Shoulder Terrible Triad (STT) Is a Traumatic Anterior Thirty Consecutive Patients with Acute STT Were Included at = 0.035)

3 The ” from two = 0.003), 2 P = 0.024), and ASES P unhappy triad of the shoulder. cases. Then, in 1994, Güven et al reported one case“ and named it the tional structures of the1991, shoulder. it In wastime described for by the Gonzalez first et al = 0.015) and 31 to 54 ( P (STT) = 0.028), Constant ( ” Journal of the American Academy of Orthopaedic Surgeons P It is a triple 1 The most frequent patterns include complete RC tears, The shoulder terrible triad (STT) is a traumatic anterior Thirty consecutive patients with acute STT were included at = 0.035). Preoperative WORC and Constant scores were Twenty-seven patients underwent a complete follow-up. P shoulder terrible triad “ is defined as a traumatic shoulder he shoulder dislocation, associated with rotator cuffinjury (RC) from tear the and brachial nerve plexus. Thisfunctional study results aimed and to prognostic describe factors the ofSTT. surgery in patients with Results: Conclusions: Abstract Introduction: Methods: anterior capsular injuries, and an axillaryimproved functional nerve scores injury. at the Patients end had of follow-upfunctional after surgery. results Better were correlated to RCinnervation tears, distal injuries to to the nerves shoulder, with andand higher WORC preoperative scores. Constant the same institution. All patients were examinedelectromyography. with Surgical x-rays, treatment MRI, and in the acuteindicated setting to was address an RC injuryfracture. Variables or registered a on displaced the greater day of tuberosity Constant surgery and were Western preoperative Ontario Rotator Cuff (WORC) scores andpattern. injury At final discharge, Constant, AmericanSurgeons Shoulder (ASES), and WORC, Elbow and subjective shoulderwere value recorded scores by an independent evaluator. The dominant arm was affected inwas 50% of 27 cases. (12 The to mean 43) follow-up months.improved The from mean 1,543 WORC to and 1,093 Constant ( scores respectively. The ASES and subjectiveend shoulder of value scores the at follow-up the and were nerve 60 injuries and that 56nerves did points, were not respectively. associated involve RC to the tears fractures better axillary and results or injuries than suprascapular to greaterrespectively, the tuberosity in axillary WORC or ( suprascapular nerves, scores ( independent prognostic factors. Research Article injury that compromises all func- dislocation associated withcuff(RC)tearandaninjurytothe a rotator brachial plexus branches. T Shoulder Terrible Triad: Classification, Functional Results, and Prognostic Factors s ’ 2020;28: From the Orthopaedic Department, Hospital del Trabajador and Clínica Universidad de los Andes (Dr. Marsalli), Orthopaedic Department, Hospital del Trabajador (Dr. Sepúlveda and Dr. Morán),Orthopaedic and Department, Hospital del Trabajador and Clínica Alemana (Dr. Breyer), Santiago, Chile. Correspondence to Dr. Marsalli: [email protected] None of the followingimmediate authors family or member any hasanything received of value fromstock or options has held stock in or company a or commercial institution related directlyindirectly or to the subjectDr. of Marsalli, this Dr. article: Sepúlveda,and Dr. Dr. Morán, Breyer. Supplemental digital content is available for this article.citation Direct appears URL in the printed textis and provided in theversions HTML of and this PDF article on the journal Web site (www.jaaos.org). J Am Acad Orthop Surg 200-207 DOI: 10.5435/JAAOS-D-19-00492 Copyright 2020 by the American Academy of Orthopaedic Surgeons. 200 Michael Marsalli, MD Oscar Sepúlveda, MD Nicolás Morán, MD Juan Manuel Breyer, MD Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.

