PRAGUE —Orthopedic surgeons should develop specific skills to correctly diagnose traumatic massive rotator cuff tears and ensure these injuries are not missed. Patients who are treated early enough stand the best chances of pain relief and recovery of an acceptable range of motion, according to a presenter at the EFORT Congress.
“The recommendations could be that if you see the patient early, and the patient is active, and you diagnose the patient well, there is no need to wait for the nerve recovery,” Przemyslaw Lubiatowski, MD, of Poznan, Poland, said during a special session organized by the European Society for Surgery of the Shoulder and Elbow. A late diagnosis — one performed 3 weeks or more following injury — could prove disabling for a patient, he said.
According to Lubiatowski, one of the problems in diagnosing massive rotator cuff tears in patients older than 40 years of age is the traumatic origin of the tear may go undetected. Therefore it is important for orthopedic surgeons to learn to distinguish between tears of a traumatic nature and tears of a degenerative origin.
Hematoma seen on ultrasound imaging, he said, is nearly always suggestive of a traumatic massive rotator cuff tear.
Lubiatowski defined the “terrible shoulder triad” and the “unhappy shoulder” as one that is anteriorly dislocated, with a rotator cuff tear and a brachial plexus tear. “It might be underestimated,” he said, noting the condition does occur based on reports in the literature, and surgeons have to be aware of it. The axillary nerve is affected in 60% of these patients. Therefore, it is important to diagnose nerve injuries early.
Electromyography studies are helpful and will show the level of the lesion and any nerve involvement. They can also be useful for post-accident monitoring of the patient, Lubiatowski said.
For patients whose massive traumatic rotator cuff tears are diagnosed late, once the nerve recovers, a latissimus dorsi transfer may be possible. However, according to Lubiatowski, should the nerve not recover and there is no chance of a nerve revision, then conservative treatment or shoulder arthrodesis are the only treatment options.
“If there is no recovery or prospect for successful nerve revision, and the patient has low demand, then conservative treatment is an option because the options are limited,” Lubiatowski said. “However, if the patient seeks some improvement, then shoulder arthrodesis is also an option.” He discussed a patient of his who presented late with an irreparable traumatic massive rotator cuff tear and underwent successful shoulder fusion, but said shoulder fusion should be done only in patients with a stable shoulder. – by Susan M. Rapp
Reference: Lubiatowski P. Traumatic massive rotator cuff tears and shoulder unhappy triad. Presented during the SECEC – European Society for Surgery of the Shoulder and Elbow session: EFORT Congress; May 27-29 2015; Prague.
Disclosure: Lubiatowski reports he is a consultant and presenter for Smith & Nephew.