JBJS | The Floating Shoulder: Clinical and Functional Results

The Journal of Bone & Joint Surgery, Volume 83, Issue 8

Articles | August 01, 2001

The Floating Shoulder: Clinical and Functional Results

Kenneth A. Egol, MD; Patrick M. Connor, MD; Madhav A. Karunakar, MD; Stephen H. Sims, MD; Michael J. Bosse, MD; James F. Kellam, MD

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Investigation performed at the Carolinas Medical Center, Charlotte, North Carolina
Kenneth A. Egol, MD
Department of Orthopaedic Surgery, NYU-Hospital for Joint Diseases, 89-06 135th Street, Suite 7C, Jamaica, NY 11418

Patrick M. Connor, MD
Stephen H. Sims, MD
Miller Orthopaedic Clinic, 1000 Blythe Boulevard, Charlotte, NC 28203

Madhav A. Karunakar, MD
Department of Orthopaedic Surgery, University of Michigan, 1500 East Medical Center Drive, Taubman Center 2912G, Ann Arbor, MI 48109-0328

Michael J. Bosse, MD
James F. Kellam, MD
Department of Orthopaedic Surgery, Carolinas Medical Center, P.O. Box 32861, MEB 503, Charlotte, NC 28232

In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from a Charlotte-Mecklenburg Health Services Foundation grant. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

The Journal of Bone & Joint Surgery. 2001; 83:1188-1194

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Abstract

Background: Displaced ipsilateral fractures of the clavicle and the glenoid neck are a complex injury pattern that is usually the result of high-energy trauma. The treatment of these injuries is controversial, as good results have been reported with both operative and nonoperative treatment.

Methods: Nineteen patients who had sustained a displaced fracture of the glenoid neck with an ipsilateral clavicular fracture or acromioclavicular separation (floating shoulder) were retrospectively evaluated. The treatment was nonoperative in twelve patients and operative in seven. At the time of final follow-up, standard radiographs were made and all patients were examined by a physical therapist and either a fellowship-trained shoulder surgeon or an orthopaedic traumatologist. In addition, each patient responded to three different validated objective functional outcome measures: the Short Form-36, the American Shoulder and Elbow Surgeons Shoulder Scale, and the Disabilities of the Arm, Shoulder and Hand Questionnaire. Isokinetic strength-testing was performed, and strength in internal and external rotation was compared with that of the uninvolved shoulder. The main outcome measures included fracture-healing, functional outcome, patient satisfaction, and muscular strength.

Results: With regard to range of motion, only the amount of forward flexion was found to be significantly greater in the operatively treated group (p = 0.03). The operatively treated shoulders were found to be weaker in external rotation at 300°/sec and weaker in internal rotation at 180°/sec. When normalized to hand dominance, however, the numbers were too small to identify any significant difference. There was no significant difference between groups with regard to the three functional outcome measures.

Conclusions: Good results may be seen both with and without operative treatment. Therefore, we cannot universally recommend operative treatment for a double disruption of the superior suspensory shoulder complex. Treatment must be individualized for each patient.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | References

The shoulder girdle complex is a functional unit consisting of the scapula, glenohumeral joint, acromioclavicular joint, clavicle, sternoclavicular joint, and their many supporting ligaments. Functionally, the shoulder girdle complex suspends the upper extremity from the thorax. This complex has been referred to as the superior suspensory shoulder complex^1,2. Isolated disruption of part of this complex is generally well tolerated; however, there is controversy about the treatment of double disruptions of the superior suspensory shoulder complex. It has been postulated that, when a clavicular fracture occurs in concert with an unstable and displaced fracture of the scapular neck, the shoulder may lose suspensory support. The weight of the arm and the muscles attached to the humerus act to pull the glenohumeral joint distally and anteromedially³. It has been theorized that a neglected floating shoulder may lead to a foreshortened extremity with muscular weakness and the potential for chronic brachial plexopathy^2,4. Good results have been reported after both operative and nonoperative treatment^3-6. Because there is limited information available, definite conclusions are difficult to make.

