Aiims rishikesh

1. FLOATING SHOULDER INJURIES
PRESENTOR - DR ASHISH PARGAIE
SENIOR RESIDENT – DR AMRIT PANDA
FACULTY – DR PRADEEP K MEENA

2. • Introduction
• Definition
• Related anatomy
• Pathoanatomy
• classification
• Investigation
• Treatment option
• Conclusion

3. Introduction :
• Ganz and Noesberger 1975 – floating shoulder – the ipsilateral
glenoid surgical neck and midshaft clavicle fracture
• Goss 1993 introduced the consept of superior shoulder
suspensory complex

4. Incidence :
• Scapular fracturre < 1 % of all fractures
• 3-5% of shoulder girdle fracture
• Age b/w 25 – 50 yr
• M > F
• it will mainly associated with polytrauma

5. Superior shoulder suspensory complex :
• GOSS , JOT 1993
• The SSSC is a bone -soft- tissue ring at the end of superior and inferior bone strut
Composed of
1- glenoid process
2- coracoid process
3- coracoclavicular ligaments
4- distal clavicle
5- ac joint
6- acromion process

6. Definition of SSSC
• Described as a bony / soft tissue ring at the end of a
superior and inferior bony strut
• Bony struts :
The superior strut
The inferior strut
The ring is composed of the glenoid fossa , coracoid
process , coracoclavicular ligament , distal clavicle
,acromioclavicular joint and the acromial process.
Function : this complex maintains a normal stable
relationship between the scapula and the axial
skeletal

7. SSSC consists of three components:
• 1. clavicle-acromioclavicular joint (ACJ)
• 2. clavicle-coracoclavicular (CC)
ligamentous coracoid
• 3. the three process scapular body
junction
A floating shoulder is defined by ipsilateral clavicular and
scapular neck fractures. The distal fragment
(glenoid and coracoid process) is connected to the proximal
fragment (acromion, scapular spine and body) by the
coracoclavicular and coracoacromial ligaments.

8. The three struts of the
superior shoulder
suspensory complex:
(1) the acromio-clavicular
joint-acromial strut
(2) the clavicular-
coracoclavicular
ligamentous-coracoid
linkage
(3) the three-process-
scapular body junction.

9. Pathoanatomy
• Fracture of surgical neck of scapula produce
• D . Distal fragment consisting of glenoid and
the coracoid process and
• P . Proximal fragment consisting of the
acromion scapular spine and scapular body

10. Pathoanatomy
• The distal fragment is attachment to the
proximal fragment by coracoacromial
ligament and to the axial skeleton, through
the clavicular shaft , by the coracoclavicular
ligamnent.
• To produce a floating shoulder ( scapula ) –
damage to these attachments is needed

11. Mechanism of injury :
• Most are following road traffic injuries
• High energy injuries
• Polytrauma associated with chest injuries – pneumo/ haemo thorax,
rib fracture

12. Associated injuries :
• SSSC injury a high incidence associated traumatic lesions.
• Local and regional injuries incidences of up to 44 %
• Permanent neurological deficit due to injury of brachial plexus
• High incidence of thoarcic trauma
 Multiple ribs fracture
 Hemothorex
 Hemopneumothorex
 tension pneumothorex

13. Clinical presentation :
• Shevere shoulder pain associated with abnormal
contour
• Dropping shoulder
• Patient hold the arm adducted position
• AC joint dislocation : local clavicular and
scapular tenderness

14. • Active and passive movement of the arm are painfull in any direction
• Neurovascular finding sometime difficult to determine on intial
physical examination
• Defenitive diagnosis is finally based on the radiographs

15. Classification of fracture
• Several classification for fracture of the SSSC
• Scapula : zdravkovic classification : divides scapula # 3 types
Type Description
Type I Fracture of the body of scapula
Type II Fracture of the apophysis including the coracoid and
acromion
Type III Fracture of the supero – lateral angle including the neck of
glenoid

16. Type I Type II Type III

17. Eyres and brooks classification : coracoid fracture
• Type I : Coracoid tip or epiphyseal fracture
• type II : Mid process
• Type III : Basal fracture
• Type IV : Involvement of superior body of scapula
• Type V : Extension into the glenoid fossa

18. Eyres and brooks classification : coracoid fracture

19. Ideberg classification : intra articular glenoid #
 Type I : avulsion fracture of the anterior margin .
 Type IA : anterior rim #
 Type IB : posterior rim #

20.  Type II : # line through glenoid fossa exiting
scapula laterally
 type II A : transverse fracture through the
glenoid fossa exiting inferiorly
 type IIb : oblique fracture through the
glenoid fossa exiting inferiorly

21. • Type III : oblique fracture through the glenoid
exiting superiorly ; often associated with an
acromioclavicular joint injury

