An unprecedented pan-brachial injury: A case report of ipsilateral floating shoulder, floating elbow, and acetabular fracture following a psychosis-induced fall

Abstract

Introduction

High-energy trauma can result in complex orthopedic injury patterns. The “floating shoulder” and “floating elbow” are distinct, severe injuries involving serial fractures of the upper extremity, disrupting adjacent joint function. The simultaneous ipsilateral occurrence of both, further complicated by a pelvic fracture, represents an exceptionally rare and challenging clinical scenario.

Case presentation

We present the case of a 45-year-old male with a history of schizophrenia who sustained multiple fractures after a fall from a height during a psychotic episode. He was diagnosed with an ipsilateral left-sided floating shoulder (Neer Type I distal clavicle fracture and a surgical neck of humerus fracture), a floating elbow (open Type I Gustilo-Anderson supracondylar and intercondylar distal humerus fracture with metaphyseal comminution, and fractures of the distal radius and ulna), and a non-displaced anterior column acetabular fracture. This report details the single-session surgical marathon performed hours after admission, which included intramedullary nailing of the humerus, open reduction and internal fixation (ORIF) of the distal humerus, and external fixation of the wrist, alongside non-operative management for the clavicle and acetabulum.

Conclusion

This report describes a unique and previously unreported combination of injuries. The patient's successful outcome depended on collaboration between multiple specialties, decisive surgical planning, and a single, extensive operation to stabilize his fractures. The patient's psychiatric condition added a significant layer of complexity to his perioperative care and rehabilitation. To our knowledge, this specific combination of ipsilateral floating shoulder, floating elbow, and acetabular fracture has not been previously reported in the literature.

Highlights

• •This case report describes a patient sustaining an ipsilateral "floating shoulder", "floating elbow", and an acetabular fracture simultaneously.
• •The extensive trauma resulted from a 10-meter fall from a bridge by a 45-year-old male during an acute psychotic episode linked to his schizophrenia.
• •The patient underwent a single-session "surgical marathon" to stabilize the entire arm, which involved multiple repositionings and included intramedullary nailing of the humerus, open reduction and internal fixation of the distal humerus, and spanning external fixation of the wrist.
• •Despite the severity of the "pan-brachial" trauma, the patient achieved a remarkable functional recovery at his one-year follow-up, with all fractures healed and good function in his shoulder, elbow, and wrist.

Introduction

High-energy trauma is a leading cause of complex musculoskeletal injuries, often resulting in unique and challenging fracture patterns. The terms “floating shoulder” and “floating elbow” describe severe injuries that create an unstable limb segment by disrupting the articular structures at both ends of a long bone [1], [2], [3]. A floating shoulder, first described by Ganz and Noesberger, typically involves fractures of the clavicular shaft and the ipsilateral glenoid neck, though variants including proximal humerus fractures are recognized. This injury disrupts the superior shoulder suspensory complex (SSSC), leading to significant instability of the shoulder girdle [1], [2], [4], [5].

Similarly, the floating elbow is defined by ipsilateral fractures of the humerus and the forearm (radius and/or ulna), effectively isolating the elbow joint and leading to profound instability [3], [6]. Both injury patterns are relatively uncommon and are almost invariably the result of significant force, such as that sustained in motor vehicle collisions or falls from height.

The simultaneous, ipsilateral occurrence of a floating shoulder and a floating elbow is exceedingly rare, with only a handful of cases documented in the literature [7], [8], [9], [10]. The addition of a concomitant pelvic ring injury, such as an acetabular fracture, to this already severe upper extremity trauma constellation makes this case exceptionally unique. Such a combination presents a formidable challenge in terms of diagnostic workup, surgical prioritization, and overall patient management.

This report details the case of a 45-year-old male who sustained this triad of injuries—ipsilateral floating shoulder, floating elbow, and an anterior column acetabular fracture—following a fall from a bridge during a psychotic episode. We describe the patient's presentation, the detailed classification of his injuries, the single-session surgical management, and discuss the biomechanical considerations and a review of the relevant literature. This case is presented in accordance with the SCARE guidelines [11].