The purpose of this study was to examine our experience with patients with a displaced clavicular fracture or acromioclavicular joint separation associated with an ipsilateral scapular neck fracture. We evaluated both the clinical and the functional results of operative and nonoperative treatment.

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Fig. 1-A:: Anteroposterior radiograph of a twenty-six-year-old man who had been involved in a motor-vehicle accident. In addition to a closed head injury, he sustained a displaced fracture of the midpart of the clavicular shaft and a displaced fracture of the glenoid neck (OTA [Orthopaedic Trauma Association] classification⁷, 9A3.2) of the dominant upper extremity.

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Fig. 1-B:: Thirty-six months after nonoperative treatment, there was complete healing of the fractures. The patient had an excellent functional result.

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Fig. 2-A:: Anteroposterior radiograph of a twenty-three-year-old man who had been involved in a motor-vehicle accident shows a double disruption of the superior suspensory shoulder complex of the dominant extremity. There is a displaced fracture of the glenoid neck and an ipsilateral clavicular fracture (OTA [Orthopaedic Trauma Association] classification⁷, 9A3.2).

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Fig. 2-B:: Figs. 2-B and 2-C Radiographs made two years after open reduction and internal fixation of both the glenoid neck and the clavicular fracture demonstrate healing of the fractures. The patient had a good clinical but a fair functional result. He did not return to work.

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Fig. 2-C:: Figs. 2-B and 2-C Radiographs made two years after open reduction and internal fixation of both the glenoid neck and the clavicular fracture demonstrate healing of the fractures. The patient had a good clinical but a fair functional result. He did not return to work.

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TABLE I: Patient Characteristics

*N/A = not applicable.

Parameter	Group I (No Surgery)	Group II (Surgery)
No. of patients	12	?7
Mean age (yr)	39.5	33.6
Cause of injury
Automobile accident	?8	?7
Bicycle accident	?1	?0
Motorcycle accident	?3	?0
Orthopaedic Trauma Association classification⁷
9B3.2, 04D2	?0	?2
9A2.3, 9A1.1	?0	?1
9A3.2	11	?2
9A3.3, 04D2	?0	?1
9B3.3	?0	?1
9A2.3, 04D2	?1	?0
Initial neurologic involvement
None	10	?5
Suprascapular nerve palsy	?0	?1
Brachial plexus palsy	?2	?0
Affected side
Right	?7	?2
Left	?5	?5
Gender
Male	?8	?6
Female	?4	?1
Complications
None	?7	?5
Infraclavicular nerve palsy	?0	?2
Clavicular nonunion	?1	?0
Clavicular bump	?2	?0
Postop. brachial plexus palsy	N/A*	?1
Hand dominance
Left	?0	?0
Right	12	?7

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TABLE I: Patient Characteristics

*N/A = not applicable.

Parameter	Group I (No Surgery)	Group II (Surgery)
No. of patients	12	?7
Mean age (yr)	39.5	33.6
Cause of injury
Automobile accident	?8	?7
Bicycle accident	?1	?0
Motorcycle accident	?3	?0
Orthopaedic Trauma Association classification⁷
9B3.2, 04D2	?0	?2
9A2.3, 9A1.1	?0	?1
9A3.2	11	?2
9A3.3, 04D2	?0	?1
9B3.3	?0	?1
9A2.3, 04D2	?1	?0
Initial neurologic involvement
None	10	?5
Suprascapular nerve palsy	?0	?1
Brachial plexus palsy	?2	?0
Affected side
Right	?7	?2
Left	?5	?5
Gender
Male	?8	?6
Female	?4	?1
Complications
None	?7	?5
Infraclavicular nerve palsy	?0	?2
Clavicular nonunion	?1	?0
Clavicular bump	?2	?0
Postop. brachial plexus palsy	N/A*	?1
Hand dominance
Left	?0	?0
Right	12	?7

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TABLE II: Results*

*OTA = Orthopaedic Trauma Association; DASH = Disabilities of the Arm, Shoulder and Hand Questionnaire; SF-36 = Short Form-36; ASES = American Shoulder and Elbow Surgeons Shoulder Score; MVA = motor-vehicle (automobile) accident; MCA = motorcycle accident; GN = glenoid neck; AC = acromioclavicular disruption; and N/A = not tested.