22. • Type IV : transverse fracture exixting
through the medial border of the scapula

23. • Type V : combination of a type II &
type IV pattern
• Type VA : type II + type IV
• Type VB : type III + type IV
• Type VC : type II+ III+IV

24. • Type VI : severe continuation of glenoid
surface (GOSS)

25. Kuhn acromial fracture classification
• Type I : nondisplaced or minimally displaced
• Type II : displaced but does not compromise the
subacromial space
• Type III: displaced & compromise the
subacromial space

26. CLAVICLE FRACTURE
• ALLMAN / CRIAG divided Clavicle fracture into 3 parts
 group I - medial 1/3rd
 group II - middle 1/3rd
 group III - lateral 1/3rd

28. • GROUP I . middle third fracture (80%)
 Undisplaced
 Displaced

29. Group II . Distal 3rd fracture (15%)
• Sub- devided according to the location of
coracoclavicular & acromioclavicular
ligamnent
• Type I : minimally displaced fracture line
b/w clavicular attachment of CC & AC joint
CC ligament r intact and attached to medial
segment.

30. Type II :
• Displaced #
• Fracture medial to the Coracoclavicular
ligament & higher incidence of non- union
Subdivded into 2 parts
 Type II A : both ligament ( conoid &
trapezoid ) attached to the distal fragment

31. TYPE II B :
• Conoid torn & traphezoid attached to the distal fragment

32. Type III :
• Fracture involving AC joint articular surface with no ligament injury

33. Type IV :
• A physeal # occurs in skeletally immature group
• CC ligament to periosteal sleeve plus proximal
fragment displaced through tear in thick periosteum.

34. Type V :
• Commuinuted # and ligament remain attached to commuinuted
fragment

35. Group III – fracture of the 3rd (5%)
Devided into 5 types
• Type I : Minimally displacement
• Typeii : Displaced
• Type III : Intra-articular
• Type IV : Epiphyseal separation
• Type V : Comminuted

37. DIAGNOSTIC METHODS - Radiographs
• Minimum requirement of two radiographs of the
shoulder area that perpendicular to each other
• 1 : AP View : perpendicular the plane of the scapula
 True AP view : the beam is angled 45 degree of the
patient rotates the body till scapula is parallel to the
x ray cassette

38. True AP view : the beam is angled 45 degree of the patient
rotates the body till scapula is parallel to the x ray cassette

39. Axillary lateral view :
• Abduction of the affected shoulder
which is usually painful is necesssary
to otain good quality axillary view

40. AXILLARY LATERAL VIEW
The arm of the patient is abducted to at least 70 degree with the beam directed upwards, from
inferiorly, to the X-ray cassette.

41. Scapulo lateral view :
• A true scapulolateral, or Y-lateral, view.
• The beam passes parallel to the spine of
the scapula to the X-ray cassette.
• This view is valuable if the patient will not
tolerate enough abduction to get a good
quality axillary lateral view

42. A true scapulolateral, or Y-lateral, view

43. MANAGEMENT : CLAVICLE FARCTURE
• Should be fixed if displaced
• Reduces risk of non union
• Reduces tension on brachial plexus
• Restore anatomical relationship
• Improves function
• ? may reduce & stabilise glenoid fracture

44. GLENOID NECK FRACTURE
• Divided into anatomical and sugical neck
• Relationship to coracoid
• Anatomical neck always unstable
• Surgical neck stability depends on
ligamentous injuries

45. SURGICAL MANAGEMENT
• Fix both (goss)
• Some authors feel if clavicle fixed it may be enough
• However if scapular fracture remain displaced it should be fixed
• Sequence of fixation has to be individualised

49. APPROACHES :
• Workhorse is the JUDET approach
• Lateral position
• Inverted – l incision

50. MODIFICATION :
• Vertical incision
• Limited disection
• Work through windows

51. GLENOID NECK : Indication of surgery

53. INDICATION OF SURGERY NECK FRACTURE
( COLE 2002 / GOSS 1998 )
• Gleno-polar angle less than 20 digree
• 1cm medialisation of glenoid
• Glenoid caudally tilted ( triceps pull )
• 100 % tranlation lateral border of scapula – lat
• Association sssc injury – clavicle

54. • SSSC
• Less than 5 mm displacement
• No caudal displacement
Operative management : Clavicle plating 1st
: scapula still unreduced
:scapula fixation – undisplace #
YES
CONSERVATIVE
MANAGEMENT
NO

55. TAKE HOME MESSAGE
• Most scapular fractures can be treated non – operatively
• Indication :
- glenoid articular displacement in young patient
- neck + clavicle fracture
- double sssc disruption
- Neck fracture with significant displacement
REMEMBER ASSOCIATED INJURIES

56. THANK YOU