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. 2023 Oct 26;15(10):e47699.
doi: 10.7759/cureus.47699. eCollection 2023 Oct.

Terrible Triad of the Shoulder: A Case Series and Literature Review

Zinon Kokkalis  1 , Vasileios Giannatos  1 , Spyridon Papagiannis  1 , Antonis Kouzelis  1 , Andreas Panagopoulos  1
Affiliations

Terrible Triad of the Shoulder: A Case Series and Literature Review

Zinon Kokkalis et al. Cureus. .

Abstract

Introduction: The shoulder terrible triad is an underdiagnosed injury pattern consisting of anterior shoulder dislocation, rotator cuff tear, and nerve injury from the brachial plexus in its original description. The purpose of this study is to raise awareness of the condition, suggest treatment strategies, and emphasize the difficulties in treating this condition.

Methods: This case series of seven patients from the same institution. All patients underwent x-rays before and after the reduction of the dislocation, MRI to assess the musculoskeletal injuries, and EMG and clinical examination to assess the nerve lesions. Early arthroscopic repair was opted for the rotator cuff tears. A conservative approach was chosen for the nerve lesions. Active forward flexion and external rotation, Constant score, and Visual to Analogue Scale (VAS) were recorded pre- and post-operatively.

Results: All the patients showed an improvement in function postoperatively. However, four of the seven patients did not recover fully. The mean Constant and VAS scores were improved from 15.2 +/- 2.8 (12 to 19) to 67 +/- 16.6 (44 to 86) and from 7.5 +/- 1 (6 to 9) to 2.3 +/- 0.8 (1 to 3), respectively. The patients were followed up for a mean time of 28.2 +/- 10.1 months (18 to 43 months). Time-to-surgery shorter than four weeks showed better results, but not statistically significant.

Conclusions: The diagnosis of the shoulder terrible triad requires a high level of suspicion. Early arthroscopic repair for the rotator cuff tears and waiting for the nerve recovery is suggested. Delayed time from injury to surgery might be related to worse outcomes, but higher-level research is needed in this direction.

Keywords: brachial plexus injury; motorvehicle accident; shoulder; shoulder dislocation; shoulder terrible triad.

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Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Figure 1
Figure 1. Pre-operatively and post-operatively constant difference between early (TIMETOSURG=0) and late (>4 weeks, TIMETOSURG=1) surgical intervention groups.
CONSTDIF = Post-operatively Constant Score – Pre-operatively Constant Score, TIMETOSURG = Time interval from injury to surgery, 0 for <4 weeks, 1 for >4 weeks.
Figure 2
Figure 2. Pre-operatively and post-operatively VAS difference between early (TIMETOSURG=0) and late (>4 weeks, TIMETOSURG=1) surgical intervention groups.
VASDIF = Post-operatively VAS – Pre-operatively VAS, TIMETOSURG = Time interval from injury to surgery, 0 for <4 weeks, 1 for >4 weeks.
Figure 3
Figure 3. Pre-operatively and post-operatively forward flexion difference between early (TIMETOSURG=0) and late (>4 weeks, TIMETOSURG=1) surgical intervention groups.
FFDIF (in o) = Post-operatively Forward Flexion – Pre-operatively Forward Flexion, TIMETOSURG = Time interval from injury to surgery, 0 for <4 weeks, 1 for >4 weeks.
Figure 4
Figure 4. Pre-operatively and post-operatively external rotation difference between early (TIMETOSURG=0) and late (>4 weeks, TIMETOSURG=1) surgical intervention groups.
ERDIF (in o) = Post-operatively External Rotation – Pre-operatively External Rotation, TIMETOSURG = Time interval from injury to surgery, 0 for <4 weeks, 1 for >4 weeks.
See this image and copyright information in PMC

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