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CASE REPORT

Floating Shoulder A Case Report

*Vijay R Tubaki, Prof R.B.Uppin

*Department of orthopedics, JN.Medical collage and KLE Hospital and MRC, Belgaum, Karnataka, India.


Address for Correspondence:
Dr. Vijay R Tubaki,
Ruturaj apartment, 2nd Floor, Flat No.5, Kolhapur circle,
Belgaum, Karnataka, India.
tubakivijay@rediffmail.com
Phone:+91 9448578703
 

INTRODUCTION:

Ipsilateral fractures of the clavicle and scapular neck, -floating shoulder injuries, are rare. It comprises of 0.1% of all fractures (1). We report you much rarer, fracture of the clavicle and scapular neck (floating shoulder) with ipsilateral fracture humerus proximal 1/3, which is not mentioned in literature so far. They result from high-energy trauma and have a high incidence of associated injuries, likely contributing to their under diagnosis and under treatment. Understanding the pathologic anatomy and appropriate treatment is important to minimize the significant morbidity from this injury (2).

 

CASE REPORT: 

A patient aged 28 years, male got admitted with history of road traffic accident. He had head injury, type II compound fracture of right shoulder. On examination he had drooping of right shoulder (fig 1) with no distal neurovascular deficits. Imaging studies X-rays (fig 2) and 3 D CT scan (fig 3), showed comminuted

fracture right scapula lateral border extending into neck, fracture medial third of right clavicle, with ipsilateral proximal third comminuted fracture Humerus.

Patient was resuscitated at casuality; primary debridement was done for shoulder wound. Right shoulder was immobilized in U slab. Following wound healing, which took two weeks, closed reduction and interlocking nail was done for comminuted fracture humerus (fig 4). Following surgery he was immobilized in shoulder arm pouch, stitches removed on day ten post operatively. Limb was

mobilized. Now patient has got good range of motion, with restriction only in terminal degrees. After 3 months, he was able to do his routine work without discomfort or pain.

Floating shoulder can be treated operatively or non operatively. Our operative treatment for humerus fracture and non operative treatment for clavicle and scapular fracture gave a good result. Patient had good range of motion with restriction only in terminal degrees. After three months of treatment he was able to perform his routine work without discomfort or pain.

 

DISCUSSION:

The Ipsilateral fractures of the clavicle and scapular neck, -floating shoulder injuries are rare. It comprises of 0.1% of all fractures.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). We report you much rarer, fracture of the clavicle and scapular neck (floating shoulder) with ipsilateral fractureof the proximal Humerus.

In floating shoulder, 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. This associated with fracture proximal humerus further worsens the biomechanics of shoulder. These finally lead to adverse healing and functional consequences such as delayed union, non-union, malunion, impingement, decreased strength in hand muscles, fatigue, neurovascular compromise and degenerative joint disease(3).

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 (4).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 (5).

Various treatment recommendations are options such as non-operative care with early mobilization (Edward 2000), non operative care with delayed mobilization after one month (Ramos 1997), open reduction and internal fixation, of all fractures (Leug 1993). We managed this case with non-operative care for clavicle and scapula fracture, closed reduction and internal fixation with intramedullary interlocking nail for fracture humerus. The functional outcome of these injuries is better than would be expected from the radiographic appearance.  On the basis of our result we cannot recommend operative treatment of all fractures in all patients. Treatment must be individualized. In our case inter locking humerus alone gave good result.

 

REFERENCES:

1. 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].
2. Edwards SG, Whittle AP, Wood GW 2nd, et al: Nonoperative treatment of ipsilateral fractures of the scapula and clavicle. J Bone Joint Surg Am 2000 Jun; 82(6): 774-80[Medline].
3. Butters KP: The scapula. In: Rockwood CA Jr, Matsen FA, eds. The Shoulder. Vol 1. Philadelphia: WB Saunders Co; 1998:391-427
4. 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].
5. 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]. 

 

 This is a peer reviewed paper 

Please cite as : Vijay R Tubaki: Floating Shoulder A Case Report

J.Orthopaedics 2005;2(6)e7

URL:
http://www.jortho.org/2005/2/6/e7

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