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Suspected acute traumatic rotator-cuff tear after reduced anterior shoulder dislocation — MSRA MCQ

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HardShoulder InjuriesSuspected acute traumatic rotator-cuff tear after reduced anterior shoulder dislocationMSRA

A 68-year-old woman is reviewed in general practice 5 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 anteroposterior and axial radiographs showed no fracture and a concentrically reduced glenohumeral joint. Despite regular paracetamol and ibuprofen, she remains unable to raise the arm to reach her head or externally rotate it to comb her hair. Active abduction is 25 degrees and active external rotation is markedly weak. Passive abduction is 150 degrees and passive external rotation is 60 degrees, limited by pain only. Deltoid contraction is palpable during attempted abduction, sensation over the lateral upper arm is normal, and hand power, pulses and capillary refill are normal. There is no recurrent deformity, fever, neck pain or paraesthesia. What is the most appropriate management now?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: E — Arrange shoulder ultrasound and refer to physiotherapy through the MSK pathway

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

This presentation suggests an acute traumatic rotator-cuff tear after a reduced dislocation. The key discriminator is profound loss of active abduction and external rotation with relatively preserved passive movement. Palpable deltoid contraction and intact sensation over the lateral upper arm make clinically significant axillary nerve palsy less likely. There is also no recurrent deformity to suggest redislocation, and no neurovascular or infective red flags requiring emergency assessment. For acute rotator-cuff injury, the NHS Dumfries and Galloway pathway advises urgent orthopaedic referral in people younger than 60 years, but in those older than 60 years advises consideration of ultrasound and physiotherapy referral. This age-specific exception is central here. Ultrasound is an appropriate first-line modality to identify a suspected cuff tear, and MSK physiotherapy supports restoration of movement and function while imaging and onward management are coordinated. A is inappropriate because persisting major functional weakness needs assessment rather than delayed review. B would fit deltoid weakness with lateral upper-arm sensory loss after dislocation. C is indicated for an unreduced or recurrent dislocation, neither of which is present. D is premature: the diagnosis has not been clarified, and injection does not address a possible acute structural cuff tear. ([rightdecisions.scot.nhs.uk](https://www.rightdecisions.scot.nhs.uk/dg-refhelp/musculoskeletal-system/shoulder/?utm_source=openai))

Reference: Shoulder | DGRefHelp, NHS Dumfries and Galloway (2024) — https://www.rightdecisions.scot.nhs.uk/dg-refhelp/musculoskeletal-system/shoulder/ Superior capsular augmentation for massive rotator cuff tears: the condition, current treatments and procedure | NICE (2018) — https://www.nice.org.uk/guidance/HTG477/chapter/2-the-condition-current-treatments-and-procedure