Is fixation of both clavicle and scapula better than clavicle alone in surgical treatment of floating shoulder injury? A retrospective study.

BACKGROUND & OBJECTIVE: Little research was available to explore which surgical fixation was better between fixation of both clavicle and scapula and clavicle alone in management of floating shoulder injury. METHODS: Total 69 patients with floating shoulder injury receiving surgery from February 2005 to July 2020 participated in the study. 49 patients underwent fixation of the clavicle alone (Group C) while 20 patients underwent fixation of both clavicle and scapula (Group C + S). They were further divided into subgroups according to age: Group C1, Group C + S1 (age ≤ 55 years old) and Group C2, Group C + S2 (age>55 years old). The radiological parameter (glenopolar angle (GPA)) and clinical outcomes (Herscovici score, Constant-Murley shoulder outcome score (CSS score), and Visual Analogue Scale score (VAS score)) were collected and compared between these groups. The correlation between age and radiological parameter and clinical outcomes was calculated by the Spearman correlation analysis. RESULTS: All people were followed up for at least 1 year. The degree of change in GPA before and after surgery in Group C + S is significantly better than that in Group C. The Herscovici and CSS score in Group C + S2 were significantly higher than those in Group C2 at 1 month, 3 months and 1 year after surgery. However, no significant difference in Herscovici and CSS score was found at final follow-up (1 year after surgery) between Group C + S1 and Group C1. The VAS score in Group C + S2 at final follow-up was significantly lower than that in Group C2. No significant difference in VAS score at final follow-up was found between Group C + S1 and Group C1. In addition, the VAS score was negatively correlated with Herscovici and CSS score. No correlation was found between VAS score and GPA. CONCLUSIONS: Both types of surgical fixation are effective in management of floating shoulder injury. For young people with floating shoulder injury, both types of surgical fixation are equally effective. However, for older people with floating shoulder injury, fixation of both clavicle and scapula is better in prognosis than fixation of clavicle alone.

Stability, deformity, and fixation of the floating shoulder: a cadaveric biomechanical study.

BACKGROUND: Floating shoulder injuries cause instability and deformity due to disruptions of the scapula, clavicle, and superior shoulder suspensory complex ligaments (SSSC). Resulting deformity of the glenopolar angle (GPA) has not previously been established, nor has the impact on stability and deformity when surgical fixation is performed. This study sought to quantify stability and deformity for multiple injury patterns and the improvement to these parameters provided by clavicle and coracoclavicular (CC) ligament fixation. METHODS: Fourteen cadaveric specimen upper extremities were used, which included the entire upper extremity, scapula, clavicle, and cranial-most ribs. After being mounted upright, a scapular neck fracture was created, followed by either a midshaft clavicle fracture or sectioning of the acromioclavicular and coracoacromial ligaments. Subsequent sectioning of the other structure(s) followed by the CC ligaments was then performed. In all specimens, the clavicle was then plated, followed by a CC ligament repair. At each step, a radiograph in the AP plane of the scapula was taken to measure GPA and displacement of the glenoid fragment using radiopaque markers placed in the scapula. These radiographs were taken both unloaded and with a 100-N applied medializing force. RESULTS: When evaluating deformity related to sectioning, the GPA was reduced when the CC ligaments were sectioned compared to an isolated scapula fracture (P = .022) and compared to a combined scapula and clavicle fracture (P = .037). For stability, displacement with a 100-N force was significantly increased when the CC ligaments were sectioned compared to an isolated scapula fracture (P = .027). In cases of an ipsilateral scapula neck and clavicle fracture with intact ligaments, fixation of the clavicle alone provided a statistically significant improvement in the GPA (P = .002); but not in reduction of displacement (P = .061). In cases of an ipsilateral scapula neck and clavicle fracture with concomitant disruption of the coracoacromial, acromioclavicular, and CC ligaments, the GPA was improved by clavicle fixation (P < .001) and increasingly so by subsequent CC ligament repair (P < .001). Displacement was also improved in these 2 states (P < .001, P = .008, respectively). DISCUSSION: This biomechanical study confirmed the importance of the acromioclavicular, coracoacromial, and CC ligaments in conferring stability in SSSC injuries. Disruption of the CC ligaments created significant deformity of the GPA and instability with a medializing force. Clinical treatment should consider the integrity of these ligaments and their repair in conjunction with clavicle fixation, knowing that this combination should restore a biomechanical state equivalent to an isolated scapula fracture.

Osteosynthesis of scapular fractures: a retrospective cohort study.

