- Email: [email protected]
Terrible triad of the shoulder
Terrible triad of the shoulder Stephen D. Simonich, MD, and Thomas W. Wright, MD, Gainesville, FL
The purpose of this study was to assess the functional outcome of the terrible triad of the shoulder, a rare combination of anterior shoulder dislocation, massive rotator cuff tear, and neurologic injury. Six patients with this condition have been treated at our institution since 1990. The mean age was 57 years. All patients underwent rotator cuff repair (RCR). The mean time from injury to surgery was 5 months. Follow-up averaged 5.6 years. Functional outcome was recorded by use of the Shoulder Pain and Disability Index. Preoperative mean active forward elevation was 24°, as compared with 98° postoperatively. Strength improved from 3 lb to a mean of 12 lb in forward elevation and from 2 lb to 16 lb in external rotation. Clinically, 5 of 6 patients achieved recovery of their nerve injury. Total Shoulder Pain and Disability Index postoperative scores revealed good or excellent results in 4 of 6 patients. For this injury pattern, performing an RCR offers the patient the best chance for a favorable outcome. Waiting for neurologic recovery before performing RCR is not recommended. (J Shoulder Elbow Surg 2003;12:566-8.)
I
n patients aged over 40 years, anterior shoulder dislocation is associated with a high percentage of rotator cuff tears (RCTs).12,14 There have also been numerous reports concerning RCT associated with nerve injury.6-9,13,14 However, there have been only a few reports in the literature regarding the rare combination of shoulder dislocation, massive RCT (⬎5 cm), and neurologic injury known as the terrible triad of the shoulder.5 The purpose of this study was to evaluate the outcome of patients with this terrible triad injury.
From the Department of Orthopaedic Surgery, College of Medicine, University of Florida. Reprint requests: Thomas W. Wright, MD, Department of Orthopaedic Surgery, Box 100246, Health Science Center, University of Florida, Gainesville, FL 32610-0246 (E-mail: [email protected]). Copyright © 2003 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2003/$35.00 ⫹ 0 doi:10.1016/S1058-2746(03)00216-7
566
MATERIALS AND METHODS Between 1990 and 1999, 6 patients (5 men and 1 woman) with a recent, documented anterior shoulder dislocation were evaluated and treated at Shands Hospital at the University of Florida (Gainesville, FL). All patients had a history of continued pain and weakness in the shoulder after the dislocation. The mean age of the patients was 57 years (range, 37-79 years). Three right shoulders and three left were involved. Three patients had their dominant shoulder involved. All patients were examined and treated surgically by the senior author and followed up until the completion of therapy. Five patients were evaluated with electromyography (EMG) and had either computed tomography/arthrography or magnetic resonance imaging of the corresponding shoulder. The EMG studies demonstrated complete axillary nerve palsies in 5 patients and an additional suprascapular nerve involvement in 1 patient. The patient who did not have an electromyogram was believed to have an axillary nerve palsy based on examination. This patient had significant deltoid atrophy, no voluntary contraction of all 3 heads of the deltoid, and numbness in the axillary nerve distribution. The imaging studies revealed massive RCTs in all of the patients. The massive cuff tears were later confirmed at the time of surgery. In this series, the mean time from injury to rotator cuff repair (RCR) was 5 months (range, 1.5-10 months). All repairs were performed in an open fashion. All repairs used osseous tunnels (no suture anchors were used); in 2 patients only a partial repair could be accomplished. The patient who also had suprascapular nerve involvement underwent an open neurolysis of the nerve at the same time as the RCR, which was done 5 months after the original injury. Another patient had a persistent axillary nerve palsy 10 months after his injury and underwent neurolysis at the time of the RCR. Postoperatively, all patients participated in a closely monitored physical therapy program. They were started on passive range-of-motion (ROM) exercises for 6 weeks and then progressed to active assisted and active ROM over the next 6 weeks. At 12 weeks, patients were allowed to begin a progressive, gradual strengthening program. Each patient had scheduled postoperative follow-up at 2 weeks, 6 weeks, 12 weeks, 6 months, and 12 months and then at yearly intervals. All were examined, and ROM, strength, and Shoulder Pain and Disability Index (SPADI) scores were recorded. ROM was recorded with a goniometer (North Coast Medical, San Jose, CA). Isometric strength was measured in external rotation and forward elevation with a handheld dynamometer (Spark Instruments and Academics, Coralville, IA) preoperatively, at 6 months, at 12 months, and at the most recent follow-up evaluation. The patients completed the SPADI13 questionnaire preoperatively as
Simonich and Wright
J Shoulder Elbow Surg Volume 12, Number 6
Table I Average preoperative and postoperative clinical results Preoperative result SPADI Pain Function Total Strength ER (lb) FE (lb) AROM ER (°) FE (°)
5 7 6
Postoperative result 0.6 2.1 1.6
2 3
16 12
11 24
47 98
ER, External rotation; FE, forward elevation; AROM, anterior range of motion.
