Thomas P. Goss

Double disruptions of the superior shoulder suspensory complex.

The superior shoulder suspensory complex (S.S.S.C.), a bony/soft tissue structure, is important both for its role as an intact unit and for the individual components that make up this unit. Traumatic “double disruptions” of the S.S.S.C. frequently create an unstable anatomic situation with adverse long-term healing and functional consequences. This “double disruption” principle underlies, unites, and allows one to understand several well-described but difficult-to-treat shoulder injuries that have previously been described in isolation. Injuries to the S.S.S.C. require careful radiologic evaluation for the possible presence of a “double disruption.” If displacement is unacceptable, surgical reduction and stabilization of one or more of the injury sites is necessary.

The floating shoulder

The floating shoulder is defined as ipsilateral fractures of the midshaft of the clavicle and the neck of the glenoid. This rare injury can be difficult to manage without a thorough understanding of the complex anatomy of the shoulder girdle. Surgical intervention needs to be considered for all of these injuries. While acceptable results can be expected with non-operative management of minimally-displaced fractures, displacement at one or both sites is best managed with surgical reduction and fixation.

Fractures of the glenoid neck

Glenoid neck fractures are uncommon and have received little attention in the literature. However, these injuries involve a major articulation and can cause considerable morbidity if significantly displaced. Consequently, a review of current diagnostic and therapeutic principles with respect to these potentially challenging fractures is justified. The vast majority of glenoid neck fractures are undisplaced or insignificantly displaced (Type I fractures) and are managed without surgery. Type II fractures, however, are significantly displaced, making surgical management a consideration. Significant displacement is defined as translational displacement greater than or equal to 1 cm or angulatory displacement greater than or equal to 40° (in either the coronol or transverse plane). The primary surgical approach is posterior; however, a superior extension is often necessary. Fixation devices include K-wires, 3.5 mm reconstruction plates, and 3.5 mm cannulated lag screws. Follow-up care and rehabilitation are absolutely critical to optimizing the final functional result.

Surgical Approaches for Glenoid Fractures

Glenoid fractures are rare injuries and most can be managed non-operatively. However, significant displacement of fractures of the glenoid neck and cavity is an indication for open reduction and internal fixation to achieve optimal upper extremity function. While anterior rim and some superior fossa fractures are approached anteriorly, most glenoid neck and cavity fractures require a posterior exposure, which is unfamiliar to many surgeons. A satisfactory reduction, adequate fixation, and a well-designed rehabilitation program help to ensure a good outcome for patients with these complex injuries.

A variant of a type V lateral clavicle fracture involving a posteriorly displaced medial segment. A case report

The clavicle connects the shoulder girdle to the axial skeleton, providing support and mobility for optimal upper extremity function. Fractures of the clavicle account for up to 4% of all fractures and comprise up to 44% of all injuries to the shoulder girdle. We present a 63-year-old female patient who suffered what appeared to be a minimally displaced Type V lateral clavicle fracture after a fall as evidenced by an anteroposterior shoulder radiograph. However, an axillary projection demonstrated the proximal segment to be posteriorly displaced and buttonholed through the trapezius musculature with tenting of the skin. The patient underwent an open reduction and Kirschner wire fixation of the fracture with complete healing, subsequent removal of the hardware and return to her previous level of function six months following surgery. After an extensive literature search, we believe this is the first case report documenting a variant of a Type V lateral clavicle fracture, specifically with significant posterior displacement of the proximal segment, mimicking a Type IV AC separation. This fracture pattern is unstable and represents a double disruption of the superior shoulder suspensory complex. Surgical management was successful in returning our patient back to her previous activity of daily living.