Background/Purpose: Due to their association with high-energy mechanisms, scapula fractures are often characterized by complex fracture patterns of the shoulder girdle and, more specifically, the superior shoulder suspensory complex (SSSC) in approximately 30% of cases. The SSSC is made up of an osseoligamentous support that helps to suspend and orient the glenohumeral joint. Goss described the floating shoulder, in which two structures in this complex are broken or torn. Such double disruptions have been used as a criterion in establishing the need for operative stabilization. Most commonly, the two disruptions include the clavicle and scapular neck. Double lesions to the SSSC may be associated with a poorer outcome. To date, no one has described more than two lesions of the SSSC, let alone the frequency of combinations, associated demographics, associated injuries, or outcome. We identified a cohort of patients with triple or quadruple disruptions of the SSSC, and hypothesized that they would have a high rate of concomitant injury and poor outcome resulting from the force needed to produce such a lesion. The purpose of this study is to describe this unusual injury and report their combinations, associated injury rates, and functional outcomes.
Methods: A prospective scapula fracture database was established in 2002 with the approval of the IRB to record the operative and outcome data of patients undergoing open reduction and internal fixation. All patients met published and clearly defined operative criteria. The cohort of all patients, greater than 17 years of age, who had more than two lesions to the SSSC underwent analysis.
Results: 14 patients with greater than 2 disruptions (12 triple and 2 quadruple) were identified. All experienced high-energy mechanisms. The mean age is 33 years (range, 18-60) with 12 males and 2 females. A total of 44 disruptions were identified in the following locations: 13 scapula neck fractures (13 operatively treated), 7 clavicle fractures (3 operative), 6 acromioclavicular separations (5 operative), 9 coracoid (6 operative), and 9 acromion fractures (7 operative). Associated injuries outside the shoulder girdle occurred in 93% (13 of 14). Rib fractures were present in 86% (12 of 14) with a mean of 4.5 ribs fractured (range, 1-10) per patient. A fracture of the spine occurred in 57% (8 of 14) of which 1 had a complete spinal cord and 3 had complete nerve root lesions. Traumatic brain injury was documented in 70%. Additional neurologic lesions were sustained in 86% (12 of 14), with 9 of 14 patients having injury distal to the brachial plexus and the other 5 patients with nerve injury at the level of the brachial plexus. Outcomes were obtained on 13 patients (93%) with a mean follow-up of 30 months (range, 7.5-75 months). Disabilities of the Arm, Shoulder and Hand (DASH) scores averaged 14.2 (range, 0-45). Mean range of motion (ROM) when expressed as the percentage of injured ROM over contralateral ROM was 94% forward flexion, 91% abduction, and 76% external rotation. Mean strength measured by a handheld dynamometer and expressed as the percentage of injured over contralateral was 62% forward flexion, 60% abduction, and 66% external rotation.
Conclusion: Patients who sustain triple and quadruple lesions to the SSSC who undergo operative stabilization of displaced fractures demonstrated satisfactory functional outcomes. Although strength was diminished, this would be expected given the high nerve injury rate. The muscular weakness did not seem to have a large effect on the patients’ DASH scores or ROM given the return to near normal levels. Further studies are needed to compare to matched cohorts of patients with fewer injuries to the SSSC.