PURPOSE: In recent years a trend from conservative to operative treatment of displaced scapula fractures has evolved. The aim of this study was to assess surgical and patient-based radiological and functional outcome after open reduction and internal fixation (ORIF) of displaced scapula fractures following predefined operative indications. METHODS: We retrospectively analyzed data of a consecutive series of patients with displaced scapula fractures following operative fixation at our institution between 06/2010 and 02/2020. The primary endpoint was a functional outcome using the QuickDASH score. Secondary outcomes were the Subjective Shoulder Value (SSV), numeric rating scale (NRS) for pain, Activities of Daily Living score (ADL) and complications. RESULTS: Twenty-six male patients were treated operatively. Twenty-three of whom were available for follow-up after a median follow-up time of 33 months (interquartile range [IQR] 8-70 months). In 18 (69%) cases a standard open approach and in 8 (31%) cases a minimal invasive (MI) approach was used. The median QuickDASH was 0 (IQR 0-0) with a median SSV of 95 (IQR 90-98). Patients reported a median NRS of 0 (IQR 0-1) and a median ADL score of 1 (IQR 1-1). Radiological fracture union was 100% without the occurrence of implant failure or mal-union. Two patients (7.7%) required early correction osteosynthesis, one patient (3.8%) developed a frozen shoulder 3 months postoperatively, and one patient (3.8%) presented with a superficial wound infection. CONCLUSION: Following previously published indications for ORIF of displaced scapula body and neck fractures a good functional outcome and a low rate of complications could be achieved.

Clinical outcomes following conservative and surgical management of floating shoulder injuries: a systematic review.

BACKGROUND: Floating shoulder is an uncommon injury characterized by fractures of the clavicle and ipsilateral scapular neck. No consensus exists on management. The purpose of this study was to analyze the existing literature on treatment and clinical outcomes of floating shoulder injuries to provide a baseline understanding of current treatment strategies of this injury. METHODS: A systematic review was performed to identity published literature on outcomes and management of floating shoulder injuries. Searches were performed using PubMed, Embase, and SCOPUS. RESULTS: Seventeen studies were identified that included data for 371 shoulders. The mean reported age was 39.4 years (range, 16-82) and the mean follow-up was 49.4 months (range, 6-312). The major mechanism of injury was motor vehicle accident (51%) followed by fall from height (16%). Of the 371 shoulders, 215 (58%) were treated surgically, whereas 156 shoulders (42%) were managed nonoperatively. The most commonly reported outcome score was the Constant-Murley score (9 studies), followed by the Herscovici Floating Shoulder Injury score (5 studies). The mean Constant-Murley score was 80% of ideal maximum for both shoulders treated surgically and those treated nonoperatively. CONCLUSION: Satisfactory outcomes can be expected following both surgical fixation and nonoperative management of floating shoulder injuries when appropriately individualized to the patient, as evidenced by clinical outcome scores. Floating shoulder injuries with significant displacement of the scapular neck may benefit from surgical fixation of both the clavicle and scapula fractures. In those with minimal or nondisplaced scapular neck fractures, good outcomes may be achieved when treated nonoperatively or with surgical fixation of the clavicle alone.

The floating shoulder.

The floating shoulder refers to a subset of complex shoulder injuries that typically occur in the setting of high-energy trauma. Identification of the full extent of complex shoulder injuries with computed tomography may have critical implications in patient management. The goals of this article are to review the anatomy, definition, imaging evaluation, and treatment of floating shoulder injuries.

Infraglenoid fracture of the scapular neck fact or myth?

In 1991, Ada and Miller described a new type of scapular neck fracture. It was a transverse fracture of the scapular body passing from the inferior border of the glenoid to the medial border of the scapular body (their type IIC). This fracture was later designated by Goss as a “fracture of neck inferior to scapula spine“. Since then, this type of fracture has been the cause of a number of controversies, mainly concerning the so-called “floating shoulder”. However, scapular neck fractures can be considered to be only those fractures that separate completely the glenoid from the scapular body. Term “fracture of neck inferior to scapula spine“ does not fit into this definition because it does not compromise the junction between the glenoid fossa and the scapular body. Actually, it is a transverse two-part fracture of the infraspinous part of the scapular body. As a result this term should no longer be used in the literature.

Management of a floating shoulder accompanied by a scapular surgical neck fracture: a case report and review of the literature.

