Treatment of a «Terrible Triad» of the Shoulder

S.S. Strafun, S.V. Bogdan, A.S. Lysak


Background. «Terrible triad» of the shoulder — a severe and quite common injury (9–18 % of all shoulder dislocations). It is a combination of shoulder dislocation, massive rotator cuff rupture, and axillary nerve damage, or damage to the subclavian parts of the brachial plexus. Aim: based on the analysis of the results of own researches, to determine the optimal strategy for the examination and treatment of patients with «terrible triad» of the shoulder. Matherials and methods. From 2000 to 2016, in the department of microsurgery and reconstructive surgery of the upper extremity of State Institution «Institute of Traumatology and Orthopedics of the National Academy of Medical Sciences of Ukraine», 120 patients with a diagnosis of traumatic shoulder dislocation were treated. Among them, 25 (20.8 % of the total number of traumatic dislocations) patients were diagnosed with «terrible triad» of the shoulder. All patients underwent a standard clinical, radiological examination, electroneuromyography (ENMG), and magnetic resonance imaging. Results. All patients with this pathology require preoperative ENMG study, in case of preservation of axillary nerve conduction more than 30 % on the first stage of treatment it is recommended to restore the integrity of the rotator cuff, with the administration of conservative therapy for neuropathy. If axillary nerve conduction is preserved for less than 30 %, on the first stage of treatment the revision and restoration of axillary nerve integrity should be performed. Shoulder fixation in reduction position should be mandatory. Conclusions. Analyzing the long-term outcomes in patients with «terrible triad» of the shoulder, we have identified the correlation between the severity of the injury and treatment results. In that case, when preoperative ENMG has shown the preservation of axillary nerve conduction and the positive dynamics of recovery, treatment outcomes in 12 months were the best. The worst results were in patients with most severe injuries — of subclavian brachial plexus.


«terrible triad» of the shoulder; axillary nerve; shoulder dislocation


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