well as at 12 weeks, at 6 months, at 12 months, and at the most recent follow-up evaluation.
RESULTS Follow-up averaged 5.6 years (range, 2-9 years). Overall ROM increased to a mean of 98° of active forward elevation (range, 30°-160°) from a preoperative value of 24° (range, 5°-40°) and to 47° of active external rotation (range, 25°-70°) from a preoperative value of 11° (range, 0°-30°) (Table I). Overall postoperative strength improved to a mean of 12 lb (range, 9.0-14.5 lb) in forward elevation and 16 lb (range, 10-22.3 lb) in external rotation, compared with preoperative values of 3 lb (range, 0-7 lb) and 2 lb (range, 0-8 lb), respectively. Strength was also measured on the uninvolved side at the most recent follow-up. The strength of the uninvolved side averaged 15 lb (range, 12.8-20.3 lb) for forward elevation and 17 lb (range, 10.7-23.0 lb) for external rotation. Final ROM was noted in all 6 patients bilaterally. Final strength measurements were available bilaterally in 4 of 6 patients. SPADI scores are used to evaluate pain and functional outcome, with a 10 being the worst score and a 0 indicating no pain and no functional deficit. With regard to these evaluations, a total score also was determined that combined pain and function scores. Patients continued to improve over 12 months postoperatively. At most recent follow-up, the mean pain, function, and total scores were 0.6, 2.1, and 1.6, respectively, compared with preoperative values of 5, 7, and 6, respectively (Table I). Deltoid recovery was monitored by improvement in atrophy, strength (posterior, middle, and anterior deltoid), and sensation. No patient had postoperative EMG studies. Of 6 patients, 5 had clinical resolution of their nerve injury by 12 months postoperatively. In 1 patient there was no recovery of deltoid function. This patient’s case was rated as a failure. The SPADI results10,13 show that 3 patients had
567
excellent results, 1 had a good result, 1 had a poor result, and 1 was not measured. There were no differences between the 2 patients who had a partial RCR and those who had a complete repair. The final result appeared to be more dependent on eventual nerve recovery rather than the ability to obtain a complete cuff repair. A deep venous thrombus developed postoperatively in 1 patient, who was treated initially with heparin. In this patient a wound hematoma subsequently developed that required surgical drainage. DISCUSSION Multiple clinical reports have documented the association of RCTs and shoulder dislocations. RCTs associated with nerve injury has been reported less frequently.2-4,8,9,14 The combination of RCT, anterior shoulder dislocation, and nerve injury has thus far only been examined in case reports. The first case report of this injury pattern was noted in an article by Gonzalez and Lopez5 in 1991, in which they discussed 2 cases. Guven et al7 in 1994 reported 1 case and Groh et al6 in 1995 reported 2 cases and coined the term terrible triad of the shoulder for the injury. Although these case reports revealed a functional range with regard to postoperative active ROM, they did not assess preoperative ROM or report preoperative/postoperative strength. In addition, the authors did not formally evaluate functional outcome in their patients. It should also be noted that of the 5 patients in the case reports, 2 were treated nonoperatively. One had a greater tuberosity fracture with no documented RCT, and the other had an arthrogram that revealed a full-thickness tear, but the size of the tear was not delineated. Of the remaining 3 patients who were treated operatively, only 1 had a massive RCT whereas the other 2 were reported as having small tears (2 cm). Neviaser et al12 reported on a series of 31 patients aged over 35 years who were unable to abduct the involved arm after reduction of a primary anterior dislocation of the glenohumeral joint. Whereas only 7.8% had evidence of axillary nerve injury, 100% had an associated RCT. In a follow-up study by Neviaser et al11 in 1993, the incidence of nerve injury was 4 of 37 patients, or 10.8%. These reports clearly suggest that an RCT is a more common cause of weakness and pain after a dislocation than a nerve injury. Brown et al2 reported on 15 patients with concomitant RCT and infraclavicular brachial plexus injuries treated with RCR. They showed that these patients have a less favorable outcome than patients with isolated cuff repairs; therefore, they recommended careful preoperative assessment to predict outcome. Of 15 patients, 11 gave a history of acute trauma to