Case

Mech. of Injury

InitialNeurologic Injury

OTA Classification7

Injury Pattern

DASH

SF-36

ASES

Internal Rotation Strength

External Rotation Strength

Internal Rotation Endurance

External Rotation Endurance

Complications

Health Percep.

Physical Function

Role Limits Physical

Role Limits Emotional

Social Function

Mental Health

Bodily Pain

Vitality

Group I

MVA

None

9A2.3, 04D2

GN, AC

?60

?40

??0

?62.5

?45

?65

Normal

None

MVA

None

9A3.2

GN, clavicle

?81

?50

?66.67

?75

?57.5

?57

Normal

Weak

None

Bicycle

None

9A3.2

GN, clavicle

?42

100

Weak

Normal

None

MCA

None

9A3.2

GN, clavicle

?56

?80

?75

100

?87.5

?67.5

?65

Weak

Normal

Weak

None

MVA

None

9A3.2

GN, clavicle

?34

100

?67

?75

?90

100

Normal

Weak

Normal

Weak

None

MVA

Brachial plexopathy

9A3.2

GN, clavicle

?31

?95

100

??0

?87.5

100

Normal

Weak

Normal

Clavicular nonunion

MVA

None

9A3.2

GN, clavicle

117

?20

?25

??0

?37.5

?22.5

?55

N/A

None

? 8

MCA

None

9A3.2

GN, clavicle

?31

?95

100

Normal

Clavicular bump

MCA

None

9A3.2

GN, clavicle

?35

?55

??0

100

Normal

Weak

Normal

None

MVA

None

9A3.2

GN, clavicle

?50

?40

?50

?33.3

?50

?55

?85

Normal

Clavicular bump

MVA

Brachial plexopathy

9A3.2

GN, clavicle

?64

?80

?25

?33.3

?25

?45

?35

N/A

None

MVA

None

9A3.2

GN, clavicle

?31

100

Normal

None

Mean

?52.7

65.8

?71.3

?60.42

?58.36

?75

72.8

?73.5

55.42

?80.2

Group II

MVA

None

9B3.2, 04D2

GN, AC

?51

?90

100

?67.5

?80

Weak

None

MVA

None

9A2.3, 9A1.1

GN, acromion

?35

100

?67

100

?95

Weak

Normal

Weak

None

MVA

None

9A3.2

GN, clavicle

?63

?10

??0

100

?37.5

?20

?85

Normal

None

MVA

Suprascapular nerve

9A3.3, 04D2

GN, AC

?37

?90

100

?87.5

100

?92

Normal

Weak

None

MVA

None

9A3.2

GN, clavicle

?55

?75

?25

?33.3

?62.5

?22.5

?77

Normal

Weak

Brachial plexopathy, infraclav. nerve injury

MVA

None

9B3.2, 04D2

GN, AC

?31

100

Normal

None

MVA

None

9B3.3

GN, clavicle

?51

?75

100

?75

?77.5

?92

Weak

Normal

Infraclav. nerve injury

Mean

?46.1

77.4

?77.1

?75

?85.8

?80.4

80.6

?69.6

66.4

?88.7

P value

??0.97

?0.24

??0.83

??0.41

??0.15

??0.66

?0.33

??0.93

?0.16

??1

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TABLE II: Results*

Case

Mech. of Injury

InitialNeurologic Injury

OTA Classification7

Injury Pattern

DASH

SF-36

ASES

Internal Rotation Strength

External Rotation Strength

Internal Rotation Endurance

External Rotation Endurance

Complications

Health Percep.

