Timing of surgery for terrible triad of the shoulder: a systematic review

Article information

Clin Shoulder Elb. 2025;28(2):251-262

Publication date (electronic) : 2025 April 25

doi : https://doi.org/10.5397/cise.2024.00829

Nachiket Deshpande¹, Moustafa S. Hadi², Eleanor C. Smith³, Ayobami L. Ward⁴, Whitney E. Muhlestein⁴, James E. Carpenter⁵, Louis T. Rodgers¹, Yamaan S. Saadeh^,4

¹Department of Neurosurgery, University of Kentucky, Lexington, KY, USA

²College of Human Medicine, Michigan State University, Grand Rapids, MI, USA

³Department of Neurological Surgery, Wake Forest University School of Medicine, Winston-Salem, NC, USA

⁴Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA

⁵Department of Orthopedic Surgery, University of Michigan, Ann Arbor, MI, USA

Corresponding author: Yamaan S. Saadeh Department of Neurosurgery, University of Michigan, 3552 Taubman Center, 1500 E. Medical Center Drive, Ann Arbor, MI 48109, USA Tel: +1-734-936-7010, Fax: +1-734-647-9233 Email: yamaans@med.umich.edu

Received 2024 October 16; Revised 2025 January 16; Accepted 2025 January 19.

Abstract

INTRODUCTION

The terrible triad of the shoulder (STT) remains a troubling presentation of traumatic injury to the shoulder girdle. Traditionally, the triad is composed of the following constellation of findings: anterior shoulder dislocation (ASD), rotator cuff tear (RCT), and injury to the brachial plexus [1]. The incidence of STT injury is reported to range 2%–18% in ASDs [2] but may be underreported, as evidenced by the predominance of case reports and small studies representing the majority of the existing STT literature. STT may result in inferior outcomes of rotator cuff repair (RCR) due to concomitant nerve injury [3,4].

Management of STT can be complex, as orthopedic and neurologic injuries often require conflicting management strategies, particularly regarding the timing of surgical intervention. Some studies emphasize the importance of early identification and treatment, as delays can result in chronic instability and poor functional outcomes. Specifically, for patients with acute traumatic RCTs and significant weakness, early surgical intervention (specifically within 3 weeks) has been shown to achieve optimal postoperative outcomes, including improved Constant scores, greater shoulder abduction, and active range of motion (ROM) [5]. However, other studies suggest that comparable clinical outcomes can still be achieved if surgery is performed within 4 months following RCT [5,6]. Nonetheless, nerve recovery is typically a gradual process, occurring spontaneously over months to years [7], highlighting the delicate balance between immediate and delayed interventions and the complexity of clinical judgment in STT management. Given the variability in neurological prognosis [3,8], patients who fail to demonstrate neurological improvement may require future surgical intervention for nerve repair or tendon transfer.

On the other hand, the appropriateness of early RCT surgery in the setting of brachial plexus injury remains uncertain. In STT with coexisting RCT and brachial plexus injury, there is concern that tendon repair of a denervated shoulder girdle may not result in optimal postoperative outcomes [9]. Persistent nerve palsy during the postoperative period can impede rehabilitation and subsequent recovery due to impaired shoulder active ROM [10]. Furthermore, recurrent dislocations in STT cases may compromise neurologic recovery and lead to significant morbidity. Early surgical intervention of RCR with labral repair greatly reduces the risk of recurrent dislocation and its associated complications.

Given the existing uncertainty regarding the optimal management of STT, a complex and potentially disabling form of acute shoulder trauma, this study systematically evaluates the impact of surgical timing on clinical outcomes in patients with STT. By reviewing and synthesizing the existing literature, we aim to provide practical guidance for clinicians and surgeons by examining whether early surgery for RCR results in inferior outcomes compared with a delayed approach. This research offers insights into treatment strategies for patients with STT, allowing healthcare providers to optimize both orthopedic and neurological recovery.

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [11], we conducted a systematic review of the STT literature. PubMed, Embase, and Web of Science were queried for all relevant English articles utilizing the following keywords/phrases: “terrible triad of the shoulder” and “shoulder dislocation AND nerve injury AND rotator cuff injury.” Sources were last searched on January 3, 2025.