Downloaded from https://journals.lww.com/jaaos by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3fgGGXf0fUkA4yilPh4ZDsrpoocajAiJdtOaDhCDQISXqFQVTejGI4w== on 05/12/2020 Downloaded from https://journals.lww.com/jaaos by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3fgGGXf0fUkA4yilPh4ZDsrpoocajAiJdtOaDhCDQISXqFQVTejGI4w== on 05/12/2020 Michael Marsalli, MD, et al term “shoulder terrible triad” was (4) Minimum follow-up of 1 year All patients underwent at least a sec- first used by Groh and Rockwood1 in for functional assessment. ond EMG during the follow-up. 1995. It has been described briefly in We excluded patients with irrepa- On the day of surgery, a Western literature as case reports.1-6 However, rable RC tears who required another Ontario Rotator Cuff (WORC) and a the patterns of injury have not been type of reconstructive surgery and Constant score were assigned to all characterized, and surgical treatment those with nondisplaced GT fractures patients scheduled for an arthroscopic results have not been described in that did not need fixation. All study RC repair.6,7 At the end of the surgery, larger series. participants provided informed con- the following variables were recorded The main objective was to de- sent, and the study was authorized by in the surgical database: sex, age, type scribe the functional results after sur- the local scientific ethics committee. of abductor injury, and type of ante- gical treatment in patients with an rior glenoid injury according to the STT. The secondary objectives were to Surgical Intervention and arthroscopic findings. According to the International Society of Arthros- (1) characterize injury patterns in a Follow-up cohort of patients with an STT and (2) copy, Knee Surgery, and Orthopaedic describe prognostic factors of surgical All patients were initially admitted Sports Medicine consensus,8 RC in- treatment in patients with an STT. to the emergency department due juries were classified based on size to a working accident, covered under according to Snyder9 and retraction the local working accidents insurance according to Patte.10 Fatty degen- Methods law. Shoulder radiographs were taken eration was classified according to before and after shoulder reduction. Goutallier et al11 as Fuchs et al12 Patient Selection All patients had their shoulder re- demonstrated that a grading system duced under conscious sedation on the of fatty degeneration is reproducible A retrospective cohort study was de- same day of the initial trauma. After as well on CT scans as on MRI scans. signed. An STT was defined as shoulder this, all patients were referred to the Subscapular injuries were classified dislocation associated with a neuro- shoulder surgery specialists. according to Lafosse et al13 and GT logical injury involving the brachial Additional imaging studies included fractures according to Mutch et al.14 plexus (root, trunk, cord, or terminal shoulder magnetic resonance for sus- Nerve injuries were described and branch) and a complete RC tear or pected RC injuries and CT scans to classified according to Seddon15 based displaced greater tuberosity (GT) frac- evaluate GT fractures before surgery. on the initial EMG findings. ture. We decided to include displaced Neurological lesions were suspected All surgeries were done by a team GTfracturesassociatedtoananterior during physical examination if any of five shoulder surgeons at a single shoulder dislocation and a neurologi- sensory or motor deficits of the mus- trauma center. RC tears were repaired cal injury involving the brachial plexus culocutaneous, radial, medium, or arthroscopically with suture anchors. as a STT. Displaced GT fractures create ulnar nerves were observed. Sensory Suture anchor repair technique was a discontinuity of the load transfer examination of the terminal branch of decided by each surgeon; 70% of the between the RC and the proximal the axillary nerve was done to find RC repairs were done with a single row humerus, so they are a functionally changes that were suggestive of axil- technique and 30% with a double-row similar injury to a complete postero- lary nerve damage. Deltoid muscle transosseous equivalent repair. The superior RC tear in the setting of an strength was not initially considered average number of anchors used was STT. Therefore, RC injuries and dis- suggestive of axillary nerve damage as 2.7 (range, 1 to 5). Fifty-two percent placed GT compromise the proximal it may be