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Floating Shoulder

From WikiSM

Other Names

  • Floating Shoulder
  • Superior shoulder suspensory complex Injury
  • Floating shoulder injury
  • Floating shoulder lesion
  • Floating shoulder fracture
  • Double disruption of the superior shoulder suspensory complex (SSSC)
  • Scapular neck fracture with clavicle fracture
  • Ipsilateral clavicle and scapular neck fracture
  • Shoulder girdle dissociation
  • Unstable shoulder girdle injury
  • Combined clavicle–scapular fracture
  • SSSC disruption involving the scapular neck

Background

History

  • The first published case of floating shoulder in the medical literature was in 1831[1]
  • The modern definition was first published by Herscovici in 1992[2]

Epidemiology

  • The incidence of this condition is very rare
  • Incidence estiamted at roughly 0.1%[3]

Introduction

Pathoanatomy of the floating shoulder
Shoulder bones and ligaments injury in the floating shoulder[4]
Clinical and Xray images of floating shoulder[5]
(a) Floating shoulder with midshaft clavicular fracture and surgical scapular neck fracture (black arrows). (b) Open reduction and internal fixation of the clavicle with fracture healing. (c) Clinical presentation with a slight persistent drooping shoulder at 61 months of follow-up (black arrow)[3]
Superior Shoulder Suspensory Complex
Superior Shoulder Suspensory Complex

General

  • ‘Floating shoulder’ is a rare fracture pattern caused by high-energy trauma to the shoulder girdle[6]
  • Definition of floating shoulder involves injury to at least two components of the SSSC, typically the scapular neck and distal clavicle[7]
  • Diagnosis is made radiographically and the best outcomes occur with surgical management
  • Associated with long-term functional complications such as muscle weakness and osteoarthritis[8]

Terminology

  • Two part fracture of the SSSC
  • Historical definition: scapular neck fracture, distal clavicle fracture
    • Definition has evolved, is now more comprehensive[9]
  • Also includes concurrent tears of the coracoacromial, acromioclavicular ligaments[10]

Mechanism of Injury

  • High energy trauma, typically motor vehicle crash[11]
  • Other mechanisms[12]
    • Fall from hieght
    • Motorcycle accident
    • Bicycle accident
    • Gunshot Wound

Pathophysiology

  • Characterized as injury to two components of the SSSC
  • This creates anatomic instability of the upper extremity
  • The weight of the arm, action of surrounding muscles pull the glenohumeral joint distally and anteromedially[13]
  • This leads to dysfunction and shoulder deformity
  • Williams showed that stability of the fractured clavicle and scapular neck was dependent on whether associated injury of the acromioclavicular or coracoclavicular ligaments also occurred[14]

Anatomy of the Superior Shoulder Suspensory Complex

Associated Injuries

Risk Factors

  • Unknown

Differential Diagnosis

Differential Diagnosis Shoulder Pain

Clinical Features

A patient with a typical drooping shoulder (left)[18]

History

  • Patients will have some history of high enery or violent trauma
    • Most commonly, amotor vehicle crash followed by fall from height[12]
  • They report severe shoulder pain
  • Inability to use the affected extremity
  • Most patients are younger to middle aged adult males

Physical Exam

  • Inspection: asyemmetry, possibly deformity compared to contralateral side[17]
    • Loss of normal shoulder contour
    • The shoulder may appear drooped or medially displaced
  • Palpation: tender over the clavicle and scapula
  • Range of motion is severally restricted[19]
  • Strength may be limited by pain, or frank weakness can be present
  • It is critical to evaluate for neurovascular, especially the axillary nerve and distal pulses

Special Tests

  • Not applicable

Evaluation

Anteroposterior shoulder radiograph in a 25-year-old man shows an oblique midclavicular shaft fracture with 10-mm displacement of the fracture fragments and a combined fracture of the spine and surgical neck (arrows) of the scapula. The acromioclavicular joint alignment and coracoclavicular interval are maintained. There is a partially evaluated comminuted humeral shaft fracture

Radiographs

  • Standard Radiographs Shoulder
    • Should include standard 3 views at a minimum
    • Not as sensitive as CT
  • Findings
    • Can identify scapular neck fractures, clavicle fractures
    • Can evaluate integrity of glenohumeral joint
  • Glenopolar Angle (GPA)[20]
    • Quantifies line between the superior/inferior poles of glenoid and superior pole of inferior scapular body
    • Normal values range from approximately 30° to 45°
    • Angles less than 20-22° suggesting significant displacement that may warrant surgical intervention