Inclusion criteria comprised articles written in English, involving human subjects, and including at least one patient with STT. STT was defined as the following constellation of presenting symptoms: traumatic ASD, RCT, and nerve injury. Case reports, prospective studies, and retrospective studies were included, whereas review articles, commentaries, cadaveric studies, and non-English articles were excluded. Additionally, studies not specifically related to the STT (e.g., terrible triad of the elbow) were also excluded. Other primary reasons for exclusion included articles focusing on conditions other than STT, studies that did not report relevant outcomes (e.g., timing of surgical intervention or orthopedic/neurological recovery) or specify directionality to shoulder dislocation, and those that did not meet the defined inclusion criteria, such as lacking clinical data on human subjects.

Two reviewers were involved in the article screening process. While one reviewer screened the PubMed database, another reviewer screened Embase and Web of Science. For each search engine, a single reviewer screened article titles and/or abstracts for relevance, after which the same reviewer completed a full-text manuscript review of any relevant articles to assess the article’s eligibility for inclusion. A third reviewer was consulted in any cases of uncertainty during the article screening process to minimize the risk of inclusion bias.

Variables of interest were extracted from relevant articles and recorded in Excel (Microsoft). Data collected from each study included the number of patients with terrible triad, management details, and key study outcomes (timing of RCR, outcome of RCR, and whether recovery of nerve palsy occurred). Subsequently, qualitative analysis was conducted to synthesize the findings from the included studies. This approach focused on summarizing and interpreting the reported clinical outcomes, treatment time courses, and management strategies of STT, rather than performing formal statistical analysis. The quality of included studies was assessed by one reviewer using the Risk of Bias Assessment Tool for Nonrandomized Studies (RoBANS) criteria [12].

RESULTS

Initially, 671 articles were identified during our PubMed, Embase, and Web of Science search. Following the exclusion of 226 duplicate articles and 42 non-English articles, 403 articles were screened. Subsequently, 349 articles were excluded based on title and/or abstract, with most being excluded because they focused on the terrible triad of the elbow rather than the shoulder. The remaining 54 articles were sought for full-text review, of which 1 could not be retrieved. Of the 53 remaining articles, 28 met the inclusion criteria (Table 1) [1,7,10,13-37]. A visual depiction of the screening process is illustrated in Fig. 1. The included studies cover 128 cases of traumatic STT, with mechanisms of injury ranging from unwitnessed trauma to occupational accidents, car accidents, and seizures, among others. Of these, 55 cases provided information on the timing of surgery and the course of treatment.

Table 1.

Summary of STT primary literature

Fig. 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) screening summary.

Timing of RCR in STT Injury

Our search identified 15 articles that included a description of the STT treatment timeline. The duration to surgery varied substantially across studies: from 10 days to 16 months following initial injury (Table 2). Early RCR was defined as within 6 weeks of injury. Outcomes of interest following RCR included standardized scoring systems (Constant, American Shoulder and Elbow Surgeons), visual analog scale, and Shoulder Pain and Disability Index, shoulder strength and ROM, triceps strength, nerve function (resolution of hypoesthesia or electrodiagnostic studies), and occurrence of reoperation (Table 2).

Table 2.

Timing of surgery for STT

Four patients with explicitly defined hospital courses underwent surgical intervention for nerve injuries (Table 2). One patient underwent neurolysis at the time of RCR [7]. The second patient required neurolysis and RCR for primary axillary nerve palsy 10 months after injury due to persistent neurological deficit. Additionally, two patients underwent nerve transfer procedures to enhance deltoid function prior to RCR surgery [29,34].

Marsalli et al. [1] reported the outcomes of 30 patients who underwent RCR an average of 2.9 months after injury: 21 patients had an axillary nerve injury; 4 patients, suprascapular nerve injury; 2 patients, combined axillary-suprascapular palsy; and 3 patients, nerve injury distal to the shoulder. Patients reported within the remaining studies had predominantly axillary nerve involvement. While several studies advocated for early surgical intervention to address RCT, others delayed surgical intervention until improvement in neurological deficits [10,16,25]. Shoulder and nerve function outcomes were comparable for patients with either early or late RCR (Table 3). However, a more recent case series by Kokkalis et al. [30] suggested that surgical timing may affect outcomes, with better results in patients operated on within 2 to 3 weeks compared to those treated 6 to 22 weeks post-injury. Although their analysis was limited by sample size, their findings highlight the potential benefit of early intervention in STT management, while acknowledging the need for further research.

Table 3.