Physical Function

Role Limits Physical

Role Limits Emotional

Social Function

Mental Health

Bodily Pain

Vitality

Group I

MVA

None

9A2.3, 04D2

GN, AC

?60

?40

??0

?62.5

?45

?65

Normal

None

MVA

None

9A3.2

GN, clavicle

?81

?50

?66.67

?75

?57.5

?57

Normal

Weak

None

Bicycle

None

9A3.2

GN, clavicle

?42

100

Weak

Normal

None

MCA

None

9A3.2

GN, clavicle

?56

?80

?75

100

?87.5

?67.5

?65

Weak

Normal

Weak

None

MVA

None

9A3.2

GN, clavicle

?34

100

?67

?75

?90

100

Normal

Weak

Normal

Weak

None

MVA

Brachial plexopathy

9A3.2

GN, clavicle

?31

?95

100

??0

?87.5

100

Normal

Weak

Normal

Clavicular nonunion

MVA

None

9A3.2

GN, clavicle

117

?20

?25

??0

?37.5

?22.5

?55

N/A

None

? 8

MCA

None

9A3.2

GN, clavicle

?31

?95

100

Normal

Clavicular bump

MCA

None

9A3.2

GN, clavicle

?35

?55

??0

100

Normal

Weak

Normal

None

MVA

None

9A3.2

GN, clavicle

?50

?40

?50

?33.3

?50

?55

?85

Normal

Clavicular bump

MVA

Brachial plexopathy

9A3.2

GN, clavicle

?64

?80

?25

?33.3

?25

?45

?35

N/A

None

MVA

None

9A3.2

GN, clavicle

?31

100

Normal

None

Mean

?52.7

65.8

?71.3

?60.42

?58.36

?75

72.8

?73.5

55.42

?80.2

Group II

MVA

None

9B3.2, 04D2

GN, AC

?51

?90

100

?67.5

?80

Weak

None

MVA

None

9A2.3, 9A1.1

GN, acromion

?35

100

?67

100

?95

Weak

Normal

Weak

None

MVA

None

9A3.2

GN, clavicle

?63

?10

??0

100

?37.5

?20

?85

Normal

None

MVA

Suprascapular nerve

9A3.3, 04D2

GN, AC

?37

?90

100

?87.5

100

?92

Normal

Weak

None

MVA

None

9A3.2

GN, clavicle

?55

?75

?25

?33.3

?62.5

?22.5

?77

Normal

Weak

Brachial plexopathy, infraclav. nerve injury

MVA

None

9B3.2, 04D2

GN, AC

?31

100

Normal

None

MVA

None

9B3.3

GN, clavicle

?51

?75

100

?75

?77.5

?92

Weak

Normal

Infraclav. nerve injury

Mean

?46.1

77.4

?77.1

?75

?85.8

?80.4

80.6

?69.6

66.4

?88.7

P value

??0.97

?0.24

??0.83

??0.41

??0.15

??0.66

?0.33

??0.93

?0.16

??1

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Following the approval of our institutional review board/research review committee, twenty-seven consecutive patients who had sustained a glenoid neck fracture and either a clavicular fracture or an injury to the acromioclavicular complex on the ipsilateral side between 1991 and 1998 were identified in our trauma registry. Four patients were excluded from the study because either the clavicular or the glenoid fracture was nondisplaced. A chart review was performed to determine the mechanism of injury, hand dominance, associated injuries, neurologic status, and treatment plan. Fractures were classified according to the Orthopaedic Trauma Association classification system⁷. Of the twenty-three patients whose radiographic findings fit the injury pattern criteria, one had died; one, who had arrived with a score of 3 on the Glasgow Coma Scale⁸, remained in a vegetative state; and two had been lost to follow-up. This left nineteen patients, who formed the basis for this report. Of these nineteen patients, twelve were treated nonoperatively (Group I) and seven were treated with surgical stabilization (Group II). Indications for operative treatment included an associated intra-articular glenoid fracture for four patients and surgeon preference for the rest. All of the patients in Group II were operated on by an orthopaedic traumatologist or a fellowship-trained shoulder surgeon. The operative procedure in each patient consisted of fixation of both the glenoid fracture and the clavicular or acromioclavicular joint injury with plates and screws, with use of standard AO techniques and principles⁹.