CT

  • Provides superior characterization of both clavicle and scapular fracture patterns
    • Including assessment of intraarticular extension, angulation, and lateral border offset[21]
  • 3 dimensional reconstruction can further enhance visualization
    • Very useful for surgical planning
  • Allows precise measurement of key parameters[22]
    • Including the glenopolar angle and glenoid index

MRI

  • Better for evaluating assocaited soft tissue injuries
    • Including coracoclavicular ligament disruption, rotator cuff tears, and labral injuries
  • However, MRI is inferior to CT for characterizing fracture planes in complex patterns

Classification

  • Not Applicable

Management

A 31-year-old woman with a case of floating shoulder of the ipsilateral humerus shaft fracture type, sustained in a car accident. (A) Radiograph showing the humerus shaft fracture with butterfly fragments (B) Radiograph showing displaced midshaft clavicle fracture (C) CT scan showing the both fractures (total floating shoulder) (D) Postoperative radiograph at one year, showing pate fixation of both fractures and successful bone union (E) Patient at one year post operation, showing full range of shoulder motion.[23]
Postoperative one year follow-up clinical photos of the patient[24]

Nonoperative

  • Indications
    • Can be considered for minimally displaced fractures?
    • (scapular neck displacement <5-10 mm) with intact coracoclavicular ligaments
  • Immobilization
  • Physical Therapy
    • Begin early, within 1-2 weeks of injury

Operative

  • Indications[12]
    • Scapular neck displacement >5-10 mm
    • Glenopolar angle <20-22°
    • Complete superior shoulder suspensory complex disruption
    • High functional demand
  • Technique
    • Clavicle ORIF
    • Clavicle and Scapula ORIF

Rehab and Return to Play

Scapular exercises that can be used in floating shoulder rehab

Rehabilitation

  • General[25]
    • Begin physical therapy within the first 2 weeks
    • Rehabilitation follows a proximal-to-distal kinetic chain approach
    • Progressive functional restoration
  • Early phase
    • Gentle passive and active-assisted range of motion exercises
    • Scapular stabilization
    • Closed-chain axial loading exercises
  • Intermediate phase
    • Progressive strengthening of rotator cuff and periscapular muscles
    • Integrated muscle activation patterns
    • Emphasizing scapular control and coupled rotator cuff function
  • Advanced
    • Sport-specific conditioning and functional training
    • Restory glenohumeral motion through facilitation by scapular control
    • Facilitated by hip and trunk activation.

General Shoulder Exercises

Return to Play/ Work

  • Athletes must[17]
    • Demonstrate radiographic evidence of fracture union
    • Pain-free full range of motion
    • Strength symmetric to the contralateral shoulder
    • Restoration of sport-specific functional capacity
  • Return-to-play decision-making process
    • Ongoing risk assessment based on the athlete's diagnosis, progress, and individual risk tolerance
    • Realistic goal setting
    • Communication among the athlete, physician, and athletic care network
  • Timeline
    • Not well defined due to rare disease

Prognosis and Complications

Prognosis

  • General[12]
    • Outcomes are good with both surgical and nonsurgical
    • Only if care appropriately individualized to fracture displacement, ligamentous integrity, and patient factors
  • Surgical management
    • Outcomes are much better with surgical management
  • Nonsurgical management
    • Rate of complications are 21.5% in patients managed nonoperatively
    • In appropriately selected patients, union occurs in 95% of patients[12]
    • One study showd 19/20 fractures pairs united and 17 had excellent results[26]

Complications

  • Brachial Plexus Injuries[27]
  • Axillary Artery Injujries
  • Functional deficits
  • Degenerative Joint Disease[28]
  • Postoperative[12]
    • 27% of surgically managed shoulders develop a complication
    • Infection

