Surgical management of a floating shoulder with multiple ribs, cervico-dorsal spine fracture and lung injury: A case report

Abstract

Floating shoulder associated with multiple rib fractures with cervical dorsal spine fractures and lung injury has not been reported in the literature.

Patient underwent single stage elective clavicle and scapula fracture stabilization.

Good functional outcome at 6 months postoperative with near normal range of movements.

Surgery allows early mobilization and better functional outcome.

A CT scan of thorax and spine is highly recommended in such high velocity shoulder injuries to detect associated rib, spinal fractures and lung injury.

Introduction

Floating shoulder, a combination of lateral end of clavicle and scapular body fracture is a rare entity. An associated multiple rib fractures with cervical, dorsal spine fractures and lung injury has not been reported in the literature. In this article we report such a rare combination. Our emphasis was on this rarest injury, how to diagnose and how we managed with surgery and physiotherapy to get a good functional outcome.

Case report

A 51 years lady presented with alleged road traffic accident injury, when the auto she was travelling was hit by a bus. She sustained injury to her left shoulder and chest. After stabilizing vitals, she was found to have swelling of left shoulder with ecchymosis and tenderness over lateral clavicle and scapula. There was no distal neurovascular deficit. X-rays showed left lateral end of clavicle fracture and scapula body fracture (Fig. 1). Computed Tomography (CT) scan revealed fracture involving lateral end of left clavicle, left body of the scapula (Fig. 2), linear fracture of left first to ninth ribs and right first to fifth ribs (posterior aspect) (Fig. 3). A linear undisplaced fracture of left transverse process of seventh cervical (C7) vertebrae (Fig. 4) and first dorsal (D1) to seventh dorsal (D7) vertebrae was also found (Fig. 5). CT thorax revealed minimal left haemothorax, pneumothorax and right upper lobe apical segment pulmonary contusion (Fig. 6).

Fig. 1.

X-ray image of left lateral end of clavicle and scapula fracture.

Fig. 2.

CT images of left lateral end of clavicle and scapula fracture.

Fig. 3.

An unfurled rib image created from chest CT DICOM data showing bilateral multiple rib fractures.

Fig. 4.

CT images of left C7 transverse process fracture.

Fig. 5.

CT image of left D1 to D7 transverse process fractures.

Fig. 6.

CT thorax image of minimal left haemothorax, pneumothorax and right upper lobe apical segment pulmonary contusion.

Patient was admitted and planned for elective clavicle and scapula fracture stabilization. The patient underwent general anaesthesia, and was placed in beach chair position with a sand bag between the shoulders. By a transverse incision along the lateral end of the clavicle, fracture exposed, reduced and the lateral end of clavicle internal fixation was done with a Titanium locking compression 5 hole hook plate under C-arm guidance (Fig. 7). By lateral decubitus position, scapula fracture was approached by a lazy ‘J’ shaped modified Judet posterolateral incision (Fig. 8). Medial column was fixed with a straight 6 hole Titanium Locking compression plate (LCP) and screws. Fixation of scapula body fracture was done with an anatomical Titanium curved LCP and screws (Fig. 9).

Fig. 7.

Intraoperative image of hook plate.

Fig. 8.

Modified Judet approach for scapula fracture.

Fig. 9.

Intraoperative image with scapula LCPs.

The bilateral rib fractures, left C7 transverse process fracture and dorsal left transverse process fractures from D1 to D7 were managed conservatively. Post operatively patient was on arm sling, deep breath exercises and chest physiotherapy from post-operative day one and pendulum exercise from post-operative day two. Gradual ROM exercise and arm sling was discarded at four weeks. At 3 months she resumed her routine work. At 6 months postoperative, patient had good functional outcome with near normal range of movements. Functional assessment with constant Murlay clinical method of functional assessment of shoulder with a score of 87 (out of 100). Regular X-rays were taken at 4,8,12 and 24 weeks postoperative (Fig. 10).

Fig. 10.

Post-operative X-ray image showing clavicle and scapular implants.

Discussion

Typically ipsilateral clavicle and scapular neck fracture combinations are described as floating shoulder [1], [2], [3]. The combination of ipsilateral lateral end of clavicle fracture and body of scapula is rarely reported. Scapula fractures occur mainly from direct high velocity injury and are associated with injury of thoracic cage. Such patients should therefore be examined carefully for additional or more extensive injuries [4]. Apart from routine X-rays of shoulder and chest, a CT scan of the thoracic cage and cervical spine can diagnose associated injuries of lung, rib and spine.

Our patient on CT had ipsilateral first to ninth rib fracture and contralateral first to fifth rib fracture, ipsilateral haemothorax and pneumothorax and contralateral upper lobe pulmonary contusion. An undisplaced ipsilateral transverse process fractures of C7 vertebra and D1 to D7 vertebrae were also detected.

In most cases, early functional treatment of fracture of the shoulder region gives good to excellent results. Some authors recommend surgical intervention in all circumstances [1]. Internal fixation of the clavicle fracture is recommended to prevent late deformity [1]. Lantry et al [5] claims fixation of clavicle and scapula for better outcome. Earlier initiation of mobilization and physiotherapy is one of the main advantage of surgical management.

In our case, the lateral end of clavicle and scapula fractures stabilized by single stage internal fixation. Multiple rib fractures, cervical, dorsal spine transverse process fractures and lung injury were managed conservatively. Chest physiotherapy and early lung expansion will be effective after surgical stabilization of shoulder fractures. Early shoulder mobilization and rehabilitation lead to patient's faster recovery.

Conclusion

In floating shoulder associated with multiple rib fractures, cervical and dorsal spine fractures and lung injury, surgery allows for early motion and effective rehabilitation. Early functional recovery of lung and thoracic cage fractures can be achieved with appropriate and adequate shoulder griddle fracture stabilization. A CT scan of thorax and spine is highly recommended in high velocity shoulder injuries to detect lung parenchymal injury, rib fracture and spinal fractures which can be missed in X-rays, all of which will affect the functional outcome.

Clinical message

This case report highlights on the rare combination of shoulder girdle, thoracic cage and cervical dorsal spine injuries. CT scan is useful to diagnose such high velocity injury. A single stage surgical procedure stabilization of clavicle and scapula is effective. It also signifies the importance of the shoulder girdle surgical stabilization and physiotherapy for effective early functional recovery of the shoulder and thoracic cage injuries.

CRediT authorship contribution statement

B. Ananda kirouchenane: Conceptualization, Data curation, Formal analysis, Investigation, Methodology. P. Bindhya: Conceptualization, Data curation, Formal analysis, Investigation, Methodology. A.B. Gopalamurugan: Data curation, Formal analysis, Conceptualization, Investigation, Methodology. A.B. Chitra: Conceptualization, Data curation, Formal analysis, Investigation, Methodology. N. Suresh Babu: Data curation, Conceptualization, Formal analysis, Investigation, Methodology.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.