568
Simonich and Wright
the shoulder, yet only 5 of the 11 had a reported glenohumeral dislocation. These studies suggest that, when evaluating any patient aged over 35 years who reports persistent pain and weakness after shoulder dislocation, the clinician should be suspicious of both an RCT and a neuropathy. This can be sorted out by use of ultrasonography, magnetic resonance imaging, or arthrography and an electromyogram. This workup should be initiated in any individual who is aged over 35 years and has had a shoulder dislocation and is not improving by 4 weeks. Although a physical examination is necessary, it should be noted that normal sensation over the lateral shoulder does not rule out an axillary nerve injury.1,2 Because this triad is rare, a consistent treatment protocol has not been established. The patients in our series were treated with RCR. Postoperatively, each patient started a 6-week therapy regimen including passive ROM, followed by active assisted ROM and active ROM for another 6 weeks. At 12 weeks postoperatively, the patients began a progressive strengthening program. Because the majority of these axillary nerve injuries are a neurapraxia, exploration of the nerve was not routinely performed at the time of the RCR. It was our belief that, if the axillary nerve required nerve grafting, the potential for neurologic recovery would be minimal in this population of patients aged over 40 years. One patient had a neurolysis of the axillary nerve at the time of his RCR because of continued nerve palsy 10 months after his injury. He never regained function of his axillary nerve. Another patient had a neurolysis of the suprascapular nerve at the time of RCR. This patient regained suprascapular nerve function. Extensive nerve reconstruction, such as with nerve grafts, may be of little benefit in these patients because of the age of this population. We cannot make a specific recommendation concerning neurolysis or nerve grafting based on this small group of patients. We do not recommend waiting for neurologic recovery before RCR. If a nerve injury were allowed to recover without repair of a massive RTC, the eventual repair would be compromised, as the cuff would have retracted and atrophied during the nerve recovery period, which can take up to 12 to 18 months. We recommend proceeding with RCR as soon as the diagnosis has been made in order to obtain the optimal results for this triad of injuries. If there is any suspicion of nerve injury, we also recommend EMG to diagnose the injury preoperatively. This is important for 3 reasons. First, the electromyogram establishes a baseline study should the neurologic injury not recover and future electromyograms become necessary. Second, it helps prognostically because, despite
J Shoulder Elbow Surg November/December 2003
our relatively good results, the addition of a neurologic injury to complete this triad of injury has been shown to affect outcome adversely.2 The results of RCR are also adversely affected when associated with neurologic injury independent of a shoulder dislocation.2 Finally, an electromyogram can help clinically, because it is possible to miss an axillary nerve palsy in a patient with a massive RCT. Observation of the neurologic injury revealed that recovery occurred in 5 of 6 patients. The treatment protocol of early RCR and nerve observation resulted in improvement in ROM, strength, and SPADI scores. Of the 6 patients, 4 had a good or excellent result based on the total SPADI score. Patients who have been appropriately diagnosed with the terrible triad of the shoulder should be counseled that they have a greater than 50% chance to obtain a good outcome but that optimal results after RCR may take up to a year to develop. REFERENCES
