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Terrible Triad of the Shoulder in a Competitive Athlete Adam G

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Terrible Triad of the Shoulder in a Competitive Athlete Adam G (aspects of sports medicine • a case report) Terrible Triad of the Shoulder in a Competitive Athlete Adam G. Miller, MD, Nicholas Slenker, MD, and Christopher C. Dodson, MD ABSTRACT nerve injury combined with massive Active ROM was limited to 85° FF. The terrible triad injury to a shoul- rotator cuff tear after traumatic dislo- Neurologically, the patient’s sensa- der consists of shoulder disloca- cation. In this injury, most neurologic tion was proximally intact. Motor tion, rotator cuff tear, and brachial symptoms resolve, prompt surgical exam, based upon a 0 to 5 strength plexus palsy. We present a case of intervention is warranted, and com- scale, revealed a decrease in wrist a high velocity shoulder dislocation in an athlete with concomitant mas- prehensive physical therapy is integral and finger extension to 3/5. Wrist sive rotator cuff tear and incom- to recovery. and finger flexion and hand intrinsic plete infraclavicular brachial plexus The patient provided written strength was 0/5. The patient also injury. In this injury, most neurologic informed consent for print and elec- had decreased sensation over radial, symptoms resolve, prompt surgi- tronic publication of this case report. median, and ulnar nerve distributions. cal intervention is warranted, and The patient’s upper extremity was well comprehensive physical therapy is CASE REPORT perfused. integral to recovery. A 42-year-old male competitive US Roentogram at the time of exami- Masters Diver sustained an acute nation showed no signs of fracture he terrible triad injury to a right shoulder anterior dislocation or dislocation. MRI revealed com- shoulder consists of shoul- during a platform diving competition. plete tears of the supraspinatus and der dislocation, rotator cuff The platform was 10 m, the highest infraspinatus with retraction (Figure). Ttear, and brachial plexus Olympic diving level, creating a high Subscapularis appeared to be intact. palsy. This is exceedingly rare but has velocity injury at water impact. Upon A small Hill-Sachs lesion was present 1-4 AJO been reported sparingly in literature. impact with the water, the patient lost without a significant Bankart lesion. Most triads describe patients with his hand-grip, forcing his arm over- Electromyography (EMG) 3 weeks a low velocity injury (eg, fall from head and posterior. The patient had after injury revealed a neuropraxia standing) and axillary nerve symp- no shoulder issues prior to this inci- with no upper motor nerve injury. toms due to stretch associated with dent. The patient’s shoulder was relo- Major findings were consistent with dislocation.5 cated in the local emergency depart- right brachial plexopathy and mild The purposeDo of this report is toNot ment shortly after the incidentCopy and suprascapular nerve abnormalities. present a case of high velocity shoul- 2 weeks prior to presentation. This Most significantly, there was involve- der dislocation in an athlete with con- was his first dislocation. The patient ment of the right axillary nerve affect- comitant massive rotator cuff tear demonstrated symptoms of brachial ing the right deltoid. and incomplete infraclavicular bra- plexopathy while in the emergency The patient underwent diagnostic chial plexus injury. Additionally, we department and a magnetic resonance arthroscopy 4 weeks after the injury; will review the literature of severe imaging (MRI) of the chest and cervi- no significant labral pathology was cal spine were obtained to rule out a brachial plexus root injury. These Dr. Miller and Dr. Slenker are Orthopaedic Surgical Residents, Department were negative for nerve transection of Orthopedics, Thomas Jefferson or root avulsion and the patient was University Hospital, Philadelphia, PA. referred to orthopedics and neurology. Dr. Dodson is Assistant Professor, Initial evaluation by the senior Rothman Institute, Philadelphia, PA. author (CCD) came 2 weeks after the Address correspondence to: Adam G. injury. On examination, the patient Miller, MD, 1015 Walnut St., Curtis Bldg., reported right shoulder weakness, and Rm. 801, Philadelphia, PA 19107 (tel, right hand numbness and weakness. 215-955-1500; fax, 215-503-1503; email, The patient’s right shoulder had a [email protected]). passive range of motion (ROM) of Figure. Coronal T2 image of acute Am J Orthop. 2012;41(5):228-229. Copyright 105° of forward flexion (FF), 40° of injury: full thickness supraspinatus rota- Quadrant HealthCom Inc. 2012. All rights external rotation (ER), and internal tor cuff tear with superior escape of reserved. rotation (IR) limited to back pocket. humeral head. ® 228 The American Journal of Orthopedics www.amjorthopedics.com Copyright AJO 2012. