You are in: eMedicine Specialties > Orthopedic Surgery > SHOULDER Floating ShoulderArticle Last Updated: Aug 13, 2002AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Eric S Gaenslen, MD, Consulting Surgeon, Department of Orthopedics, Advanced Healthcare, SC Eric S Gaenslen is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, and American Society for Surgery of the Hand Editors: Cato T Laurencin, MD, PhD, University Professor, Lillian T Pratt Distinguished Professor and Chairman, Department of Orthopaedic Surgery, The University of Virginia; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Pekka A Mooar, MD, Associate Professor, Department of Orthopedic Surgery, Temple University School of Medicine; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; Mary Ann E Keenan, MD, Professor, Vice Chair for Graduate Medical Education, Department of Orthopedic Surgery, University of Pennsylvania School of Medicine; Chief of Neuro-Orthopedics Program, Department of Orthopedic Surgery, Hospital of the University of Pennsylvania Author and Editor Disclosure Synonyms and related keywords: ipsilateral fractures of the clavicle and scapular neck INTRODUCTIONSection 2 of 11
  Ipsilateral fractures of the clavicle and scapular neck, or floating shoulder injuries, are rare. They result from high-energy trauma and have a high incidence of associated injuries, likely contributing to their underdiagnosis and undertreatment. Understanding the pathologic anatomy and appropriate treatment is important to minimize the sometimes-significant morbidity from this injury. History of the ProcedureLittle historical literature on floating shoulder injuries exists; most reports are from the last decade. Only occasional case reports or reports of small groups of patients within a broader topic of injuries can be found in the literature prior to 1990. The term floating shoulder was used in 1992 by Herscovici et al to describe their series of ipsilateral fractures of the clavicle and scapular neck (Herscovici, 1992). Although some have questioned the accuracy of this definition (Kumar, 1997), the term floating shoulder usually refers to ipsilateral fractures of the clavicle and scapular neck in contemporary use. ProblemThe upper extremity is suspended primarily from the axial skeleton by a bony and ligamentous ring, the superior shoulder suspensory complex (SSSC) (Goss, 1993). The ring consists of the middle and distal clavicle, coracoclavicular and acromioclavicular ligaments, acromion, coracoid process, and glenoid. Of these, the clavicle is the primary support to the axial skeleton. The musculotendinous attachments from the spine, sternum, ribs, and medial clavicle to the scapula, distal clavicle, and proximal humerus provide the secondary support. A double disruption of the SSSC ring results in an unstable construct and is the most accurate description of a floating shoulder (Goss, 1993). The most common double disruption of this ring is the combined fracture of the clavicle and scapular neck, and the terms are usually equated. The deforming forces acting on this unstable construct include the weight of the arm and the force of the muscles acting on the proximal humerus, both of which pull the glenoid fragment distally and anteromedially. FrequencyIpsilateral fractures of the clavicle and scapular neck are exceedingly rare, comprising approximately 0.1% of all fractures (Herscovici, 1992). EtiologyIpsilateral fractures of the clavicle and scapular neck typically occur following high-energy trauma, such as motor vehicle accidents, falls from a height, crush injuries, or gunshot wounds. With the exception of those occurring from gunshot wounds, most are closed injuries. ClinicalThe assessment of patients with ipsilateral fractures of the clavicle and scapular neck includes evaluation of the injury and evaluation of the whole patient. An emergency physician and often a trauma surgeon, depending on the associated injuries, are usually the first to see these patients. As with most scapula fractures, ipsilateral fractures of the clavicle and scapular neck have a high incidence of associated injuries, which may result in underdiagnosis as attention is drawn to more life-threatening injuries (Ada, 1991; Rowe, 1988). In series in which associated injuries specifically are reported, the incidence ranges from 40-96% (Ada, 1991; Leung, 1993,9). In one series, 5 of 36 patients died from their associated injuries, and 4 of 36 had severe head trauma that precluded shoulder rehabilitation for more than 3 months (Edwards, 2000). Closed head injuries and pulmonary injuries (eg, pneumothorax, multiple rib fractures, hemothorax) each comprise approximately one third of associated injuries. Cervical spine injuries and long bone fractures each comprise another 10-20%. Other reported injuries include brachial plexus and subclavian artery injury, liver lacerations, and most other forms of intra-abdominal injury secondary to blunt trauma. Specific clinical findings in the involved upper extremity can vary with the severity of the trauma and the presence and severity of associated injuries. However, some findings are common. Pain is much greater than that observed with isolated upper extremity fractures, not only because of the additional fracture, but also because of the resulting displacement and secondary muscle spasm. Traction neuritis of the brachial plexus also can increase the pain. The patient's limb usually hangs lower than that of the uninjured side. Some of this effect is attributable to the inferior displacement of the distal fracture fragments, and some is secondary to postural changes assumed by the patient to increase comfort. The scapula usually appears to be protracted as part of the postural changes. A loss of the normal concavity at the anterior aspect of the shoulder is likely to occur as the distal glenoid fragment and humeral head are displaced anteriorly. Routine complete history and physical examination of the patient are followed by appropriate laboratory and radiographic studies (see Workup). INDICATIONSSection 3 of 11