1. Blom S, Dahlback LO. Nerve injuries in dislocations of the shoulder joint and fractures of the neck of the humerus. Acta Chir Scand 1970;36:461-6. 2. Brown T, Newton P, Steinmann S, Levine W, Bigliani L. Rotator cuff tears and associated nerve injuries. Orthopedics 2000;23: 329-32. 3. Donovan WH, Kraft GH. Rotator cuff tear versus suprascapular nerve injury: a problem in differential diagnosis. Arch Phys Med Rehabil 1974;55:424-8. 4. Drez D Jr. Suprascapular neuropathy in the differential diagnosis of rotator cuff injuries. Am J Sports Med 1993;16:130-47. 5. Gonzalez D, Lopez R. Concurrent rotator cuff tear and brachial plexus palsy associated with anterior dislocation of the shoulder. A report of two cases. J Bone Joint Surg Am 1991;73:620-1. 6. Groh G, Rockwood C. The terrible triad: anterior dislocation of the shoulder associated with rupture of the rotator cuff and injury to the brachial plexus. J Shoulder Elbow Surg 1995;4:51-4. 7. Guven O, Akbar Z, Yalcin S, Gundes H. Concomitant rotator cuff tear and brachial plexus injury in association with anterior shoulder dislocation: unhappy triad of the shoulder. J Orthop Trauma 1994;8:429-30. 8. Kaplan PE, Kernahan WT. Rotator cuff rupture: management with suprascapular neuropathy. Arch Phys Med Rehabil 1984;65: 273-5. 9. Kay SP, Yaszemski MJ, Rockwood CA Jr. Acute tear of the rotator cuff masked by simultaneous palsy of the brachial plexus. J Bone Joint Surg Am 1988;70:611-2. 10. Lastayo P, Wright T, Jaffe R, Hartzel J. Continuous passive motion after repair of the rotator cuff: a prospective outcome study. J Bone Joint Surg Am 1998;80:1002-11. 11. Neviaser RJ, Neviaser TJ, Neviaser JS. Anterior dislocation of the shoulder and rotator cuff rupture. Clin Orthop 1993;291:103-6. 12. Neviaser RJ, Neviaser TJ, Neviaser JS. Concurrent rupture of the rotator cuff and anterior dislocation of the shoulder in the older patient. J Bone Joint Surg Am 1988;70:1308-11. 13. Roach KE, Budiman-Mak E, Songsiridej N, Lertratanakul Y. Development of a shoulder pain and disability index. Arthritic Care Res 1991;4:143-9. 14. Toolanen G, Hildingsson C, Hedlund T, Kribestol M, Oberg L. Early complications after anterior dislocation of the shoulder in patients over 40 years: an ultrasonographic and electromyographic study. Acta Orthop Scand 1993;64:549-52.
The purpose of this study was to assess the functional outcome of the terrible triad of the shoulder, a rare combination of anterior shoulder dislocation, massive rotator cuff tear, and neurologic injury. Six patients with this condition have been treated at our institution since 1990. The mean age was 57 years. All patients underwent rotator cuff repair (RCR). The mean time from injury to surgery was 5 months. Follow-up averaged 5.6 years. Functional outcome was recorded by use of the Shoulder Pain and Disability Index. Preoperative mean active forward elevation was 24°, as compared with 98° postoperatively. Strength improved from 3 lb to a mean of 12 lb in forward elevation and from 2 lb to 16 lb in external rotation. Clinically, 5 of 6 patients achieved recovery of their nerve injury. Total Shoulder Pain and Disability Index postoperative scores revealed good or excellent results in 4 of 6 patients. For this injury pattern, performing an RCR offers the patient the best chance for a favorable outcome. Waiting for neurologic recovery before performing RCR is not recommended. (J Shoulder Elbow Surg 2003;12:566-8.)
I
n patients aged over 40 years, anterior shoulder dislocation is associated with a high percentage of rotator cuff tears (RCTs).12,14 There have also been numerous reports concerning RCT associated with nerve injury.6-9,13,14 However, there have been only a few reports in the literature regarding the rare combination of shoulder dislocation, massive RCT (⬎5 cm), and neurologic injury known as the terrible triad of the shoulder.5 The purpose of this study was to evaluate the outcome of patients with this terrible triad injury.
