Floating Shoulder

Floating Shoulder

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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. [1] Although some have questioned the accuracy of this definition, the term floating shoulder, in contemporary use, usually refers to ipsilateral fractures of the clavicle and scapular neck but can also apply to any combined injury to the superior shoulder suspensory complex (SSSC). [2]

Floating shoulder injuries are rare. They result from high-energy trauma and have a high incidence of associated injuries, which likely contribute to their underdiagnosis and undertreatment. Understanding the pathologic anatomy and instituting appropriate treatment are important for minimizing the sometimes significant morbidity from this injury. [3, 4, 5, 6]

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. [7]

The upper extremity is suspended primarily from the axial skeleton by a bony and ligamentous ring (ie, the SSSC). [8]  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. [8]  The most common double disruption of this ring is the combined fracture of the clavicle and scapular neck, and the terms are usually equated. However, the term floating shoulder can apply to any combined injury to the SSSC.

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.

Ipsilateral fractures of the clavicle and scapular neck typically occur after high-energy trauma, such as the following:

With the exception of those occurring from gunshot wounds, most such fractures are closed injuries.

Ipsilateral fractures of the clavicle and scapular neck are exceedingly rare, constituting approximately 0.1% of all fractures. [1]

Displaced ipsilateral fractures of the clavicle and scapular neck are rare. These patients often have significant associated injuries because of the severity of the initial trauma. Initial treatment of these patients involves assessment and stabilization of the often life-threatening associated injuries.

The prognosis for injuries treated nonsurgically often depends on the predicted rotator cuff dysfunction. Excessive glenoid displacement from combined injuries will alter the normal lever arm of the rotator cuff and the surrounding musculature. [9] In patients who do not have contraindications for surgical treatment, the best outcomes are achieved most predictably with reduction and stabilization of at least one part of the SSSC. [10]

Herscovici D Jr, Fiennes AG, Allgower M, Rucdi TP. The floating shoulder: ipsilateral clavicle and scapular neck fractures. J Bone Joint Surg Br. 1992 May. 74(3):362-4. [Medline].

Kumar VP, Satku K. Fractures of clavicle and scapular neck. J Bone Joint Surg Br. 1993 May. 75(3):509. [Medline].

Owens BD, Goss TP. The floating shoulder. J Bone Joint Surg Br. 2006 Nov. 88(11):1419-24. [Medline].

DeFranco MJ, Patterson BM. The floating shoulder. J Am Acad Orthop Surg. 2006 Aug. 14(8):499-509. [Medline].

van Noort A, van der Werken C. The floating shoulder. Injury. 2006 Mar. 37(3):218-27. [Medline].

Davidson JJ. Floating shoulder injuries. Wheeless’ Textbook of Orthopaedics, presented by Duke Orthopaedics. Available at http://www.wheelessonline.com/ortho/floating_shoulder_injuries. January 3, 2013; Accessed: March 11, 2019.

Reisch B, Fischer J. Rehabilitation of a patient with ‘floating shoulder’ and associated fractures: a case report. Physiother Theory Pract. 2012 Oct. 28 (7):542-51. [Medline].

Goss TP. Double disruptions of the superior shoulder suspensory complex. J Orthop Trauma. 1993. 7(2):99-106. [Medline].

Gilde AK, Hoffmann MF, Sietsema DL, Jones CB. Functional outcomes of operative fixation of clavicle fractures in patients with floating shoulder girdle injuries. J Orthop Traumatol. 2015 Sep. 16 (3):221-7. [Medline]. [Full Text].

Kim KC, Rhee KJ, Shin HD, Yang JY. Can the glenopolar angle be used to predict outcome and treatment of the floating shoulder?. J Trauma. 2008 Jan. 64(1):174-8. [Medline].

Ada JR, Miller ME. Scapular fractures. Analysis of 113 cases. Clin Orthop Relat Res. 1991 Aug. (269):174-80. [Medline].