Patient characteristics and rotator cuff repair outcomes

DISCUSSION

STT is well established and understood, but prompt diagnosis and optimal management remain a challenge for clinicians. Our study suggests that early RCR, even in the presence of brachial plexus injury, results in favorable shoulder and neurological outcomes. Recovery of function in the included studies generally occurred between 3 and 12 months post-injury. There remains little consensus regarding the ideal timing of surgery for RCR in patients with STT. Notwithstanding RCT functional recovery being greatest when RCR is performed within 6 weeks of injury [5,38], the typical timeline for surgical repair is lengthier, as found in the STT literature (Table 2). This may be due to delays in further workup for neurological deficits associated with brachial plexus injury [25]. Some surgeons elect to wait until recovery of nerve palsy and/or shoulder muscle function before operating on the rotator cuff [10,25,39], which may take several months and prolong the treatment timeline. However, our study indicates that early surgical intervention did not hinder nerve recovery. The findings included in this study suggest that recovery generally occurred between 3 and 12 months from injury. A delay in treatment of this length may be detrimental to functional RCT recovery and could reduce the efficacy of surgery, potentially leading to irreversible degeneration, compromised shoulder function and stability, and greater complexity in future surgical interventions [25,31].

Given that nerve injuries in STT are often due to neuropraxia and the majority recover with conservative management, early surgical exploration is not recommended [7]. However, the resolution of neurologic deficits can vary in both degree and timing, creating uncertainty regarding the exact timing of surgical intervention for nerve injuries. As a result, instances of STT must be treated on a case-by-case basis. Early surgical intervention does not allow for the possibility of spontaneous nerve recovery. However, if operated on too late, nerve reconstruction is unlikely to be successful; after 12–18 months, irreversible changes in the neuromuscular junction inhibit muscle reinnervation [40]. Nerve reconstruction for closed brachial plexus injuries should be performed between 6 and 9 months after injury in those without evidence of nerve recovery [2,40]. Serial examinations and EMG studies are useful for identifying patients in whom spontaneous reinnervation is not occurring and who may benefit from surgical reconstruction [2]. The duration to neurological recovery in the published literature ranged from 3 to 12 months.

Only 4 of the 55 patients included in this review underwent nerve exploration and decompression [7,29,34]. Most patients with nerve injuries recovered spontaneously and did not require intervention. The natural history of most nerve injuries in STT appears to be spontaneous recovery and is not clearly affected by the timing of RCR. All patients offered early RCR after index injury showed good recovery of motor and nerve function at follow-up, the earliest being 2 months post-surgery. For those patients in whom surgery was deferred pending brachial plexus recovery, full recovery to baseline functional status was typically achieved by final follow-up [7,29]. These findings suggest that, while the timing of surgery remains uncertain, early RCR combined with conservative management of nerve injuries offers promising results in STT patients.

Regarding clinical decision making and management, patients presenting with STT should be evaluated for both shoulder and neurological injuries early after the injury. Providers should consider early RCR, ideally within the first 6 weeks after injury, as recovery of function is optimal during this period, and early surgical intervention did not negatively impact neurological recovery or shoulder outcomes in our review (Fig. 2). Conservative management is typically preferred for nerve injuries, as spontaneous recovery is common. If there is no significant improvement in nerve function 3 months post-injury, providers should consider further examination. In rare cases, surgical intervention for nerve injury may be considered to optimize shoulder function and prevent long-term disability.

Fig. 2.

Schematic summary comparing outcomes of early versus late surgical intervention in terrible triad of the shoulder. Figure created with BioRender.com; accessed on 10 January 2025.

There are limitations to this systematic review. First, only one reviewer screened articles for inclusion within each search engine, which may have introduced selection bias. This bias may theoretically have led to omitting relevant articles. However, this bias was minimized by adhering to a strict definition of STT as a combination of ASD, RCT, and nerve injury, screening multiple databases, along with the use of a second reviewer to resolve any uncertainties. Additionally, the management of STT injuries may be underreported in the literature, limiting the amount of data available for analysis. Lastly, many reported articles consist of case reports and series, introducing selection and publication bias (Table 4).

Table 4.

Risk of bias assessment

CONCLUSIONS

STT continues to be a troubling presentation of shoulder trauma. Patients undergoing surgical RCR demonstrate excellent functional and neurologic outcomes, even in the presence of brachial plexus injury. Early RCR in the setting of nerve injury did not result in inferior shoulder or neurological outcomes. Nerve injuries should be managed conservatively with watchful waiting, as most recover spontaneously. Nerve injuries that do not recover by 3 months postoperatively may need additional peripheral nerve specialist evaluation.

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