From the Department of Orthopaedic Surgery, College of Medicine, University of Florida. Reprint requests: Thomas W. Wright, MD, Department of Orthopaedic Surgery, Box 100246, Health Science Center, University of Florida, Gainesville, FL 32610-0246 (E-mail: [email protected]). Copyright © 2003 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2003/$35.00 ⫹ 0 doi:10.1016/S1058-2746(03)00216-7
566
MATERIALS AND METHODS Between 1990 and 1999, 6 patients (5 men and 1 woman) with a recent, documented anterior shoulder dislocation were evaluated and treated at Shands Hospital at the University of Florida (Gainesville, FL). All patients had a history of continued pain and weakness in the shoulder after the dislocation. The mean age of the patients was 57 years (range, 37-79 years). Three right shoulders and three left were involved. Three patients had their dominant shoulder involved. All patients were examined and treated surgically by the senior author and followed up until the completion of therapy. Five patients were evaluated with electromyography (EMG) and had either computed tomography/arthrography or magnetic resonance imaging of the corresponding shoulder. The EMG studies demonstrated complete axillary nerve palsies in 5 patients and an additional suprascapular nerve involvement in 1 patient. The patient who did not have an electromyogram was believed to have an axillary nerve palsy based on examination. This patient had significant deltoid atrophy, no voluntary contraction of all 3 heads of the deltoid, and numbness in the axillary nerve distribution. The imaging studies revealed massive RCTs in all of the patients. The massive cuff tears were later confirmed at the time of surgery. In this series, the mean time from injury to rotator cuff repair (RCR) was 5 months (range, 1.5-10 months). All repairs were performed in an open fashion. All repairs used osseous tunnels (no suture anchors were used); in 2 patients only a partial repair could be accomplished. The patient who also had suprascapular nerve involvement underwent an open neurolysis of the nerve at the same time as the RCR, which was done 5 months after the original injury. Another patient had a persistent axillary nerve palsy 10 months after his injury and underwent neurolysis at the time of the RCR. Postoperatively, all patients participated in a closely monitored physical therapy program. They were started on passive range-of-motion (ROM) exercises for 6 weeks and then progressed to active assisted and active ROM over the next 6 weeks. At 12 weeks, patients were allowed to begin a progressive, gradual strengthening program. Each patient had scheduled postoperative follow-up at 2 weeks, 6 weeks, 12 weeks, 6 months, and 12 months and then at yearly intervals. All were examined, and ROM, strength, and Shoulder Pain and Disability Index (SPADI) scores were recorded. ROM was recorded with a goniometer (North Coast Medical, San Jose, CA). Isometric strength was measured in external rotation and forward elevation with a handheld dynamometer (Spark Instruments and Academics, Coralville, IA) preoperatively, at 6 months, at 12 months, and at the most recent follow-up evaluation. The patients completed the SPADI13 questionnaire preoperatively as
Simonich and Wright
J Shoulder Elbow Surg Volume 12, Number 6
Table I Average preoperative and postoperative clinical results Preoperative result SPADI Pain Function Total Strength ER (lb) FE (lb) AROM ER (°) FE (°)
5 7 6
Postoperative result 0.6 2.1 1.6
2 3
16 12
11 24
47 98
ER, External rotation; FE, forward elevation; AROM, anterior range of motion.
well as at 12 weeks, at 6 months, at 12 months, and at the most recent follow-up evaluation.
RESULTS Follow-up averaged 5.6 years (range, 2-9 years). Overall ROM increased to a mean of 98° of active forward elevation (range, 30°-160°) from a preoperative value of 24° (range, 5°-40°) and to 47° of active external rotation (range, 25°-70°) from a preoperative value of 11° (range, 0°-30°) (Table I). Overall postoperative strength improved to a mean of 12 lb (range, 9.0-14.5 lb) in forward elevation and 16 lb (range, 10-22.3 lb) in external rotation, compared with preoperative values of 3 lb (range, 0-7 lb) and 2 lb (range, 0-8 lb), respectively. Strength was also measured on the uninvolved side at the most recent follow-up. The strength of the uninvolved side averaged 15 lb (range, 12.8-20.3 lb) for forward elevation and 17 lb (range, 10.7-23.0 lb) for external rotation. Final ROM was noted in all 6 patients bilaterally. Final strength measurements were available bilaterally in 4 of 6 patients. SPADI scores are used to evaluate pain and functional outcome, with a 10 being the worst score and a 0 indicating no pain and no functional