Case presentation

Patient history and initial assessment

A 45-year-old male was brought to our Level 1 trauma center by emergency medical services after a fall from a height of approximately 10 m from a road bridge. The patient had a long-standing diagnosis of paranoid schizophrenia with a history of poor medication adherence. In the days preceding the incident, he had stopped his antipsychotic medication, leading to an acute psychotic decompensation. He experienced escalating auditory hallucinations of a commanding nature and developed a complex persecution delirium, believing he was being pursued by an organization intending to harm him. In a state of intense fear and panic, he fled his home and jumped from the bridge in what he later described as an attempt to “escape his pursuers”.

Emergency services found him conscious on the grassy embankment below, agitated and complaining of severe pain in his left arm and hip. He was hemodynamically stable, and after cervical spine immobilization and intravenous access, he was transported to the hospital.

Upon arrival in the emergency department, his vital signs were a blood pressure of 135/80 mmHg, a heart rate of 115 beats per minute, and an oxygen saturation of 98% on room air. His Glasgow Coma Scale (GCS) score was 15, but he remained fearful and suspicious of the medical team. The primary survey according to Advanced Trauma Life Support (ATLS) protocols was unremarkable for immediate life-threatening injuries.

The secondary survey revealed the extent of his orthopedic injuries. His entire left upper extremity was massively swollen, tense, and ecchymotic. Palpable crepitus and gross instability were present at the shoulder, elbow, and wrist. A 1 cm transverse laceration over the posterior olecranon, oozing serosanguinous fluid, confirmed a Gustilo-Anderson Type I open fracture. His left lower limb was held in external rotation, with exquisite tenderness on palpation of the hip, the distal neurovascular examination of the left hand was surprisingly intact: the hand was warm with a capillary refill of less than 3 s, radial and ulnar pulses were strong, and he could demonstrate active finger motion with grossly intact sensation to light touch. Intravenous fentanyl was administered for analgesia, a tetanus booster was given, and the psychiatry liaison service was urgently consulted to manage his acute psychosis.

Diagnostic imaging and fracture classification

Due to the patient's agitated state and the need for emergent management, advanced imaging such as computed tomography was deferred. A comprehensive radiographic survey was performed to define the constellation of injuries. The combination of a clavicle fracture and an ipsilateral proximal humerus fracture constituted a “floating shoulder”. The concomitant fractures of the distal humerus and forearm bones defined an ipsilateral “floating elbow”. The presence of both of these complex injuries in the same limb created a catastrophic “pan-brachial” disruption, signifying a complete bony dissociation of the upper extremity from the axial skeleton.

Radiographs of the left shoulder girdle revealed a displaced, comminuted fracture of the distal third of the clavicle. The fracture was located just medial to the coracoclavicular ligamentous insertion, with significant superior displacement of the proximal fragment due to the pull of the sternocleidomastoid muscle. This was classified as a Neer Type I and a Robinson Type 2B1 injury (Fig. 1). The same series showed a displaced two-part surgical neck fracture of the proximal humerus. The humeral head was severely impacted into a varus position, and the shaft was displaced medially, corresponding to a Neer two-part and an AO/OTA 11-A3 classification (Fig. 1).

Fig. 1.

AP X ray view of the left shoulder.

The left elbow series demonstrated a complex injury to the distal humerus. The radiographs showed a completely shattered articular surface with both the capitellum and trochlea fractured into multiple fragments. This articular destruction was accompanied by severe metaphyseal comminution, creating a void between the diaphysis and the articular fragments. This pattern was consistent with a Riseborough and Radin Type IV and an AO/OTA 13-C3 classification, representing the most severe end of the injury spectrum (Fig. 2). The open nature of this fracture was confirmed clinically.

Fig. 2.

X ray series of the left elbow (a) AP view (b) ML view.

Imaging of the left wrist and forearm identified the distal components of the floating elbow. There was a highly comminuted, intra-articular distal radius fracture. The lunate facet was split, and there was significant dorsal comminution and impaction of the metaphysis, leading to a loss of radial height and inclination. This was classified as a Melone Type IIB and an AO/OTA 2R3C2.1 fracture. This severe radial injury was associated with a displaced fracture at the base of the ulnar styloid. The combination of the complex intra-articular distal radius fracture and the ulnar styloid fracture also fit the criteria for a Frykman Type VIII injury, indicating extensive radio- and ulnocarpal ligamentous disruption (Fig. 3).