All patients were examined by either an orthopaedic traumatologist or a fellowship-trained shoulder surgeon at the time of follow-up. After obtaining the patient’s informed consent, the physician performed a full musculoskeletal and neurologic evaluation of the affected and unaffected extremities. A certified physical therapist performed isokinetic strength-testing of both the involved and the uninvolved shoulder with a calibrated Cybex 6000 isokinetic dynamometer (Cybex, Division of Lumex, Ronkonkoma, New York). The performance of the shoulder in internal and external rotation was measured with use of reciprocal motions of internal and external rotation with the shoulder in slight abduction. Prior to isokinetic testing, all subjects performed a standardized warm-up consisting of five minutes of clockwise movement on an upper-body ergometer (Cybex) at an intensity of 600 kg/min using a 90-rpm angular velocity setting. The subject’s uninvolved extremity was tested first.

The subjects were placed in a standing position with the dynamometer adjusted so that shoulder height was level. They were instructed not to move the trunk or hips to assist with movement of the dynamometer, and any excess movement was cause for repeating the test at the given speed. Subjects were tested at 60°, 180°, and 300°/sec with a one-minute rest interval between sets. The subjects were asked to perform five repetitions twice and then ten repetitions at the respective speeds. Peak torque was the dependent variable that was analyzed for both internal and external rotation.

For the purposes of this study, the results of the Cybex testing were normalized with respect to hand dominance. The results of testing at 60°/sec were considered indicative of strength, and the results of testing at 300°/sec were indicative of endurance. The patients were then grouped according to whether the injury was on the dominant or nondominant side. Weakness of the nondominant extremity was defined as a deficit of >20% compared with the dominant extremity¹⁰. Weakness of the dominant extremity was defined as any deficit compared with the nondominant extremity. Endurance and strength, normalized with respect to hand dominance, were then compared between the operatively treated and nonoperatively treated patients.

The degrees of healing and joint displacement were determined by comparing anteroposterior radiographs made in the plane of the scapula as well as by comparing scapular Y lateral and axillary lateral radiographs with radiographs made at the time of the injury.

In addition, before their follow-up office visit, the patients filled out three separate validated, objective outcome questionnaires: the Short Form-36 (SF-36)¹¹, the American Shoulder and Elbow Surgeons (ASES)¹² Shoulder Scale, and the Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire¹³. During the office visit, all materials were reviewed with the patients to make sure that all responses had been recorded correctly.

Standard statistical methods were employed. Descriptive statistics, including means and standard deviations, or counts and percentages were calculated. The two groups (the patients who did not have surgery and those who had surgery) were compared. The Mann-Whitney U test was used to compare all data. SAS software (SAS Institute, Cary, North Carolina) was used for all analyses. A p value of less than 0.05 was considered significant.

Results

Introduction | Materials and Methods | Results | Discussion | References

Patient characteristics are shown in Table I. Twelve patients were treated nonoperatively (Group I), and seven were treated operatively (Group II). Group I was composed of eight men and four women with a mean age of forty years (range, sixteen to sixty-eight years). Group II consisted of six men and one woman with a mean age of thirty-four years (range, twenty-one to sixty-four years). There were sixteen associated injuries in the twelve patients in Group I, and there were nine associated injuries in five of the seven patients in Group II. There were no significant differences between the two groups in terms of age, mechanism of injury, hand dominance, gender, or duration of follow-up.

Fractures were classified according to the OTA (Orthopaedic Trauma Association) system⁷. In Group I, there were eleven 9A3.2 fractures and one 9A2.3, 04D2 fracture. (Eleven patients had ipsilateral fractures of the glenoid neck and the clavicle, and one had an ipsilateral fracture of the glenoid neck and injury of the acromioclavicular complex.) In Group II, there were two 9A3.2 fractures; two 9B3.2, 04D2 fractures; one 9A2.3, 9A1.1 fracture; one 9A3.3, 04D2 fracture; and one 9B3.3 fracture. (Three had a glenoid neck fracture and acromioclavicular disruption; three had a glenoid neck and clavicular fracture; and one had a glenoid neck and acromial fracture.)