deficit. With regard to these evaluations, a total score also was determined that combined pain and function scores. Patients continued to improve over 12 months postoperatively. At most recent follow-up, the mean pain, function, and total scores were 0.6, 2.1, and 1.6, respectively, compared with preoperative values of 5, 7, and 6, respectively (Table I). Deltoid recovery was monitored by improvement in atrophy, strength (posterior, middle, and anterior deltoid), and sensation. No patient had postoperative EMG studies. Of 6 patients, 5 had clinical resolution of their nerve injury by 12 months postoperatively. In 1 patient there was no recovery of deltoid function. This patient’s case was rated as a failure. The SPADI results10,13 show that 3 patients had
567
excellent results, 1 had a good result, 1 had a poor result, and 1 was not measured. There were no differences between the 2 patients who had a partial RCR and those who had a complete repair. The final result appeared to be more dependent on eventual nerve recovery rather than the ability to obtain a complete cuff repair. A deep venous thrombus developed postoperatively in 1 patient, who was treated initially with heparin. In this patient a wound hematoma subsequently developed that required surgical drainage. DISCUSSION Multiple clinical reports have documented the association of RCTs and shoulder dislocations. RCTs associated with nerve injury has been reported less frequently.2-4,8,9,14 The combination of RCT, anterior shoulder dislocation, and nerve injury has thus far only been examined in case reports. The first case report of this injury pattern was noted in an article by Gonzalez and Lopez5 in 1991, in which they discussed 2 cases. Guven et al7 in 1994 reported 1 case and Groh et al6 in 1995 reported 2 cases and coined the term terrible triad of the shoulder for the injury. Although these case reports revealed a functional range with regard to postoperative active ROM, they did not assess preoperative ROM or report preoperative/postoperative strength. In addition, the authors did not formally evaluate functional outcome in their patients. It should also be noted that of the 5 patients in the case reports, 2 were treated nonoperatively. One had a greater tuberosity fracture with no documented RCT, and the other had an arthrogram that revealed a full-thickness tear, but the size of the tear was not delineated. Of the remaining 3 patients who were treated operatively, only 1 had a massive RCT whereas the other 2 were reported as having small tears (2 cm). Neviaser et al12 reported on a series of 31 patients aged over 35 years who were unable to abduct the involved arm after reduction of a primary anterior dislocation of the glenohumeral joint. Whereas only 7.8% had evidence of axillary nerve injury, 100% had an associated RCT. In a follow-up study by Neviaser et al11 in 1993, the incidence of nerve injury was 4 of 37 patients, or 10.8%. These reports clearly suggest that an RCT is a more common cause of weakness and pain after a dislocation than a nerve injury. Brown et al2 reported on 15 patients with concomitant RCT and infraclavicular brachial plexus injuries treated with RCR. They showed that these patients have a less favorable outcome than patients with isolated cuff repairs; therefore, they recommended careful preoperative assessment to predict outcome. Of 15 patients, 11 gave a history of acute trauma to
568
Simonich and Wright
the shoulder, yet only 5 of the 11 had a reported glenohumeral dislocation. These studies suggest that, when evaluating any patient aged over 35 years who reports persistent pain and weakness after shoulder dislocation, the clinician should be suspicious of both an RCT and a neuropathy. This can be sorted out by use of ultrasonography, magnetic resonance imaging, or arthrography and an electromyogram. This workup should be initiated in any individual who is aged over 35 years and has had a shoulder dislocation and is not improving by 4 weeks. Although a physical examination is necessary, it should be noted that normal sensation over the lateral shoulder does not rule out an axillary nerve injury.1,2 Because this triad is rare, a consistent treatment protocol has not been established. The patients in our series were treated with RCR. Postoperatively, each patient started a 6-week therapy regimen including passive ROM, followed by active assisted ROM and active ROM for another 6 weeks. At 12 weeks postoperatively, the patients began a progressive strengthening program. Because the majority of these axillary nerve injuries are a neurapraxia, exploration of the nerve was not routinely performed at the time of the RCR. It was our belief that, if the axillary nerve required nerve grafting, the