Fig. 3.

X ray series of the left wrist (a) AP view (b) ML view.

Finally, a pelvic series including anteroposterior, iliac oblique, and obturator oblique (Judet) views was performed to evaluate the hip pain. These radiographs identified a subtle, non-displaced fracture line extending through the anterior column of the left acetabulum, superior to the pubic ramus. This was classified as a simple, stable anterior column fracture according to the Judet and Letournel system (Fig. 4).

Fig. 4.

AP view X ray image of the pelvis.

Management strategy and surgical sequence

The combination of injuries necessitated a logistically demanding, multi-stage, single-session surgical marathon that required several changes in patient positioning and draping. Our primary surgical goal was to stabilize the humeral shaft first. This provided a stable foundation, which made the complex reconstruction of the elbow joint more manageable.

Stage 1: Proximal Humerus Fixation (Beach Chair Position). The procedure commenced with the patient being placed in a beach chair position under general anesthesia supplemented by an interscalene nerve block for postoperative pain control. The torso was elevated to 70 degrees, and the head was securely cradled in a padded headrest. The entire left upper extremity was prepped with chlorhexidine solution and draped to allow unrestricted manipulation and C-arm access. The primary objective was to stabilize the proximal humerus fracture. A minimally invasive deltoid-splitting approach was executed through the anterolateral Neviaser portal, superior to the acromion. The rotator cuff was identified, and an incision was made in line with its fibers to expose the humeral head. The varus impaction of the surgical neck fracture was carefully disengaged using an elevator. Reduction was then achieved through a combination of manual traction on the arm and direct manipulation of the fragments under fluoroscopic guidance. A 2.5 mm K-wire inserted into the humeral head served as a joystick to correct the varus tilt, while a ball-spiked pusher applied counter-pressure to the medially displaced shaft. Once anatomic alignment was confirmed in both AP and lateral views, a guide wire was inserted down the humeral canal. A Short MultiLoc antegrade humeral nail was then passed over the wire to the appropriate depth. Proximal locking screws were deployed into the humeral head, and distal interlocking screws were placed 15 cm proximal to the olecranon fossa to ensure robust rotational control (Fig. 5). The rotator cuff interval was repaired, and the wound was closed in layers. A sterile dressing was applied, completing the first stage.

Fig. 5.

Fluoroscopic series of proximal humerus fixation using MultiLoc nail (a) AP view (b) distal locking (c) gap between proximal and distal fixations.

Stage 2: Distal Humerus Fixation (Lateral Decubitus Position). This stage required a complete repositioning. The surgical drapes were removed, and the anesthesia team ensured the patient's airway and lines were secure. The patient was then carefully log-rolled by a team of four into the right lateral decubitus position and stabilized with a vacuum beanbag and padded bolsters. The left arm was carefully placed over a padded side support (a “hobby horse”) with the elbow flexed to 90 degrees, and the entire limb was re-prepped and re-draped. The surgical focus now shifted to the open, comminuted distal humerus fracture. The 1 cm traumatic laceration was incorporated into a posterior midline incision. This was deepened through the triceps fascia, developing a Bryan-Morrey approach. The ulnar nerve was meticulously identified in its cubital tunnel, dissected free, and protected with a vessel loop. A transverse olecranotomy was then performed using a microsagittal saw, allowing the entire triceps mechanism to be reflected proximally, which provided an unparalleled panoramic view of the shattered articular surface. The joint was thoroughly irrigated with 6 l of pulsatile lavage. The articular reconstruction was the most critical step; the multiple fragments of the trochlea and capitellum were reassembled on the back table and then provisionally fixed in situ with multiple 1.2 mm K-wires. Once the articular block was restored, it was fixed to the nail-stabilized humeral shaft using a dual-plate 90/90 construct. Two pre-contoured 3.5 mm locking reconstruction plates were applied, one posterolaterally and one medially, creating an orthogonal and exceptionally stable frame. The transverse olecranotomy was then anatomically reduced and repaired using an AO tension band technique with two parallel K-wires and a figure-of-eight 18-gauge wire (Fig. 6). After confirming stable fixation through a full range of motion, the ulnar nerve was transposed anteriorly into the subcutaneous tissue to prevent irritation from the medial hardware. The wound was closed in layers over a deep drain and dressed.