In this article, we want to present a floating shoulder case accompanied by a scapular surgical neck fracture and review the literature about its diagnosis and management. Case Presentation: Our patient was a 40-year-old man who suffered a severe left shoulder injury as a result of a car-to-pedestrian accident. Computed tomography scan revealed a scapular surgical neck and body fracture, a spinal pillar fracture, and a dislocation of the acromioclavicular (AC) joint. The medial-lateral displacement and glenopolar angle were 21.65 mm and 19.8°, respectively. There was a 37° angular displacement and a greater than 100% translational displacement.Initially, the AC joint dislocation was approached via a superior incision on the clavicle and reduced with a single hook plate. A Judet approach was then used to expose the scapula fractures. The scapular surgical neck was fixed with a reconstruction plate. The spinal pillar was stabilized with two reconstruction plates following reduction.Following a year of follow-up, the patient's shoulder range of motion was acceptable, and an American Shoulder and Elbow Surgeons score of 88 was achieved. Discussion and Conclusion: Floating shoulder management is still controversial. Floating shoulders are often treated surgically due to their consequent instability and potential risk of nonunion and malunion. As shown in this article, the indications for operating on isolated scapula fractures may also apply to floating shoulders. A well-planned approach to fractures is also imperative, and the AC joint should always be a priority.

Early total care in polytrauma patient with floating shoulder and occlusion of bilateral subclavian artery: A case report.

INTRODUCTION: Fracture in polytrauma patients have higher risk of morbidity and mortality compared to those found in monotrauma patients. The ideal approach of orthopaedic injuries is to perform definitive fixation of all fractures in one single procedure, an approach known as Early Total Care (ETC). PRESENTATION OF CASE: A patient presented with history of being struck by heavy material forklift. He complained of pain in the shoulder and difficulty in breathing. The patient was diagnosed with polytrauma ISS Score 25, which consists of floating shoulder, closed fracture of multiple ribs, open hematopneumothorax, and thrombosis of subclavian artery. The following procedures were performed: debridement, ORIF plate and screw of right clavicle, ORIF lag screw of right glenoid scapula, thoracotomy segmental lobectomy, bypass of bilateral carotid artery to bilateral brachial artery. DISCUSSION: An early surgical treatment is paramount in the management of this patient, with the aim of restoring the joint and blood flow to the distal part of the hand, which will allow for early motion and more effective physiotherapy for the patient'srecovery. Early definitive fracture fixation in ETC in recommended in for stable patients and those who falls under the category of borderline and unstable patients who responds well to resuscitation. ETC allows for early mobilization and therapies for the patient. CONCLUSION: Early total care is an appropriate choice of treatment for polytrauma patients presenting with floating shoulder.

Functional Outcome of Open Reduction and Internal Fixation of Displaced Extra-Articular Scapula Fractures.

BACKGROUND: Scapular fractures are uncommon injuries of upper extremity resulting mostly from high-energy trauma. Extra-articular fractures form the majority of them. Un-displaced fractures can be managed conservatively with good results. But displaced fracture does not yield satisfactory results and needs surgical fixation. In this case series, we report our experience about such fractures. METHODS: This was a retrospective study of 12 patients with displaced scapular body and neck fractures treated between 2015 and 2018. Scapular fractures were exposed by modified Judet approach and fixed with either 3.5 mm T buttress or recon locking plate and screws. One case had associated clavicle fracture which was fixed along with scapula. Patients were put on structured rehabilitation and followed up regularly. Functional outcome and range of motion were analyzed. RESULTS: The patients included 10 males and two females. Mean age was 42 years. Average follow-up was 33 months. Average constant and Murley score was 80. Excellent results were seen in four patients, good results in seven patients and one patient has got fair result. The mean post-operative range of motion of the shoulder at the time of final follow-up was 140° of forward flexion, 136° of abduction, and 34° of external rotation. CONCLUSION: Displaced extra-articular scapular fractures managed by internal fixation using T buttress locking plates and reconstruction plates give good functional outcome.

The Smashed-Up Shoulder: A Case of Complex Ipsilateral Scapula, Clavicle and Proximal Humerus Fractures With Complete Brachial Plexus Injury.

Simultaneous ipsilateral fractures involving all the bones around the shoulder girdle, namely, the scapula, clavicle and humerus, are rare. We describe an interesting case of a 31-year-old patient who presented after a motor vehicle accident with excruciating pain over his left shoulder and a flail left upper limb. Radiographs and computed tomography (CT) scan revealed the presence of comminuted left scapula, clavicle and proximal humerus fractures. He was also diagnosed with a complete brachial plexus injury of the left shoulder. The patient underwent a tedious surgery involving screw fixation and plating of the scapula, clavicle and proximal humerus. Despite achieving stable fixations of the shoulder and radiographic union of all the fractures, he did not recover from the complete brachial plexus injury 14 months after the trauma. The presence of ipsilateral clavicle, scapula and humerus fracture suggests involvement in high-energy trauma, and therefore, associated injuries especially neurovascular compromise should not be missed. Despite its rarity, management of this complex injury should always be individualised to ensure optimal functional outcomes are achieved.