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Nonoperative Treatment of Ipsilateral Fractures of the Scapula and Clavicle*

Background: Internal fixation of one or both bones is the recommended treatment for floating shoulder injuries (ipsilateral fractures of the scapula and clavicle). Perceived risks of nonoperative treatment include abduction weakness, decreased range of motion, chronic pain, malunion, and nonunion. None of these problems, however, have been confirmed by clinical studies. The purpose of this retrospective study was to analyze the clinical and radiographic results of nonoperative treatment of floating shoulder injuries. Methods: Twenty patients with a floating shoulder injury were treated with either a sling or a shoulder immobilizer. Eleven clavicular fractures were displaced ten millimeters or more, and five scapular fractures were displaced more than five millimeters. Physical therapy was begun three days to two weeks after the injury. Patients were evaluated with three separate scoring systems: those of Herscovici et al., Rowe, and Constant and Murley. Shoulder abduction and flexion were measured, and abduction strength was evaluated by clinical examination and comparison with the uninjured extremity. The duration of follow-up averaged twenty-eight months (range, nine to seventy-nine months). Results: Nineteen of the twenty pairs of fractures united uneventfully. One clavicular nonunion occurred secondary to segmental bone loss from a gunshot wound. On the basis of the Herscovici rating system, seventeen patients had an excellent result and three had a good result. According to the Rowe system, eighteen patients had an excellent result, one had a good result, and one had a fair result. The average Rowe score was 95. The average Constant score was 96. In all twenty patients, the strength of the injured extremity was equal to that of the uninjured extremity. Eighteen patients had a full, symmetrical range of shoulder motion, one lost 15 degrees of flexion, and one lost 20 degrees of abduction. Conclusions: Nonoperative treatment of floating shoulder injuries, especially those with less than five millimeters of fracture displacement, can achieve satisfactory results that are probably equal or superior to those reported after operative treatment, without the risk of operative complications.