THE MANAGEMENT OF COMBINED FRACTURES OF THE CLAVICLE AND THE SCAPULAR NECK (FLOATING SHOULDER)

Abstract

Introduction: The combined fractures of the clavicle (or A-C dislocation) and the scapular neck are complex injuries related to high energy trauma. Their management varies depending on the degree of instability and the presence of neurovascular complications. We evaluated the results of the treatment given to this rare injury.

Material and Method: During a five year period (1997–2001) we treated 12 patients with floating shoulder. The injury was in all cases the result of severe road traffic accident. Nine patients were males and three females with age ranging from 20 to 51 years. Seven patients had injured the right shoulder, the remaining five having injured the left one. Eight patients had additional injuries (chest in four, head in two, fracture of the T4 with complete paraplegia in one, chest and abdominal in one).

Three patients had neurovascular complications and were operated upon. Two of them with vascular injury were operated ungently and had arterial graft and stabilization of the clavicle or the A-C joint with tension band. The third patient with only neurological injury (axillary and suprascapular nerves) had similar stabilization of his clavicle. The remaining nine patients with minor displacement of the fractures and stable shoulder girdle were managed conservatively.

Results: We reexamined eleven patients. The mean follow-up period was 19 months (8–56 months). In nine patients-including the three operated-the fractures had healed in satisfactory position. In the remaining two the fracture of the scapular neck was malunited, resulting in loss of shoulder normal configuration and restriction of shoulder elevation. In two of the operated patients the coexistence of neurological injury resulted in poor functional outcome. The third one-with the axillary and suprascapular nerve injury-improved in relation to the axillary nerve within six months from the injury and had a fairly useful upper extremity. In the Constant-Murley scale the score ranged from 28–89 points (average 67 points).

Conclusion: In conclusion, fractures of the clavicle (or A-C dislocations) and the scapular neck are injuries of high energy and are usually encountered in multiplez injured patients. Severe displacement is usually related to instability of the shoulder girdle and neurovascular injuries; urgent operation is then necessary and the final result is often poor. In cases of severe displacement the stabilization of only the clavicle is not sufficient and open reduction and internal fixation of the scapular neck is recommended.