potential for neurologic recovery would be minimal in this population of patients aged over 40 years. One patient had a neurolysis of the axillary nerve at the time of his RCR because of continued nerve palsy 10 months after his injury. He never regained function of his axillary nerve. Another patient had a neurolysis of the suprascapular nerve at the time of RCR. This patient regained suprascapular nerve function. Extensive nerve reconstruction, such as with nerve grafts, may be of little benefit in these patients because of the age of this population. We cannot make a specific recommendation concerning neurolysis or nerve grafting based on this small group of patients. We do not recommend waiting for neurologic recovery before RCR. If a nerve injury were allowed to recover without repair of a massive RTC, the eventual repair would be compromised, as the cuff would have retracted and atrophied during the nerve recovery period, which can take up to 12 to 18 months. We recommend proceeding with RCR as soon as the diagnosis has been made in order to obtain the optimal results for this triad of injuries. If there is any suspicion of nerve injury, we also recommend EMG to diagnose the injury preoperatively. This is important for 3 reasons. First, the electromyogram establishes a baseline study should the neurologic injury not recover and future electromyograms become necessary. Second, it helps prognostically because, despite
J Shoulder Elbow Surg November/December 2003
our relatively good results, the addition of a neurologic injury to complete this triad of injury has been shown to affect outcome adversely.2 The results of RCR are also adversely affected when associated with neurologic injury independent of a shoulder dislocation.2 Finally, an electromyogram can help clinically, because it is possible to miss an axillary nerve palsy in a patient with a massive RCT. Observation of the neurologic injury revealed that recovery occurred in 5 of 6 patients. The treatment protocol of early RCR and nerve observation resulted in improvement in ROM, strength, and SPADI scores. Of the 6 patients, 4 had a good or excellent result based on the total SPADI score. Patients who have been appropriately diagnosed with the terrible triad of the shoulder should be counseled that they have a greater than 50% chance to obtain a good outcome but that optimal results after RCR may take up to a year to develop. REFERENCES
1. Blom S, Dahlback LO. Nerve injuries in dislocations of the shoulder joint and fractures of the neck of the humerus. Acta Chir Scand 1970;36:461-6. 2. Brown T, Newton P, Steinmann S, Levine W, Bigliani L. Rotator cuff tears and associated nerve injuries. Orthopedics 2000;23: 329-32. 3. Donovan WH, Kraft GH. Rotator cuff tear versus suprascapular nerve injury: a problem in differential diagnosis. Arch Phys Med Rehabil 1974;55:424-8. 4. Drez D Jr. Suprascapular neuropathy in the differential diagnosis of rotator cuff injuries. Am J Sports Med 1993;16:130-47. 5. Gonzalez D, Lopez R. Concurrent rotator cuff tear and brachial plexus palsy associated with anterior dislocation of the shoulder. A report of two cases. J Bone Joint Surg Am 1991;73:620-1. 6. Groh G, Rockwood C. The terrible triad: anterior dislocation of the shoulder associated with rupture of the rotator cuff and injury to the brachial plexus. J Shoulder Elbow Surg 1995;4:51-4. 7. Guven O, Akbar Z, Yalcin S, Gundes H. Concomitant rotator cuff tear and brachial plexus injury in association with anterior shoulder dislocation: unhappy triad of the shoulder. J Orthop Trauma 1994;8:429-30. 8. Kaplan PE, Kernahan WT. Rotator cuff rupture: management with suprascapular neuropathy. Arch Phys Med Rehabil 1984;65: 273-5. 9. Kay SP, Yaszemski MJ, Rockwood CA Jr. Acute tear of the rotator cuff masked by simultaneous palsy of the brachial plexus. J Bone Joint Surg Am 1988;70:611-2. 10. Lastayo P, Wright T, Jaffe R, Hartzel J. Continuous passive motion after repair of the rotator cuff: a prospective outcome study. J Bone Joint Surg Am 1998;80:1002-11. 11. Neviaser RJ, Neviaser TJ, Neviaser JS. Anterior dislocation of the shoulder and rotator cuff rupture. Clin Orthop 1993;291:103-6. 12. Neviaser RJ, Neviaser TJ, Neviaser JS. Concurrent rupture of the rotator cuff and anterior dislocation of the shoulder in the older patient. J Bone Joint Surg Am 1988;70:1308-11. 13. Roach KE, Budiman-Mak E, Songsiridej N, Lertratanakul Y. Development of a shoulder pain and disability index. Arthritic Care Res 1991;4:143-9. 14. Toolanen G, Hildingsson C, Hedlund T, Kribestol M, Oberg L. Early complications after anterior dislocation of the shoulder in patients over 40 years: an ultrasonographic and electromyographic study. Acta Orthop Scand 1993;64:549-52.