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. A. G. Miller et al encountered. A complete tear of the dislocation.7 Another report of infra- ation has concluded, these injuries supraspinatus and infraspinatus ten- clavicular palsies with dislocation and are no longer amenable to conserva- dons was repaired using a double row cuff pathology suggests generally tive treatment and prompt surgical technique. A bursectomy was per- favorable results but prolonged recov- intervention allows for a tension–free formed without subacromial decom- ery of 2 years or more.8 repair. Early surgical intervention pression since there was no evidence We present a single case of a trau- with aggressive physical therapy was of impingement. matic high-energy anterior shoulder the reason for success. Postoperative protocol consisted dislocation, massive rotator cuff tear, This case highlights the importance of sling immobilization for 4 weeks. and incomplete infraclavicular brachi- in detecting nerve pathology associ- Immediate therapy for fingers, wrist, al plexus nerve palsy in an athlete. The ated with triad injury. Initial physi- and elbow after surgery was begun mechanism of injury in this patient cal examination should be confirmed without shoulder movement. Supine is most likely brachial plexus contu- with MRI and EMG 3 weeks after the passive forward flexion and external sion injury secondary to dislocation. injury. A patient dedicated to physi- rotation exercises in the plane of the Unique attributes of this case include cal therapy seems to hasten recovery scapula were initiated after 2 weeks. the distribution of the palsy in pre- time and improve overall function. Formal physical therapy for the shoul- sentation with a high–energy injury, Realistic goals and outcomes largely der was initiated at 4 weeks post- acute diagnosis of rotator cuff tear rely on patient factors and this should operatively. The patient complied to despite masking nerve symptoms, and be discussed prior to surgery. therapy 3 days a week for 4 months. remarkable recovery of a competitive Stretching was performed on days athlete in 6 months’ time. AUTHORS’ DISCLOSURE without therapy. Additional aqua Rotator cuff pathology is common STATEMENT therapy, before and after surgery, with shoulder dislocation. However, The authors report no actual or began with letting the arm simply given nerve symptoms distally, one potential conflict of interested in rela- float. Over months, more effort and must differentiate between a complete tion to this article. motion was added. brachial plexus injury and rotator cuff The patient went from not being pathology. Lack of sensory symp- REFERENCES able to move his fingers or wrist at toms proximally and the nature of 1. Goubier JN, Duranthon LD, Vandenbussche E, Kakkar R, Augereau B. Anterior dislocation of all, to a return to typing within 6 cuff pain led to the suspicion of cuff the shoulder with rotator cuff injury and brachial weeks. At 7 weeks postoperatively, pathology. MRI confirmed a massive plexus palsy: a case report. J Shoulder Elbow AJO Surg. 2004;13(3):362-363. all neurologic motor symptoms had rotator cuff tear, accounting for his 2. Gonzales D, Lopez R. Concurrent rotator- resolved. Intermittent ulnar parathe- proximal pain and weakness. Acute cuff tear and brachial plexus palsy associ- ated with anterior dislocation of the shoulder. sias remained, but continued to repair of such tears has been shown A report of two cases. J Bone Joint Surg Am. resolve. At final follow-up, 13 months to improve pathology and likely con- 1991;73(4):620-621. 9 3. Güven O, Akbar Z, Yalçin S, Gündes H. postoperatively, the patient had 170° tributed to his recovery. Concomitant rotator cuff tear and brachial plex- of active FF, 170° of abduction, 70° Cases with pathology on EMG us injury in association with anterior shoulder ER, and internal rotation to T4 level. involving the suprascapular or axil- dislocation: unhappy triad of the shoulder. J Do Not CopyOrthop Trauma. 1994;8(5):429-430. All motor groups tested in the shoul- lary nerve have been suggested to 4. Groh GI, Rockwood CA Jr. The terrible triad: der, elbow, and wrist were 5/5 and have poorer prognosis.10 The patient anterior dislocation of the shoulder associated with rupture of the rotator cuff and injury to symmetric to the contralateral side. returned postoperatively and recov- the brachial plexus. J Shoulder Elbow Surg. The patient returned to limited com- ered from nerve symptoms at a pace 1995;4(1 Pt 1):51-53. 5. Vad VB, Southern D, Warren RF, Altchek DW, petitive diving at 6 months postop- that is quicker than most cases previ- Dines D. Prevalence of peripheral neurologic eratively and regained full capabil- ously reported in the literature, with injuries in rotator cuff tears with atrophy. J Shoulder Elbow Surg. 2003;12(4):333-336. ity at 1 year, finishing 3rd in a diving no residual axillary symptoms. This 6. Neviaser RJ, Neviaser TJ, Neviaser JS. competition. can be attributed to the quick diag- Concurrent rupture of the rotator cuff and anteri- or dislocation of the shoulder in the older patient. nosis, the timing of surgery, and the J Bone Joint Surg Am. 1988;70(9):1308-1311. DISCUSSION dedication to physical therapy by the 7. Brown TD, Newton PM, Steinmann SP, Levine Rotator cuff tears with associated patient.
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