Fig. 6.

Fluoroscopic series of distal humerus fixation (a) AP view (b) ML view.

Stage 3: Wrist Fixation (Supine Position). For the final stage, the patient underwent a third positioning. The drapes were removed, and he was log-rolled back into the supine position. A radiolucent hand table was attached to the operating bed, and the left arm, now with a stable humerus and elbow, was placed upon it. The forearm and hand were prepped and draped. To address the grossly unstable distal radius and ulna, a spanning external fixator was applied. Under fluoroscopic guidance, two 3.0 mm Schanz pins were placed in the radial diaphysis through a small stab incision, and two pins were placed in the shaft of the second metacarpal. A simple stainless steel rod frame was constructed, and distraction was applied across the wrist joint. This ligamentotaxis maneuver successfully restored radial height and inclination, providing indirect reduction and stable fixation of the comminuted fragments (Fig. 7).

Fig. 7.

Fluoroscopic series of distal radius fixation (a) AP view (b) ML view.

The displaced distal clavicle fracture was managed non-operatively. The non-displaced acetabular fracture was determined to be stable and suitable for conservative management with strict non-weight-bearing on the left side for six weeks. Postoperative radiographs confirmed satisfactory alignment and hardware placement for all fixated fractures.

Postoperative management

The postoperative course was exceptionally demanding, requiring a tightly integrated, multidisciplinary approach. The patient was initially transferred to the surgical intensive care unit (SICU) for 48 h for continuous hemodynamic monitoring and frequent neurovascular assessments of the operated limb. A multimodal analgesia regimen was instituted, consisting of scheduled, nurse-administered intravenous opioids which were transitioned to oral analgesics as tolerated, alongside scheduled intravenous acetaminophen and gabapentin. This strategy was specifically chosen over a patient-controlled analgesia (PCA) pump to ensure consistent and safe pain management while mitigating risks associated with the patient's underlying psychiatric condition. The left upper extremity was positioned on an elevation pillow to minimize the significant swelling. The surgical drain at the elbow was removed on postoperative day two.

The psychiatry liaison service was paramount to his recovery. They conducted daily rounds, adjusted his antipsychotic medication to achieve therapeutic efficacy, and provided psychoeducation to help the patient understand his illness and the critical importance of medication adherence. This consistent engagement was crucial in maintaining his cooperation with the demanding rehabilitation protocol.

Rehabilitation began on postoperative day one, guided by a specialized orthopedic therapy team. The initial focus was on edema control and initiating safe, early motion. The elbow brace was unlocked for supervised sessions, allowing a controlled active-assisted range of motion from 30 to 90 degrees of flexion. Gentle, passive pendulum (Codman) exercises for the shoulder were started at 3rd week mark to prevent capsular adhesions. A hand therapist initiated active digital range of motion, tendon gliding exercises, and edema management for the hand. Concurrently, a physical therapist began mobilization, focusing on safe bed-to-chair transfers and use of a rolling walker while maintaining strict non-weight-bearing status on the left lower limb to protect the acetabular fracture. Pin site care for the wrist external fixator, consisting of daily cleansing with antiseptic solution, was taught to the nursing staff and the patient.

After stepping down from the SICU, the patient's rehabilitation intensified. The elbow range of motion was progressively increased by 10 degrees in flexion and extension each week, as tolerated. By week two, active shoulder forward flexion and external rotation in the scapular plane were introduced. After a 14-day hospital stay, the patient, being medically and psychiatrically stable but unable to be discharged home.

Follow-up

The patient was followed regularly in the outpatient orthopedic clinic after his discharge to the rehabilitation facility. At the six-week postoperative visit, radiographs of the left hip and pelvis showed early callus formation at the acetabular fracture site, with no evidence of displacement. The wrist external fixator was removed in the clinic, and the pin sites were clean and dry. He was cleared to begin progressive weight-bearing as tolerated on the left lower limb and was transitioned to a removable wrist splint, initiating active wrist range of motion exercises.