difficult to test after a recent underwent an acromioplasty. No cap- humerus abductor complex and can be traumatic episode and a concomi- sulolabral or bony Bankart repair was considered different types of STT. tant GT fracture or RC tear.4 The done as an associated procedure. Split Patients from our surgical database STT was diagnosed by the shoulder GT fractures were fixed with plate from 2014 to 2016 were reviewed. specialist after clinical and imaging and screws, and avulsion fractures Inclusion criteria were as follows: evaluations and surgery were indi- werefixedwithopensurgeryand (1) A consecutive series of patients cated. All patients were examined suture anchors. Examples of RC re- with an STT. using electromyography (EMG) to pairs and GT fixations can be seen in (2) Admitted for an arthroscopic confirm the presence and extension of Supplemental Digital Content 1 (Fig- repair of a complete RC tear or a nerve injuries. For changes in EMG to ure 1, A, http://links.lww.com/JAAOS/ GT fracture fixation. manifest Wallerian degeneration, the A438); Supplemental Digital Content (3) First anterior shoulder dislo- EMG was done between the fourth 2 (Figure 1, B, http://links.lww.com/ cation episode before surgery. and sixth week after the initial injury.5 JAAOS/A439); Supplemental Digital

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Table 1 of independent variables. From the analysis of variance tests, significant Summary of Anatomic Injury Findings in Patients With Shoulder Terrible # Triad models were chosen (P 0.05). Among them, the determination co- Injury Incidence (%) (N) efficients (R2) were used to identify Abductor complex injury known variables that most influ- RC 83.3 (25) enced the functional results. All sta- Greater tuberosity 16.7 (5) tistical analyses were conducted with Anterior glenoid injury SPSS (SPSS). Capsular 63 (19) Bankart 17 (5) Results Bony Bankart 20 (6) Neurologic injury Overall, data for 100 consecutive Axillary nerve 70 (21) patients with shoulder anterior dis- Suprascapular nerve 13 (4) locations and abductor complex in- Axillary and suprascapular nerves 7 (2) juries were found in our surgical Nerves distal to the shoulder 10 (3) database during the study period. Of them, 30 had a nerve injury involving RC = rotator cuff the brachial plexus (30%), and STT was diagnosed. Content 3 (Figure 2, A, http://links. Statistical Analysis The average age of patients was 56 lww.com/JAAOS/A440); and Supple- (range, 36 to 74; SD = 7.4) years, and Patients were grouped by their abduc- mental Digital Content 4 (Figure 2, B, 73% were men. The dominant arm tor complex injury, anterior glenoid http://links.lww.com/JAAOS/A441). was affected in 50% of cases. The injury, and brachial plexus injury, average length of time from the injury All patients were put in a shoulder and a descriptive analysis was done. to surgery was 2.9 months (SD = 1.05) immobilization device for the first Abductor complex injuries were grou- for RC tears and 0.81 months (SD = 3 weeks, only allowing them hand ped as an RC or GT injury. Anterior 0.66) for GT fractures. and elbow exercises alone. Between glenoid injuries were grouped as a the third and sixth weeks, passive capsular, labral, or bony Bankart assisted mobilization was initiated. injury. In the absence of labral or bony Injury Description After 6 weeks onward, the shoulder Bankart injuries, we classified the The most frequent abductor complex immobilization device was not used injury as anterior capsular injury injury was the RC tear (83.3%). The anymore, and scapular balance ex- because there must be at least some most frequent anterior glenoid in- ercises were initiated. From week 12 capsular stretching after an ante- jury was a pure capsular lesion (63%). onward, strength exercises were added. rior shoulder dislocation. Brachial All bony Bankart injuries were less During follow-up, GT fractures plexus injuries were grouped based than 20% of the glenoid surface area. were followed with x-rays until bone on anatomic patterns and by Sed- According to EMG findings, the axil- union was observed. Patients who don15 classification. lary nerve was the most frequent nerve underwent RC repair also underwent The analysis of variance test was used involved (70%), followed by the an MRI during follow-up if after to compare the means of functional suprascapular nerve. According to 6 months persisted with pain at 90° of scores before surgery and at the end of the