Shoulder scenario

[ghost dog]

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Hey folks,

I was wondering if I could pick your brains on a case I saw recently:

A 65 year old worker sustained an external rotation / abduction shoulder injury , and subsequently experienced increasing levels of pain the following AM.

He attended the ER , where a Dx of subacromial bursitis was made.

Approximately 1week later an X-ray was performed at his family MD's which revealed chronic complete rotator cuff deficiency with degenerative subacromial pseudoarthrosis.

Approx 2 - 3 weeks later : an U /s was done showing a complete rotator cuff tear, which was felt to be " probably chronic."

2 months later , an MRI confirmed this DX - massive rotator cuff tear.

During the ortho exam ( 2 months later), the pt has an exam consistent with a symptomatic massive tear.

The family MD and worker indicate no prior hx of shoulder problems.

With the above information: do you think the worker is being untruthful in regards to his Hx, or that the rad made a bad call ( at time of ultrasound)
in respect to the chronicity of the tear ?

 

[PMR 4 MSK]

X-ray cannot show rotator cuff tear, it can only suggest it based on the position of the humeral head in relation to the glenoid. It is very unreliable. If arthrogram was done, that can show leakage of contrast from the joint.

By "degenerative subacromial pseudoarthrosis" do you mean type 3 acromion with impingement signs on x-ray? That would be potentially consistent with chronic rotator cuff tear. However, it could have just been the set-up for the tear - osteophyte sitting on top of the cuff waiting for the opportunity to strike...😀

To my knowledge, US has not been demonstrated to be able to separate acute from chronic rotator cuff tears, but I'll give them benefit of doubt and experience.

Overall, I would give the benefit of doubt to the injured worker and repair the cuff. If the MRI instead showed significant glenohumeral degeneration c/w rotator cuff arthropathy, I would more likely side with the company.

 

[RUOkie]

A lot of this depends upon the amout of retraction seen on U/S and MRI. I wonder why it took so long to get the MRI, or did ortho just not trust the U/S? Given the timeframe, I would probably state that this is work related.

However, much of this depends upon your jurisdiction. Here in OK, that is certainly work comp. When I worked in Colorado, probably not (assuming that there was already marked DJD and elevation of the humeral head on x-ray)

 

[SSdoc33]

socialized medicine

 

[ghost dog]

socialized medicine

Yup, Canada.

Am I wrong in assuming that: U / S is very operator dependent ?

What the hell does " probably " mean on the U / S ? The rad should do a MSK fellowship ?

No doubt " clinical correlation is required."

I didn't have the benefit of more information, apart from what I have revealed above. This was a worker's comp paper review.

I basically concluded that this injury was the causative agent of the tear.

 

[facetguy]

Yup, Canada.

Am I wrong in assuming that: U / S is very operator dependent ?

What the hell does " probably " mean on the U / S ? The rad should do a MSK fellowship ?

No doubt " clinical correlation is required."

I didn't have the benefit of more information, apart from what I have revealed above. This was a worker's comp paper review.

I basically concluded that this injury was the causative agent of the tear.

"Follow-up per clinical guidelines or as necessary" 😴