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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].
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