At the three-month follow-up, radiographs of the entire left upper extremity demonstrated solid bridging callus at all fracture sites. The non-operative clavicle fracture had healed with predictable deformity but was stable and non-tender. The elbow brace was discontinued, and the focus of therapy shifted to strengthening exercises for the entire limb and restoring full, active range of motion.

By six months post-injury, the patient was ambulating independently without an assistive device. He continued to work with outpatient physical and occupational therapy to address residual stiffness and weakness. His psychiatric condition remained stable on his medication regimen.

Outcomes

At the final one-year follow-up, the patient had achieved a remarkable functional recovery despite the severity of his injuries. All fractures were radiographically healed with no signs of hardware failure, avascular necrosis, or significant post-traumatic arthritis (Fig. 8 and Fig. 9).

Fig. 8.

X ray series of shoulder and elbow 6 months post-operatively indicating healing of all fractures, olecranon K-wire tension banding was removed 6 weeks post operatively (a) AP view (b) ML view.

Fig. 9.

X ray series of the wrist 6 weeks post-operatively indicating healing of the distal radius fracture (a) AP view (b) ML view.

Functionally, his left shoulder had a forward flexion of 140 degrees and abduction of 120 degrees. The Constant-Murley score was 78, indicating a good result. The left elbow achieved a functional arc of motion from 15 degrees of extension to 120 degrees of flexion. The Mayo Elbow Performance Score (MEPS) was 85, also considered a good result. Forearm rotation was 60 degrees of supination and 70 degrees of pronation. His left wrist had 50 degrees of flexion and 60 degrees of extension. His grip strength was 80% of the contralateral side.

The overall upper extremity function, assessed by the Disabilities of the Arm, Shoulder and Hand (DASH) score, was 25, signifying mild residual disability. He was able to perform most activities of daily living independently but reported difficulty with heavy lifting and overhead activities. He had returned to living independently and was compliant with his psychiatric care. He walked with a normal gait and without pain, having a full recovery from his acetabular fracture.

Discussion

This case report details the successful management of a complex and exceedingly rare pattern of injuries: an ipsilateral floating shoulder, floating elbow, and an associated stable acetabular fracture resulting from a psychosis-induced fall. The complexity of this case lies not only in the severe multi-level skeletal trauma but also in the profound influence of the patient's psychiatric condition on the mechanism, management, and recovery.

The simultaneous occurrence of an ipsilateral floating shoulder and floating elbow is an exceptional event, with only a few cases reported in the literature [8]. The addition of a pelvic fracture to this “pan-brachial” injury pattern makes this case, to our knowledge, unique. The literature describes similar severe injuries, such as a floating elbow combined with a dislocated floating shoulder, as being so rare that no prior cases had been reported [7], [9], [10]. This highlights the severity of the traumatic forces our patient sustained. We hypothesize a multi-stage impact sequence from the fall. The primary impact was likely an axial load onto the outstretched left hand with the elbow in slight flexion. This force would have caused the comminuted distal radius fracture and transmitted proximally to shatter the distal humerus and cause the surgical neck fracture [3], [12], [13]. The floating shoulder component, specifically the distal clavicle fracture, may have resulted from a secondary, direct impact to the superolateral aspect of the shoulder as the patient rolled after the initial landing [2], [14], [15]. The non-displaced anterior column acetabular fracture is a classic axial load injury pattern consistent with landing on the lower limb. The patient's impaired protective reflexes due to his acute psychosis likely contributed to the severity and multiplicity of these injuries.

The management of such a severely unstable limb requires meticulous strategic planning. We opted for a single, definitive surgical session involving multiple patient repositionings. This was deemed preferable to a staged damage control approach (e.g., spanning external fixation of all long bones followed by later conversion) primarily due to the patient's psychiatric condition [16], [17]. Minimizing the number of anesthetic events and surgical procedures was intended to reduce psychological distress and the risk of non-compliance with a prolonged, multi-stage treatment plan.