As with other rare injuries, no large series studies have been reported with matched patient groups in which 2 or more treatments are compared. Instead, information to arrive at and support treatment recommendations has come mainly in 2 forms. First is the understanding of the anatomy and function of the superior shoulder suspensory complex and the concern for a potential poor result if the injury is not stabilized. Second are data provided by several small series of patients (Edwards, 2000; Herscovici, 1992; Ramos, 1997; Rikli, 1995). Treatment recommendations have included most available options, such as nonoperative care with early mobilization (Edwards, 2000), nonoperative care with delayed mobilization at one month (Ramos, 1997), open reduction and internal fixation (ORIF) of the clavicle alone (Herscovici, 1992), and ORIF of both fractures (Leung, 1993). Edwards et al reported on 20 patients treated with a sling or shoulder immobilization for comfort with early instigation of pendulum exercises (Edwards, 2000). Fifteen of the scapula neck fractures were displaced less than 5 mm. Nine of the clavicle fractures were displaced less than 1 cm. The patient was weaned from the sling or shoulder immobilization, and active and passive ranges of motion were started as comfort allowed. This occurred over a 3- to 8-week period. Follow-up averaged more than 2 years, and results were assessed based on pain, strength, range of motion, stability, and radiographic assessment. Edwards et al used several rating systems to classify results, including the system used by Herscovici (Herscovici, 1992). On final follow-up, no further displacement from the original radiographs was noted. One clavicle nonunion was observed. The remainder of the fractures healed. Two patients had a 20° loss of elevation. Five patients (25%) complained of moderate-to-severe pain, 3 patients were unhappy with the appearance of their shoulder, and 4 were dissatisfied with their result. The least generous rating systems used gave 17 patients an excellent result and 3 patients a good result. Ramos et al reported on 13 patients treated by immobilization for one month followed by physical therapy (Ramos, 1997). Results were assessed using the scoring system of Herscovici (Herscovici, 1992). Results were rated excellent in 11 patients, good in 1 patient, and fair in 1 patient. All fractures united. Four patients had elevation limited to 80-120°. Three patients had significant weakness on examination. Nine of 13 patients returned to their sedentary occupations, 2 others returned to heavy physical work, and 2 had to give up their previous heavy physical occupation. A closer reading of the series suggests that the results of nonoperative treatment may be less positive than the conclusions suggest. In a series by Edwards et al, a group of patients had relatively nondisplaced or minimally displaced injuries. An additional 16 patients were eliminated from this study because of serious associated injuries and failure of follow-up. The rating systems used assign considerable weight to factors such as muscle strength and stability, which are less likely to be affected by this injury. No value is assigned for deformity. For example, a patient with severe pain (eg, at rest, requiring daily medication), deformity, total disability from work, and an ability to elevate the shoulder to 130° is allotted a good result in this system. In the series by Edwards et al, patients with more pain and dissatisfaction tended to have fractures involving the distal third of the clavicle. Herscovici et al reported on 7 patients treated with ORIF of the clavicle and on 2 patients treated nonoperatively (Herscovici, 1992). Surgical treatment consisted of plate and bicortical screw fixation. The scapular neck fracture was not exposed. Active range of motion exercises began 3-5 days postoperatively. Pain, lifestyle changes, range of motion, and muscle strength were scored for results reporting. All fractures in each treatment group healed. All 7 patients treated surgically had excellent results; 5 patients had no pain, and 2 had mild pain on exertion. Two patients failed to return to their prior occupation or sporting activity. No patient in the operative group had a significant deformity of the shoulder. Of the 2 patients treated nonoperatively, one had a good result, and one had a poor result (although the poor result largely was caused by severe associated injuries). Both patients treated nonoperatively had significant asymmetry of their shoulders. Leung et al reported on 15 patients with ipsilateral fractures of the clavicle and scapular neck treated with ORIF of both fractures (Leung, 1993). Postoperatively, passive range of motion was started as soon as the patient's medical condition allowed. Rowe's scoring system, which places more emphasis on shoulder stability but also considers range of motion and a patient's subjective sense of function (Rowe, 1988), was used in follow-up evaluation. Eight patients had elevation