Surgical Management of the Floating Shoulder

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Injuries to the superior shoulder suspensory complex (SSSC), also known as ″the floating shoulder,″ can be a devastating injury associated with high energy trauma. The SSSC is a bony-soft tissue ring made up by the glenoid, coracoid, and acromion processes, as well as the distal aspect of the clavicle and their corresponding ligaments; the acromioclavicular joint also belongs to this structure. The superior support for the SSSC is the clavicle, and the inferior strut, the lateral portion of the scapula. Disruptions of 1 of the components of the SSSC are relatively common and may not compromise its overall suspensory function. However, lesions to 2 or more of these structures often result in significant displacement at each individual site of the SSSC, often requiring operative stabilization. Treatment recommendations consist primarily of stabilizing the clavicle, or both lesions, to restore the integrity to the SSSC, hence maintaining a stable relationship between the upper extremity and the axial skeleton and providing firm attachment points for the soft tissues that enable shoulder function.

Diagnosis of the injury begins as per ATLS protocol with the routine chest radiographs obtained for all trauma patients. This provides the initial evidence of an SSSC injury. The most helpful further radiographic studies include: (1) an anteroposterior (AP) x-ray, (2) a 30 degree antero-oblique x-ray, (3) a lateral Y view (axial view), (4) an AP view with the arm in abduction, and (5) a CT scan of the shoulder.

The first step to restore stability in an SSSC injury is the operative stabilization of the clavicle. After clavicle stabilization, with the presence of an additional fracture of the scapula with a glenoid neck angulation of 40 degrees or with displacement of more than 10 mm, the reduction and fixation of the scapular neck is also mandated.

As a result of an injury to the SSSC, axillary nerve palsy, infraspinatus weakness, shoulder stiffness, shoulder pain, and complications related to other associated injuries have been reported.

There are several keys for treatment of this SSSC complex injury to provide the patient with a good clinical outcome/functional shoulder. These include early recognition of the injury with adequate work-up, operative treatment with staged fixation when indicated, and an aggressive program of rehabilitation.

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