Floating Shoulder Treatment & Management

Nonoperative management may consist of immobilization followed by physical therapy (see Indications, above).

The surgical procedure used for floating shoulder injuries is familiar to most general orthopedic surgeons. The patient is positioned in the semirecumbent position. A Mayfield (ring) type headrest is useful for positioning and facilitates intraoperative imaging of the shoulder. The neck is slightly tilted and rotated toward the contralateral side for better access to the medial aspect of the surgical exposure. The field is widely draped from the base of the neck and the entire upper extremity is draped free. Intraoperative manipulation of the upper extremity can be useful in reducing the fracture.

An incision is made in line with the clavicle. Supraclavicular nerves are often identifiable and should be protected as much as possible. The junction of the aponeurosis of the trapezius superiorly and the deltoid and pectoralis inferiorly is split to expose the fracture. Commonly, the displaced fracture already has exposed the plane of dissection. This split is repaired at the completion of the procedure. Reduction and stabilization is carried out using standard internal fixation techniques.

The 3.5-mm reconstruction plate works well for this injury because it is easy to contour to the S-shaped clavicle. The plate can be placed superiorly or anteriorly on the clavicle, depending on the orientation of the fracture. Placement of a blunt elevator deep to the clavicle during drilling of the screw holes protects against risk of pneumothorax and neurovascular injury. A short longitudinal split in the deltoid can be made over the coracoid process. The split should not exceed 5 mm to avoid risk of injury to the axillary nerve. Access to the coracoid can be useful in facilitating reduction of the fractures. Some surgeons have advocated intramedullary fixation of the clavicle. This is a reasonable approach for middle third fractures of the clavicle but is more technically demanding than plate and screw fixation and is less familiar to most surgeons.^[15]

Following surgery, the patient is placed in a sling, and the shoulder is mobilized as the stability of the fracture and the medical status of the patient allow.

Fracture healing should be complete in 6-12 weeks with comfort, mobility, and strength improving over 6-9 months.

Complications can be quite varied in this group of patients, with a relatively high incidence of associated injuries. Complications specific to the surgical treatment of these patients are rare but may include infection, nonunion of the fractures, pneumothorax, and neurovascular injury. Some numbness just distal to the incision can be expected and may improve over time.

Displaced ipsilateral fractures of the clavicle and scapular neck are rare. These patients often have significant associated injuries. Initial treatment of these patients involves assessment and stabilization of their associated injuries. In patients who do not have contraindications to surgical treatment, the best outcomes are achieved most predictably with reduction and stabilization of the disrupted shoulder suspensory complex by means of internal fixation of the clavicle fracture.^[16]

Although this unstable injury tends to have a better outcome in patients in whom the clavicle fracture is surgically stabilized (particularly more distal clavicle fractures), the injury should be assessed in the context of the whole patient. Consideration of the age, demands, associated injuries, and the severity and displacement of the fracture may make nonoperative treatment preferable, with an expectation of a good result.^[17]