The mean time from the injury to the time of follow-up was fifty-three months (range, twelve to eighty-one months) in Group I and thirty-six months (range, twelve to seventy-eight months) in Group II. There were no significant differences between the two groups with respect to the mean DASH score (52.7 in Group I and 46.1 in Group II), the mean score for the ASES Shoulder Scale (80.2 in Group I and 88.7 in Group II), or any of the eight domains of the SF-36 (Table II).

The mean forward elevation was greater in Group II (176°) than in Group I (153°). This difference was significant, with a p value of 0.03. The mean amount of external rotation and internal rotation was not significantly different between the two groups.

The operatively treated shoulders (Group II) were found to be 35% and 22% weaker in external rotation at 300°/sec (p = 0.02) and in internal rotation at 180°/sec (p = 0.04), respectively. These differences were significant. The results of the muscle strength-testing were then normalized according to hand dominance⁴. Of the five patients whose nondominant side had been treated nonoperatively, none had decreased strength and only one had decreased endurance in internal rotation. Of the five patients who had had the nondominant side treated operatively, one had global weakness with regard to both strength and endurance in both internal and external rotation, two had decreased endurance in external rotation, and one had decreased endurance in both internal and external rotation. All of the patients with nonoperative treatment on the dominant side had decreased strength or endurance, or both (Figs. 1-A and 1-B). Finally, of the two patients whose dominant shoulder had been treated operatively, one had persistent strength deficits in both internal and external rotation (Figs. 2-A, 2-B, and 2-C). The numbers in the groups that had been normalized for hand dominance were too small to yield any significant comparisons (Table II).

Complications in Group II (the operatively treated group) included two persistent infraclavicular nerve palsies. One iatrogenic brachial plexus injury had completely resolved at the time of the latest follow-up. In Group I, there was one asymptomatic clavicular nonunion. In addition, two patients in Group I were dissatisfied with the appearance at the site of the healed clavicular fracture.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

There is controversy with regard to the treatment of displaced double disruptions of the superior suspensory shoulder complex. Several authors have reported small series in which "floating shoulder" was treated operatively^3-5. Leung and Lam⁵ reported on fifteen patients in whom ipsilateral fractures of the scapular neck and the clavicle had been treated with open reduction and internal fixation of both the scapula and the clavicle. They reported a good-to-excellent result in fourteen of the fifteen patients and recommended operative treatment for all patients with this complex injury pattern. However, they had no nonoperative controls.

Herscovici et al.³ reported on nine patients, seven of whom had been treated operatively (with fixation of the clavicle only) and two of whom had been treated nonoperatively. Their good results led them to recommend operative treatment for the floating shoulder; however, they recommended open reduction and internal fixation of the clavicle only.

Rikli et al.⁴ reported on the operative treatment of twelve patients with a double disruption. Eleven of the twelve underwent open reduction and internal fixation of the clavicle alone, whereas one had both the clavicle and the glenoid fixed. Gender and age-adjusted Constant scores averaged 96%. As with the other studies, the authors did not include a control or comparison group.

Ramos et al.⁶ reported good functional outcomes in nineteen patients in whom ipsilateral fractures of the scapula and clavicle had been treated nonoperatively. However, they did not mention the degree of displacement of either fracture.

Biomechanical data have recently defined a role for the coracoacromial and coracoclavicular ligaments in stabilization of scapular neck fractures. Williams et al.¹⁴ showed that the acromioclavicular disruption allows for increased translation of the scapular neck fracture.

Ramsey et al.¹⁵ reported the functional outcomes in nine patients with a floating shoulder. They suggested that the degree of glenoid displacement may be the most important factor. In their study, patients with 25 mm of glenoid medialization had considerably less forward elevation and more pain than patients with <25 mm of medial glenoid displacement.

