction. Hand power, sensation, radial pulse and capillary refill are normal. She is afebrile. What is the most appropriate next step in management?

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Correct answer: E — Arrange urgent same-day orthopaedic assessment via the local on-call pathway

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

This patient has a new focal neurological deficit after a reduced traumatic shoulder dislocation: anaesthesia over the lateral upper arm with absent deltoid contraction strongly indicates axillary nerve dysfunction. The preserved hand neurology, pulse and capillary refill do not make this safe for routine rehabilitation; they localise the problem rather than exclude clinically important post-traumatic nerve injury. UK NHS referral guidance identifies neurovascular symptoms following shoulder dislocation as an urgent referral criterion. Same-day orthopaedic assessment is therefore appropriate to confirm and document the deficit, reassess joint position and associated injury, and determine the required follow-up. A is appropriate only after serious post-dislocation complications have been excluded; rehabilitation should not be used as the initial response to a new motor and sensory deficit. B is plausible because adults over 40 years may sustain a rotator-cuff tear after dislocation, but a cuff tear does not explain the dermatomal sensory loss and absent deltoid contraction. D delays assessment of a clinically evident neurological complication and imaging should be directed by the specialist assessment. E would be reasonable for uncomplicated improving pain after reduction, but not for progressive neurological signs.

Reference: NHS Borders Ref Help Toolkit: Primary shoulder dislocation (Last reviewed 31 July 2025) — https://www.rightdecisions.scot.nhs.uk/borders-ref-help-toolkit/orthopaedic/shoulder/primary-shoulder-dislocation/ Early and Emergency Department Management of Infraclavicular Brachial Plexus Injuries Secondary to Shoulder Trauma (2026) — https://pubmed.ncbi.nlm.nih.gov/42434619/