062-a THE FLOATING SHOULDER

INTRODUCTION

The floating shoulder is a combined fracture of the clavicle and the neck of the scapula. The cause is usually a trauma of the shoulder by a fall with a motorcycle, moped or bicycle. It is a serious injury mainly by additional serious complicating injuries that are often overlooked. Treatment usually consists of osteosynthesis of the clavicle fracture.

Clavicle fractures occur frequently, especially for cyclists. Five percent of all fractures in adults are clavicle fractures. Of all fractures in the shoulder region, 35 percent is a clavicle fracture.
Fractures of the scapula are rare however. Only 5 percent of all shoulder fractures are fractured scapulae. Virtually all professional cyclists have at least once during their career and more often, a broken clavicle.
Although cyclists often fall on their shoulders a fracture of the scapula is extremely rare.
A fracture of the scapula may occur solitarily but combined with the clavicle fracture it is a notorious injury known under the name FLOATING SHOULDER.
Definition of floating shoulder: clavicle fracture with a fracture of the neck of the scapula constitutes about 0.1% of all fractures.
It is always a serious injury in which an extensive specialist examination is necessary for the correct diagnosis and determination of the severity of the additional injuries, before starting the treatment.

PITFALLS

The floating shoulder is always the result of a high energy trauma, often in combination with other serious injuries that often are overlooked and therefore remain untreated.
Understanding of the pathological anatomy and right treatment is of great importance to the sometimes significant morbidity of this injury.

POSSIBLE ADDITIONAL  INJURIES OR PROBLEMS
  • rib fractures
  • Pneumothorax or hematothorax
  • Severe head injury
  • Bleeding subclavian artery
  • Brachial plexus injury
  • Cervical spine injury
  • Blunt abdominal trauma (liver damage)
  • Nerve scapularis injury
  • Nerve axillaris injury
  • Other fractures e.g. wrist and elbow.
  • Adequate pain relief is needed. This trauma causes much pain.

Multidisciplinary research of the patient by various specialists is needed. The injury itself is a matter for an orthopaedic surgeon.   The entire patient has to be examined by specialists with special knowledge and attention of the neurovascular system in this area.  It is necessary to have a clear idea of the severity of the injury and the extent of the additional injuries.

THE SUPERIOR SHOULDER SUSPENSORY COMPLEX (SSSC)

The upper arm is firmly connected to the body by a bony and ligamentous ring. This ring is called the superior shoulder suspensor complex (SSSC) which ensures a stable connection of the arm with the body.

This ring is formed by:

  • the clavicle
  • The acromioclavicular joint and associated ligaments. These are the coracoclavicular ligament and the acromioclavicular ligament
  • the acromion
  • The coracoid process
  • glenoid

A double break of this ring creates an unstable structure which causes a delayed and disturbed healing   and the risk of causing chronic complaints in the future.
A double-break of the SSSC must therefore be treated surgically by stabilizing of the ring or the reconstruction of the SSSC.

A floating shoulder creates a so called ‘dropping’ shoulder. A dropping shoulder has   a significantly lower position than the opposite healthy side. Since the function of the SSSC is lost, and thus the stable connection between the upper arm and the body, it is impossible to elevate this arm actively. This is an important alarm symptom.

Because of the weight of the arm, the fracture of the neck of the scapula is dislocated,  so the risk of persistent symptoms  after consolidation of the fracture in this position is large.
Typically, a surgical intervention is necessary, where the clavicle fracture is fixed  by means of a plate. In medical terms this is called osteosynthesis of the clavicle.
This procedure is sufficient for the stability of the SSSC to recover and causing the scapula fracture to be relieved and heal normally without causing complications.
The prognosis of the floating shoulder depends on the degree of dislocation (displacement) of the fractures and the severity of the accompanying injuries of the soft tissues, in this case the brachial plexus.

Healing of fractures lasts 6 -12 weeks. It can then take 6 – 9 months before mobility and strength have recovered. A surgical intervention of the floating shoulder gives the best chance of a full recovery. A small percentage of these patients, however,  pain remains with a limited function of the shoulder.

Photo 1: right shoulder view from the front.
Photo 2: photo of haematoma and dropping shoulder on 20 october 2012. 18 days after the accident.
Photo 3: fracture neck shoulderblade with dislocation and clavicle fracture with dislocation. The floating shoulder.
Photo 4: Het Susperior Shoulder Suspensory Complex (SSSC)