See Also

References

  1. ↑ Liria, Josep, et al. "Case report: floating-clavicle from the 17th century: the oldest case?." Clinical Orthopaedics and Related Research® 470.2 (2012): 622-625.
  2. ↑ Herscovici, D., et al. "The floating shoulder: ipsilateral clavicle and scapular neck fractures." The Journal of Bone & Joint Surgery British Volume 74.3 (1992): 362-364.
  3. ↑ 3.0 3.1 gis Pailhes, ReÌ, et al. "Floating shoulders: Clinical and radiographic analysis at a mean follow-up of 11 years." International Journal of Shoulder Surgery 7.2 (2013): 59.
  4. ↑ Sharifpour, Sadula, et al. "Management of a floating shoulder accompanied by a scapular surgical neck fracture: a case report and review of the literature." Annals of Medicine and Surgery 85.4 (2023): 960-964.
  5. ↑ Paladini, Paolo, et al. "Treatment of clavicle fractures." Translational Medicine@ UniSa 2 (2012): 47.
  6. ↑ Owens, B. D., and T. P. Goss. "The floating shoulder." The Journal of Bone & Joint Surgery British Volume 88.11 (2006): 1419-1424.
  7. ↑ Kani, Kimia Khalatbari, et al. "The floating shoulder." Emergency radiology 26.4 (2019): 459-464.
  8. ↑ Egol, Kenneth A., et al. "The floating shoulder: clinical and functional results." JBJS 83.8 (2001): 1188-1194.
  9. ↑ Williams, Gerald R., et al. "The floating shoulder: a biomechanical basis for classification and management." JBJS 83.8 (2001): 1182-1187.
  10. ↑ Oh, Chang, et al. "The treatment of double disruption of the superior shoulder suspensory complex." International orthopaedics 26.3 (2002): 145-149.
  11. ↑ Mohamed, Sayid Omar, et al. "The term “floating” used in traumatic orthopedics." Medicine 98.7 (2019): e14497.
  12. ↑ 12.0 12.1 12.2 12.3 12.4 12.5 Dombrowsky, Alex R., et al. "Clinical outcomes following conservative and surgical management of floating shoulder injuries: a systematic review." Journal of shoulder and elbow surgery 29.3 (2020): 634-642.
  13. ↑ Hashiguchi, Hiroshi, and Hiromoto Ito. "Clinical outcome of the treatment of floating shoulder by osteosynthesis for clavicular fracture alone." Journal of shoulder and elbow surgery 12.6 (2003): 589-591.
  14. ↑ Williams, Gerald R., et al. "The floating shoulder: a biomechanical basis for classification and management." JBJS 83.8 (2001): 1182-1187.
  15. ↑ Dreizin, David, et al. "CT of Acute Shoulder Girdle Fractures in Adults: Biomechanics, Classification, and Management." RadioGraphics 46.1 (2025): e250025.
  16. ↑ Reynolds, Alan W., et al. "Stability, deformity, and fixation of the floating shoulder: a cadaveric biomechanical study." Journal of Shoulder and Elbow Surgery 32.3 (2023): 519-525.
  17. ↑ 17.0 17.1 17.2 Herring, Stanley A., et al. "Initial assessment and management of select musculoskeletal injuries: a team physician consensus statement." Current Sports Medicine Reports 23.3 (2024): 86-104.
  18. ↑ Van Noort, A., and Chr van der Werken. "The floating shoulder." Injury 37.3 (2006): 218-227.
  19. ↑ Edwards, Scott G., A. Paige Whittle, and George W. Wood. "Nonoperative treatment of ipsilateral fractures of the scapula and clavicle." JBJS 82.6 (2000): 774.
  20. ↑ Yadav, V., et al. "A prospective study comparing conservative with operative treatment in patients with a ‘floating shoulder’including assessment of the prognostic value of the glenopolar angle." The bone & joint journal 95.6 (2013): 815-819.
  21. ↑ Laur, Olga, et al. "ACR Appropriateness Criteria® Acute Shoulder Pain: 2024 Update." Journal of the American College of Radiology 22.5 (2025): S36-S47.
  22. ↑ Dreizin, David, et al. "CT of Acute Shoulder Girdle Fractures in Adults: Biomechanics, Classification, and Management." RadioGraphics 46.1 (2025): e250025.
  23. ↑ Baek, Jeong Kook, et al. "Operative Treatment for Midshaft Clavicle Fractures in Adults: A 10-Year Study Conducted in a Korean Metropolitan Hospital." Journal of Trauma and Injury 29.4 (2016): 105-115.
  24. ↑ Elmadag, Mehmet, et al. "Floating shoulder: ipsilateral clavicle, scapular body and glenoid fracture. a case report." Malaysian Orthopaedic Journal 6.SupplA (2012): 35.
  25. ↑ Kibler, W. Ben, J. O. H. N. McMullen, and T. I. M. Uhl. "Shoulder rehabilitation strategies, guidelines, and practice." Orthopedic Clinics 32.3 (2001): 527-538.
  26. ↑ Edwards, Scott G., A. Paige Whittle, and George W. Wood. "Nonoperative treatment of ipsilateral fractures of the scapula and clavicle." JBJS 82.6 (2000): 774.
  27. ↑ Gonuguntla, Rishi K., et al. "Floating Shoulder Review." Int J Ortho Res, 5 (1), 43 46 (2022).
  28. ↑ Owens, B. D., and T. P. Goss. "The floating shoulder." The Journal of Bone & Joint Surgery British Volume 88.11 (2006): 1419-1424.
Created by:
John Kiel on 28 January 2026 14:22:40
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28 January 2026 16:44:50
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