The surgical sequence—proximal humerus, distal humerus, then wrist—was a critical decision. Stabilizing the humeral shaft with an intramedullary nail first was the cornerstone of the strategy. This established a solid, length-stable bony column, which greatly simplified the subsequent, technically demanding articular reconstruction of the distal humerus. Attempting to fix the shattered distal humerus to a “flail”, un-stabilized proximal segment would have been significantly more challenging. Our approach is in contrast to other reports where a distal-to-proximal fixation was performed, which can also be successful but may pose technical difficulties in restoring length and rotation without a stable proximal anchor [18], [19], [20], [21].

The decision to manage the clavicle fracture non-operatively is supported by studies on floating shoulders which suggest that with stable internal fixation of the associated humerus or scapula fracture, good functional outcomes can be achieved without clavicular fixation, especially when displacement is not severe [18], [20], [22], [23]. Similarly, the stable, non-displaced acetabular fracture was appropriately managed conservatively, avoiding the significant morbidity of pelvic surgery. The use of a spanning external fixator for the wrist provided excellent provisional stability through ligamentotaxis, allowing the soft tissues to recover while maintaining alignment of the highly comminuted distal radius.

Our case shares similarities with, but is distinct from, other severe injuries reported. Azhar et al. described a floating shoulder and elbow in a young male after a motor vehicle accident, which was managed with plating of all fractures [8]. While a pan-brachial injury, the fracture patterns and fixation methods differed. More comparably, a case of a floating elbow with a pubic rami fracture after a fall from height was reported, highlighting the association between severe upper extremity trauma and pelvic injuries [9]. In that case, the patient was hemodynamically unstable, necessitating a damage control approach with external fixation, which contrasts with our ability to perform definitive fixation in a single session due to our patient's physiological stability. The extreme rarity of our case is underscored by reports where even less complex combinations, such as a floating elbow with a shoulder dislocation, are presented as novel findings [7], [8], [9], [10].

The patient's schizophrenia was not an incidental finding but a central element of this case. It was the direct cause of the traumatic event and presented significant challenges throughout his care. His initial agitation complicated the diagnostic workup. The management plan was tailored to his condition, specifically the choice of a single definitive surgery, the avoidance of a PCA pump, and the enforcement of a strict non-weight-bearing protocol due to concerns about compliance and safety. The integral role of the psychiatry liaison service cannot be overstated. Their co-management was essential for stabilizing his mental state, ensuring medication adherence, and fostering the therapeutic alliance necessary for him to engage in the arduous rehabilitation process. This case powerfully illustrates that in patients with severe mental illness, the medical and psychiatric aspects of care are inextricably linked and must be managed concurrently for a successful outcome.

Conclusion

We present an exceptionally rare case of an ipsilateral floating shoulder, floating elbow, and acetabular fracture in a patient with schizophrenia. This case highlights that with meticulous preoperative planning, a logical surgical sequence prioritizing humeral shaft stability, and modern fixation techniques, a good functional outcome can be achieved even in the face of complex pan-brachial trauma. Critically, it underscores the necessity of an integrated, multidisciplinary team approach, where orthopedic and psychiatric care are seamlessly combined to manage the complex interplay between severe physical injury and mental illness.

CRediT authorship contribution statement

Yassine Fath El Khir: Writing – review & editing, Supervision, Methodology, Data curation, Conceptualization. Zakaria Chabihi: Writing – review & editing, Writing – original draft, Visualization, Software, Methodology, Formal analysis, Conceptualization. Abdelwahed Soleh: Writing – review & editing, Validation. El Mehdi Boumediane: Writing – review & editing, Supervision. Mohamed Amine Benhima: Validation, Supervision. Imad Abkari: Validation, Supervision.

Statement of informed consent

Written informed consent was obtained from the patient's guardian for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Statement of human and animal rights

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 (5).

Statement of funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors

Clinical trial number

Not applicable.

Statement of ethics

The study was waived by the Scientific Committee and the Medical Council of Mohamed VI University Hospital for being a retrospective non interventional study. Written informed consent was obtained from the all patients for publication of this report and any accompanying images in accordance with the principles of the Declaration of Helsinki.

Code availability

Not applicable.

Declaration of competing interest

The authors declare that there is no conflict of interest.

Data availability

All data generated or analyzed during this study are included in this published article.