Rowe CR. Evaluation of the shoulder. Rowe CR, ed. The Shoulder. New York: Churchill Livingstone; 1988. 631-7.

Leung KS, Lam TP. Open reduction and internal fixation of ipsilateral fractures of the scapular neck and clavicle. J Bone Joint Surg Am. 1993 Jul. 75(7):1015-8. [Medline].

Edwards SG, Whittle AP, Wood GW 2nd. Nonoperative treatment of ipsilateral fractures of the scapula and clavicle. J Bone Joint Surg Am. 2000 Jun. 82 (6):774-80. [Medline].

Ramos L, Mencia R, Alonso A, Ferrandez L. Conservative treatment of ipsilateral fractures of the scapula and clavicle. J Trauma. 1997 Feb. 42(2):239-42. [Medline].

Rikli D, Regazzoni P, Renner N. The unstable shoulder girdle: early functional treatment utilizing open reduction and internal fixation. J Orthop Trauma. 1995 Apr. 9(2):93-7. [Medline].

Samy MA, Darwish AE. Fixation of clavicle alone in floating shoulder injury : functional and radiological outcome. Acta Orthop Belg. 2017 Jun. 83 (2):292-296. [Medline].

Bartoníček J, Tuček M, Frič V, Obruba P. Fractures of the scapular neck: diagnosis, classifications and treatment. Int Orthop. 2014 Oct. 38 (10):2163-73. [Medline].

Morey VM, Chua KHZ, Ng ZD, Tan HMB, Kumar VP. Management of the floating shoulder: Does the glenopolar angle influence outcomes? A systematic review. Orthop Traumatol Surg Res. 2018 Feb. 104 (1):53-58. [Medline]. [Full Text].

Izadpanah K, Jaeger M, Maier D, Kubosch D, Hammer TO, Südkamp NP. The floating shoulder—-clinical and radiological results after intramedullary stabilization of the clavicle in cases with minor displacement of the scapular neck fracture. J Trauma Acute Care Surg. 2012 Feb. 72 (2):E8-13. [Medline].

Shaffer BS, Conway J, Jobe FW, Kvitne RS, Tibone JE. Infraspinatus muscle-splitting incision in posterior shoulder surgery. An anatomic and electromyographic study. Am J Sports Med. 1994 Jan-Feb. 22 (1):113-20. [Medline]. [Full Text].

Chen YC, Lian Z, Lin YN, Wang XJ, Yao GF. Injury to the axillary artery and brachial plexus caused by a closed floating shoulder injury: A case report. World J Clin Cases. 2018 Dec 6. 6 (15):1029-1035. [Medline]. [Full Text].

Mohit N Gilotra, MD Assistant Professor, Department of Orthopaedics, Shoulder and Elbow Service, University of Maryland School of Medicine

Mohit N Gilotra, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Maryland Orthopaedic Association

Disclosure: Nothing to disclose.

James Paul Hovis, MD Resident Physician, Department of Orthopedics, University of Maryland Medical System

James Paul Hovis, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, Maryland Orthopaedic Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Pekka A Mooar, MD Professor, Department of Orthopedic Surgery, Temple University School of Medicine

Pekka A Mooar, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

S Ashfaq Hasan, MD Associate Professor, Chief, Shoulder and Elbow Service, Department of Orthopaedics, University of Maryland School of Medicine

S Ashfaq Hasan, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Shoulder and Elbow Surgeons

Disclosure: Nothing to disclose.

Cato T Laurencin, MD, PhD University Professor, Albert and Wilda Van Dusen Endowed Distinguished Professor of Orthopedic Surgery, and Professor of Chemical, Materials, and Biomolecular Engineering, University of Connecticut School of Medicine

Cato T Laurencin, MD, PhD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Eric S Gaenslen, MD Consulting Surgeon, Department of Orthopedics, Advanced Healthcare, SC

Eric S Gaenslen, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Society for Surgery of the Hand

Disclosure: Nothing to disclose.

Floating Shoulder

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