Seddon15 classification, 46% of elevation, there was a positive Jobe the follow-up. A Student t-test was done cases had neuropraxias and 53% sign, belly press sign, lag signs, pseu- to compare the means of independent axonotmesis. All neurological in- doparesia, or pseudoparalisis.16,17 variables. A bivariate correlation juries were postganglionic and were All patients with at least 1-year analysis between numerical variables managed without surgery. Table 1 follow-up were called back at the was done. A multiple linear regression demonstrates the summary of the same time for a functional evaluation was done to study the relationship findings. which was done by an independent between known identified independent Regarding RC injuries, 60% were surgeon. Constant, WORC, Ameri- variables and functional results. complete tears of the posterosuperior can Shoulder and Elbow Surgeons A regression was done for each cuff and 92% had a Goutallier (ASES), and subjective shoulder value functional score, using a backward score #2. The posterosuperior cuff (SSV) functional scores were done. stepwise method to choose the subset injurieshadaC3andC4extensionin

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56.5% of the cases and a Patte 3 Table 2 retraction in 30.4%.9,10 Subscapular Descriptive Analysis of RC Injuries tendon tears were Lafosse type 2 in 80% of the cases and Patte 2 in 57%. RC Injury (25 Cases) Incidence (%) (N) A descriptive analysis of RC injuries Tendons can be found in Table 2. Of GT frac- Posterosuperior 60 (15) tures, four were split fractures and one Anterior 8 (2) was an avulsion type fracture.14 Posterosuperior 1 anterior 32 (8) Fatty degeneration Functional Results Goutallier 0 32 (8) The median follow-up period was 27 Goutallier 1 36 (9) (12 to 43) months, and 27 of the 30 Goutallier 2 24 (6) patients admitted had an on-site func- Goutallier 3 8 (2) tional assessment. The results are sum- Posterosuperior extension (23 cases) marized in Table 3. Preoperative C1 9 (2) Constant and WORC scores of patients C2 35 (8) who had an RC repair improved at the C3 13 (3) end of the follow-up (Table 4). C4 43 (10) The rate of RC retears diagnosed by Posterosuperior retraction MRI was 24% (6/25). Of these, five Patte 1 26 (6) required another surgery. Confirmed Patte 2 44 (10) RC retears had a significantly worse Patte 3 30 (7) Constant score than patients who did Anterior injury extension (10 cases) not require an MRI during follow-up Lafosse 1 10 (1) (33.7 versus 60.4; P =0.003).The Lafosse 2 80 (8) mean WORC (P =0.332),ASES(P = Lafosse 3 10 (1) 0.342), and SSV (P = 0.830) scores Anterior retraction were worse for confirmed retears. Patte 1 40 (4) The mean time from initial trauma to Patte 2 60 (6) surgery in patients who had a retear was Patte 3 0 2.4 months (SD = 0.48), and the mean age was 57 (SD = 4.88) years. Initially, RC = rotator cuff all had a complete posterosuperior RC tear, and three had an associated sub- 13 scapular Lafosse type 2 tendon tear. Table 3 The posterosuperior extension was Functional Scores at Final Follow-up C49 in five patients, and retraction was Patte 3 in four patients.10 Three Score Min. Max. Mean SD were reoperated with a reverse pros- Constant 17 100 50 26.8 thesis and two with a new RC repair. WORC 5 1,935 1,172 583.1 One (1/5) GT fracture was loosened ASES 13 100 59 25.5 and required a revision surgery. SSV 0 100 57 24.2 No patient suffered a recurrent dislocation after surgery. All nerve ASES = American Shoulder and Elbow Surgeons, SSV = subjective shoulder value, WORC = injuries showed at least partial Western Ontario Rotator Cuff recovery in EMG findings and clinical evidence of a reinnervation WORC (P = 0.781), ASES (P = included in the multiple linear regres- process during their follow-up with- 0.986), and SSV (P = 0.378). sion (Table 5). out the need for nerve surgery. No Of all patients, those with RC tears difference was found between neu- Prognostic Factors and injuries to nerves with innervation ropraxias and axonotmesis in the Independent variables from the dif- distal to the shouldercorrelatedwith final follow-up Constant (P = 0.345), ferent injury patterns identified were better Constant, WORC, and ASES

