Floating Shoulder is the term given to combined fracture of clavicle bone and glenoid neck. Floating shoulder rare injury constituting approximately 0.1% of all fractures and results from high-energy trauma. These have a high incidence of associated injuries.
The upper extremity is suspended from the axial skeleton ring formed by middle and distal clavicle, ligaments, acromion, coracoid process, and glenoid and ligaments attached to them. A double injury to the ring like floating shoulder results in an unstable construct and is the most accurate description of a floating shoulder.
Floating shoulder typically occurs from 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.
Presentation of Floating Shoulder
As most of these injuries result from high energy trauma, the injury might be missed due to other serious life-threatening injuries involved and may result in underdiagnosis.
Closed head injuries and Lung injuries, multiple rib fractures are very commonly associated with floating shoulder each constitutes approximately one-third of associated injuries. Cervical spine injuries and long bone fractures also occur commonly. Brachial plexus injury, subclavian artery injury, liver lacerations, and intra-abdominal injury secondary to blunt trauma may occur though less commonly.
The patient would present with pain which would be much greater than that observed with isolated upper extremity fractures due to greater displacement and secondary muscle spasm. Moreover, traction on the brachial plexus also can increase the pain.
On examination, the patient’s limb usually hangs lower than that of the uninjured side. 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.
Xrays of the shoulder injury should include plain radiographs of the clavicle and the shoulder trauma series which include anteroposterior view of the glenohumeral joint axillary view, and scapular lateral view.
CT scan of the scapula may be done if the scapular neck fracture is inadequately depicted on the plain films or there is doubt of intraarticular extension.
A chest radiograph, cervical spine series, and electrocardiogram are often also required.
Treatment of Floating Shoulder
Treatment of the floating shoulder may be affected by the presence of concomitant injuries.
Treatment options include nonoperative care, open reduction and internal fixation of the clavicle alone, and open reduction and internal fixation of both fractures.
Open reduction and internal fixation of the clavicle is recommended for most cases of floating shoulder. Nonoperative treatment may be appropriate in patients with nondisplaced fractures and in those with medical illnesses and surgical risk.
Nonoperative management may consist of immobilization followed by physical therapy.
Surgical management of floating shoulder includes fixation of the clavicle and if required glenoid as well. Clavicle can be fixed by plating or intramedullary fixation.
Operative intervention should be considered for the following:
- Glenoid displacement of > 3.0 cm
- Displaced fracture clavicle that requires internal fixation
- Multiple trauma where upper extremity weight-bearing is required soon
- Greater than 40 degrees of abnormal glenoid version