The floating shoulder.

The floating shoulder is an uncommon but important injury pattern. Although it is frequently defined as an ipsilateral fracture of the clavicle and scapular neck, recent studies suggest that ligament disruption associated with a scapular neck fracture contributes to the functional equivalent of this injury pattern, with or without an associated clavicle fracture. Determining the specific injury patterns indicates the potential for significant instability, and correlating these patterns with clinical outcome is a challenge. Because the degree of ligament disruption is difficult to assess on radiographs, indications for nonsurgical and surgical management are not well defined. Minimally displaced fractures typically do well with nonsurgical care. However, the degree of fracture displacement and ligament disruption that results in less predictable outcomes after nonsurgical treatment is uncertain, and the indications for surgery can be controversial. Internal fixation of a displaced clavicle fracture restores the contour of the shoulder, regulates soft-tissue tension, and often indirectly reduces the scapular neck fracture. Fixation of both fractures is recommended in certain fracture patterns. Because these controversies cannot be resolved by current evidence, surgeons must choose an individualized approach based on an understanding of the pathoanatomy and personal experience.