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Table 4 Bankart lesions. Pure capsular lesions, in which no labral or anterior glenoid Preoperative and Final Follow-up Constant and WORC Scores of Patients Who Had a Rotator Cuff Repair lesion was observed under arthroscopic vision, were the most frequent. This 6 6 P Score Preop (Mean SD) Postop (Mean SD) Value agrees with what has been described Constant 31 6 15 54 6 26 0.003 previously. Older patients have less WORC 1,544 6 346 1,092 6 596 0.015 incidence of Bankart injuries after an anterior shoulder dislocation.18 WORC = Western Ontario Rotator Cuff. In patients with an RC tear associated with the first episode of shoulder dislocation, the surgical technique im- plemented by our team did not involve injury according to Seddon,15 or Table 5 Bankart repair. This is because we amount of nerves innervating the Independent Variables Included in have observed a greater tendency of shoulder involved did not correlate to the Analysis to Study the stiffness than instability in these pa- Relationship With Functional functional scores (P $ 0.05). tients after surgery. The same is true Results Age did not have a significant cor- for GT fractures associated with a Abductor complex injury relation with the Constant score (P = shoulder dislocation, where fixation of RC tear 0.83), WORC (P = 0.44), ASES (P = the proximal humerus is traditionally 0.72), and SSV (P = 0.63). GT fracture the only planned surgery. In patients Anterior glenoid injury with their first episode of a shoulder Capsular Discussion dislocation and RC tear, we only Bankart repair bony Bankart lesions with crit- Bony Bankart . The objectives of this study were to ical glenoid bone loss ( 20%). In this Brachial plexus injury describe injury patterns, functional cohort of STTs, no patient with these Distal to shoulder nerves results, and prognostic factors of characteristics was seen, but it has 1 nerve to the shoulder (axillary or surgical treatment in a cohort of pa- been previously described within STT suprascapular) 19 tients with an STT. To date, this is in the literature. 2 nerves to the shoulder (axillary and suprascapular) the largest study in this group of pa- Three different anatomical patterns Neurapraxia tients. There were different injury of nerve injuries of the brachial Axonotmesis patterns under the same definition of plexus were identified. The most fre- Preoperative functional scores (RC STT that have not been described quent one was an isolated injury of a injuries) in detail previously and surgical terminal branch that innervates the WORC treatment had improved functional shoulder, being an isolated axillary Constant results. nerve injury. Then, a similar inci- RC healing status Regarding abductor complex in- dence was found between brachial Healed juries, RC tears were the most fre- plexus injuries that involved inner- Retear quent type of injury, with an isolated vation distal to the shoulder, isolated posterosuperior cuff tear as the most suprascapular nerve injuries, or in- GT = greater tuberosity, RC = rotator cuff, frequent pattern. Most of them juries to both terminal branches to WORC = Western Ontario Rotator Cuff had a Goutallier score $1; hence, the shoulder. According to the Sed- we can assume that these were don15 classification, almost half of scores (P # 0.05, R2 =0.22to0.33) probably acute over chronic tendon our cases had a neurapraxia and (Table 6). injuries or chronic injuries. The the other half an axonotmesis. No In the RC tear subgroup, better incidence of a complete RC tear patient had a neurotmesis. preoperative WORC and Constant associated with a shoulder disloca- The incidence of an axillary nerve scores were correlated with better tion increases with age, reaching injury in shoulder dislocations has functional results in Constant, WORC, 100% in patients older than 70 been estimated to be between 9% and ASES, and SSV scores at the end of the years.18 18%.19 An injury to the axillary follow-up (P # 0.05, R2 =0.33to Three injury patterns were identified nerve may be caused by either a 0.66) (Table 7). Anterior glenoid in- in the anterior glenoid rim: capsular direct compression mechanism of juries, RC healing status, type of nerve injuries, Bankart injuries, and bony the humeral head or by a traction