The importance of the present study is that it is the first report, to our knowledge, comparing the functional and clinical outcomes of operative and nonoperative treatment of floating shoulders. Although the numbers of patients were not large enough to generate many significant results, there were some interesting trends. Better forward flexion of the shoulder was observed in the operatively treated group. On normalized isokinetic strength-testing, good functional results appeared to be achieved with nonoperative management, although nonoperatively treated dominant-sided injuries tended not to fare as well. The weakness in external rotation of the operatively treated shoulders could be related to the surgical approach, in which the teres minor was taken down (in six of the seven patients), or it could be related to nerve injury, which occurred in two of the seven patients.

The recent orthopaedic literature supports operative treatment of floating shoulders with open reduction and internal fixation of both the clavicle and the scapula or of the clavicle alone. These conclusions were based on relatively small series without control groups. It is apparent from the results of the current study that patient satisfaction can be achieved with either operative or nonoperative treatment. The functional outcome of these injuries is better than would be exprected from the radiographic appearance. On the basis of our results, we cannot recommend operative treatment of these complex injuries in all patients. Treatment must be individualized for each patient.

Note: The authors thank Sherry C. Lloyd and Alan Tyson, CPT, for their help in the completion of this project.

References

Introduction | Materials and Methods | Results | Discussion | References

Cuomo F. Shoulder trauma: bone. In: Kasser JR, editor. Orthopaedic knowledge update V. Rosemont, IL: American Academy of Orthopaedic Surgeons; 1996. p 217-32.

Goss TP. Double disruptions of the superior shoulder suspensory complex. J Orthop Trauma,1993;7: 99-106. 799 1993 [PubMed]

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Fig. 1-B:: Thirty-six months after nonoperative treatment, there was complete healing of the fractures. The patient had an excellent functional result.

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TABLE I: Patient Characteristics

*N/A = not applicable.

Parameter	Group I (No Surgery)	Group II (Surgery)
No. of patients	12	?7
Mean age (yr)	39.5	33.6
Cause of injury
Automobile accident	?8	?7
Bicycle accident	?1	?0
Motorcycle accident	?3	?0
Orthopaedic Trauma Association classification⁷
9B3.2, 04D2	?0	?2
9A2.3, 9A1.1	?0	?1
9A3.2	11	?2
9A3.3, 04D2	?0	?1
9B3.3	?0	?1
9A2.3, 04D2	?1	?0
Initial neurologic involvement
None	10	?5
Suprascapular nerve palsy	?0	?1
Brachial plexus palsy	?2	?0
Affected side
Right	?7	?2
Left	?5	?5
Gender
Male	?8	?6
Female	?4	?1
Complications
None	?7	?5
Infraclavicular nerve palsy	?0	?2
Clavicular nonunion	?1	?0
Clavicular bump	?2	?0
Postop. brachial plexus palsy	N/A*	?1
Hand dominance
Left	?0	?0
Right	12	?7

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TABLE I: Patient Characteristics

*N/A = not applicable.

Parameter	Group I (No Surgery)	Group II (Surgery)
No. of patients	12	?7
Mean age (yr)	39.5	33.6
Cause of injury
Automobile accident	?8	?7
Bicycle accident	?1	?0
Motorcycle accident	?3	?0
Orthopaedic Trauma Association classification⁷
9B3.2, 04D2	?0	?2
9A2.3, 9A1.1	?0	?1
9A3.2	11	?2
9A3.3, 04D2	?0	?1
9B3.3	?0	?1
9A2.3, 04D2	?1	?0
Initial neurologic involvement
None	10	?5
Suprascapular nerve palsy	?0	?1
Brachial plexus palsy	?2	?0
Affected side
Right	?7	?2
Left	?5	?5
Gender
Male	?8	?6
Female	?4	?1
Complications
None	?7	?5
Infraclavicular nerve palsy	?0	?2
Clavicular nonunion	?1	?0
Clavicular bump	?2	?0
Postop. brachial plexus palsy	N/A*	?1
Hand dominance
Left	?0	?0
Right	12	?7