higher than 150°, and 7 had elevation higher than 120 degrees. Eight patients had normal strength, 2 had good strength, and 5 had fair strength. Three patients considered their shoulders normal, 11 had mild limitations, and 1 had moderate limitations that resolved after the prominent scapular plate was removed. All 15 patients returned to their jobs doing manual labor. Although the literature on this subject is relatively limited, comparison of the patients in the reported series suggests that the best results tend to be achieved with ORIF of the clavicle fracture. This is particularly true if the fracture involves the distal third of the clavicle. ORIF of the clavicle all but eliminates the risk of deformity or asymmetry of the involved shoulder, and it also likely results in the improved comfort, range of motion, and strength found in patients treated in this manner. For most patients, and barring specific contraindications, ORIF of the clavicle is recommended for displaced ipsilateral fractures of the clavicle and scapular neck. However, in patients with nondisplaced fractures and in those in whom underlying medical status or severe associated injuries create excessive surgical risk, nonoperative treatment can often yield an acceptable result. RELEVANT ANATOMYSection 4 of 11
See Introduction, Problem, above. CONTRAINDICATIONSSection 5 of 11
Concomitant injuries may preclude surgery for floating shoulder. Nonoperative treatment may be appropriate in patients with nondisplaced fractures and in those in whom underlying medical status or severe associated injuries create excessive surgical risk. WORKUPSection 6 of 11
Lab Studies
Imaging Studies
TREATMENTSection 7 of 11
Medical therapyNonoperative management may consist of immobilization followed by physical therapy (see Indications, above). Surgical therapyThe surgical procedure used for floating shoulder injuries is familiar to most general orthopedic surgeons. The patient is positioned in the semirecumbent position. A Mayfield (ring) type headrest is useful for positioning and facilitates intraoperative imaging of the shoulder. The neck is slightly tilted and rotated toward the contralateral side for better access to the medial aspect of the surgical exposure. The field is widely draped from the base of the neck and the entire upper extremity is draped free. Intraoperative manipulation of the upper extremity can be useful in reducing the fracture. An incision is made in line with the clavicle. Supraclavicular nerves are often identifiable and should be protected as much as possible. The junction of the aponeurosis of the trapezius superiorly and the deltoid and pectoralis inferiorly is split to expose the fracture. Commonly, the displaced fracture already has exposed the plane of dissection. This split is repaired at the completion of the procedure. Reduction and stabilization is carried out using standard internal fixation techniques. The 3.5-mm reconstruction plate works well for this injury because it is easy to contour to the S-shaped clavicle. The plate can be placed superiorly or anteriorly on the clavicle, depending on the orientation of the fracture. Placement of a blunt elevator deep to the clavicle during drilling of the screw holes protects against risk of pneumothorax and neurovascular injury. A short longitudinal split in the deltoid can be made over the coracoid process. The split should not exceed 5 mm to avoid risk of injury to the axillary nerve. Access to the coracoid can be useful in facilitating reduction of the fractures. Some surgeons have advocated intramedullary fixation of the clavicle. This is a reasonable approach for middle third fractures of the clavicle but is more technically demanding than plate and screw fixation and is less familiar to most surgeons. Preoperative detailsFollowing surgery, the patient is placed in a sling, and the shoulder is mobilized as the stability of the fracture and the medical status of the patient allow. Follow-upFracture healing should be complete in 6-12 weeks with comfort, mobility, and strength improving over 6-9 months. COMPLICATIONSSection 8 of 11
Complications can be quite varied in this group of patients, with a relatively high incidence of associated injuries. Complications specific to the surgical treatment of these patients are rare but may include infection, nonunion of the fractures, pneumothorax, and neurovascular injury. Some numbness just distal to the incision can be expected and may improve over time. OUTCOME AND PROGNOSISSection 9 of 11
Displaced ipsilateral fractures of the clavicle and scapular neck are rare. These patients often have significant associated injuries. Initial treatment of these patients involves assessment and stabilization of their associated injuries. In patients who do not have contraindications to surgical treatment, the best outcomes are achieved most predictably with reduction and stabilization of the disrupted shoulder suspensory complex by means of internal fixation of the clavicle fracture. FUTURE AND CONTROVERSIESSection 10 of 11
Although this unstable injury tends to have a better outcome in patients in whom the clavicle fracture is surgically stabilized (particularly more distal clavicle fractures), the injury should be assessed in the context of the whole patient. Consideration of the age, demands, associated injuries, and the severity and displacement of the fracture may make nonoperative treatment preferable, with an expectation of a good result. REFERENCESSection 11 of 11
Article Last Updated: Aug 13, 2002 |