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Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Michael Marsalli, MD, et al mechanism of the nerve in the pos- Table 6 terior axillary gap.20 Suprascapular Variables Associated With Better Functional Scores nerve injuries are supposed to be a a 2 result of a traction mechanism in line Score Variables P Value R R with a complete posterosuperior RC WORC RC 1 distal nerves 0.028 0.51 0.26 tear; meanwhile, combined injuries of Constant RC 1 distal nerves 0.024 0.58 0.33 the suprascapular and axillary nerves ASES RC 1 distal nerves 0.035 0.41 0.17 may be a combination of both mech- anisms or an injury located at the ASES = American Shoulder and Elbow Surgeons, RC = rotator cuff, WORC = Western Ontario superior trunk.20 Rotator Cuff a There was no correlation found between known variables and subjective shoulder value. The mean functional results achieved at the end of the follow-up were only regular. The scores in all func- Table 7 tional scales ranged from 50% to Rotator Cuff Repair Subgroup Variables Associated With Better Functional 60%, with a wide dispersion. How- Score ever, patients with an RC repair Score Variables P Value R R2 showed notable statistical and clinical improvement with respect to their WORC Preop. WORC 1 distal nerves 0.006 0.65 0.42 preoperative scores.21 RC retears Constant Preop. Constant 1 distal nerves 0.001 0.81 0.66 had worse Constant score at final ASES Preop WORC 1 distal nerves 0.021 0.58 0.33 follow-up. SSV Preop WORC 1 distal nerves 0.009 0.68 0.46 To date, only clinical and functional results have been described in a ASES = American Shoulder and Elbow Surgeons, SSV = subjective shoulder value, WORC = Western Ontario Rotator Cuff series of patients with STT. Simonich and Wright described a series of six patients with an average age of 57 group. Nothing has been described injuries recover partially or com- and 5.6 years of follow-up. Total about this difference and must be pletely after a post-traumatic interval Shoulder Pain and Disability Index studied in future in larger series. between 3 to 24 months22,24 with postoperative scores revealed good or None of the different anterior gle- reported rates in the literature excellent results in four patients. noid injuries correlated with func- ranging from 87.5% to 100% of Clinically, five patients achieved nerve tional scores at the end of the follow- cases.5,25 Although some authors injury recovery.22 These results were up. No patient had a residual insta- recommend surgery for nerve in- better than ours; however, compari- bility despite the absence of an anterior juries if there is no improvement in son between studies becomes difficult glenoid injury repair. These findings terms of the clinical and/or electro- because RC injuries were not suggest that in most cases, anterior physiological recovery status within described in detail and different scores glenoid injuries do not need any sur- 3 to 4 months after the injury, we were used. In addition, it should be gery to prevent a new shoulder dislo- think that nerve injuries associated to considered that all patients in our cation. However, we still do not know shoulder dislocations can be ob- series were under a workers’ com- whether a Bankart or bony Bankart served longer because most of them pensation insurance law, which has repair influences functional scores as will show enough reinnervation and been described as a prognostic factor they restorenormal articularanatomy. muscle function during follow-up.26,27 for poorer results in RC repairs.23 These findings must be compared with Injuries to the brachial plexus which Among the different structures those of patients who have undergone involved nerves with innervation dis- injured in an STT, we identified some anterior glenoid repair. tal to the shoulder correlated with prognostic factors in the different pat- All patients in this series showed better shoulder functional results terns. Between the two types of evidence of partial or full nerve than injuries to the axillary nerve abductor complex injuries, repaired recovery at their last EMG during and/or suprascapular nerve. This may RC correlated with better results than follow-up and clinical evidence of a be explained because only shoulder GT fixation. The number of reoper- reinnervation process. None of them functional scores were done at the ations in each group was 20% because had a clinical deficit that required final follow-up. As shoulder innerva- of an RC retear or GT loosening. This surgery. Irreversible nerve injuries tion was not injured, it may not com- finding may be influenced by the small associated with acute shoulder dis- promise shoulder scores. Other number of patients in the GT fixation locations are rare. Most of the nerve functional evaluations, such as the

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Figure 1 Conclusions

Patients with STT have different injury patterns. The most frequent patterns include complete RC tears, anterior capsular lesions, and an axillary nerve injury. Although patients undergoing surgical treatment had improved functional results, these were only regular at the final follow-up. RC tears and injuries to nerves with innervation distal to the shoulder correlated with better functional results. In patients undergoing RC repair, preoperative functional scores (Constant and WORC) correlated positively with Shoulder terrible triad classification. final results at the end of follow-up. The revision surgery rate was high Disabilities of the Arm, Shoulder, and in group B, observation is initially due to complications in the abduc- Hand score, should be used to have a advised if there is no evidence of tor complex injury and none due to wider view of the functional effect of being preganglionic. Most will not residual instability. A working classi- distal brachial plexus injuries.28 require subsequent surgical treatment. fication for STT based on the findings Functional results were not influenced Shoulder function may be influenced of this study regarding anatomic pat- by having one or two injured nerves by the extension of the brachial plexus terns, prognostic factors, and surgical innervating the shoulder. injury. Most of the injuries in group C indications could be helpful in guiding Neuropraxias and axonotmesis had do not require surgery without caus- treatment and future studies in these similar functional results at the final ing residual instability. However, sur- patients. follow-up, and none of them influ- gery should be considered for critical enced the final results as prognostic glenoid defects (.20%), especially References factors. We think this may be ex- when associated with other risk fac- plained because axonotmesis nerve tors of shoulder dislocation in this References printed in bold type are injuries recovered as well as neuro- group of combined instability and RC those published within the past 5 praxias at the final follow-up. How- tears.20 years. ever, a standardized clinical and The sample size and retrospective 1. Groh GI, Rockwood CA: The terrible triad: electrophysiological follow-up is nec- design are considered the limitations Anterior dislocation of the shoulder essary to determine the speed and the of this study. This is due to a low associated with rupture of the rotator cuff and injury to the brachial plexus. J Shoulder final degree of recovery of both types of frequency combination of injuries Elbow Surg 1995;4:51-53. lesions. to the shoulder. Other limitations 2. Gonzalez D, Lopez R: Concurrent rotator- We propose the following working include its transverse final evalua- cuff tear and brachial plexus palsy classification for STT based on the tion, only 1-year follow up, a lack associated with anterior dislocation of the shoulder: A report of two cases. J Bone findings of this study regarding ana- of nonsurgical control group, a het- Joint Surg Am 1991;73:620-621. tomic patterns, prognostic factors, and erogeneous sample of patients, and 3. Güven O, Akbar Z, Yalçin S, Gündes¸ H: surgical indications (Figure 1): (A) multiple surgeons involved in the Concomitant rotator cuff tear and brachial plexus abductor complex injury—(1) RC and treatment of these patients. Neuro- injury in association with anterior shoulder — dislocation: Unhappy triad of the shoulder. J (2) GT; (B) brachial plexus injury (1) logical lesions were not followed in a Orthop Trauma 1994;8:429-430. distal nerves and (2) shoulder nerves; standardized manner, so there is an — 4. Mitchell JJ, Chen C, Liechti DJ, Heare A, and (C) anterior glenoid injury (1) absence of the exact degree of recov- Chahla J, Bravman JT: Axillary nerve palsy capsulolabral and (2) bony Bankart. ery and time to recover. A future, and deltoid muscle atony. JBJS Rev 2017;5:e1. Surgery is indicated for injuries in larger series should evaluate func- 5. Visser CPJ, Coene LNJEM, Brand R, Tavy group A. Repairable complete tears tional and prognostic results of this DLJ: The incidence of nerve injury in anterior dislocation of the shoulder and its of the RC and displaced GT fractures behavior within the different patterns influence on functional recovery. J Bone should be repaired early. For injuries of injuries described. Joint Surg 1999;81:679-685.

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