The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 82, Issue 6

Articles | June 01, 2000

Nonoperative Treatment of Ipsilateral Fractures of the Scapula and Clavicle*

Scott G. Edwards, M.D.†; A. Paige Whittle, M.D.†; George W. WoodII, M.D.†

Investigation performed at the Department of Orthopaedic Surgery, University of Tennessee-Campbell Clinic, Memphis, Tennessee
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
†Campbell Foundation, 910 Madison Avenue, Suite 500, Memphis, Tennessee 38103.

J Bone Joint Surg Am, 2000 Jun 01;82(6):774-774

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Abstract

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.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | References

The term floating shoulder has been used to describe a variety of injuries, including ipsilateral fractures through the scapula, clavicle, and humerus, but most often it refers to unstable ipsilateral fractures of the clavicle and the scapular neck. Goss⁷ provided the most recent and useful definition of a floating shoulder injury: a double disruption of the superior shoulder suspensatory complex. The superior shoulder suspensatory complex is an osseous and soft-tissue ring supported by superior and inferior osseous struts. The ring is composed of the glenoid process, the coracoid process, the coracoclavicular ligament, the distal part of the clavicle, the acromioclavicular joint, and the acromial process. The superior strut is the middle part of the clavicle, and the inferior strut is the lateral part of the scapular body and the scapular spine.

Internal fixation of one or both bones is currently the recommended treatment for ipsilateral fractures of the clavicle and scapula^{1-3,5,8-10,12,13,15,17,18}. Nonoperative treatment has been used less frequently because of perceived risks of abduction weakness, decreased range of motion, chronic pain, malunion, and nonunion^1,6-9. However, we are not aware of any published data documenting the prevalence of these complications. There have been only a few small series in which fair-to-excellent results have been reported after operative fixation^9,12,15, but no nonoperative controls were included in those series. The purpose of the present retrospective study was to analyze the functional and radiographic results of nonoperative treatment of ipsilateral fractures of the clavicle and scapula.

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Fig. 1-A:: Figs. 1-A, 1-B, and 1-C: Case 5, a patient who had segmental bone loss from an open gunshot wound.
Figs. 1-A and 1-B: Computed tomography scan and anteroposterior radiograph made at the time of the injury.

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Fig. 1-B::

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Fig. 1-C:: Radiograph made at ten months after the injury. The patient had good function despite a clavicular nonunion.

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Fig. 2-A:: Figs. 2-A and 2-B: Photographs showing the clinical appearance of two shoulders after fracture-healing.
Fig. 2-A: Case 14, a sixty-year-old man with a substantial deformity that was of no concern to him.

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Fig. 2-B:: Case 19, a nineteen-year-old man who perceived the deformity to be worse than it was judged to be by the physician. The patient rated the appearance of the shoulder as his primary concern.

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Fig. 3:: Drawings showing a stable fracture of the scapular neck (A) and a fracture of the scapular neck with a fracture of the clavicle and disruption of the coracoclavicular ligament, which renders the scapular fracture unstable (B). (Reprinted, with permission, from: Butters, K. P.: The scapula. In The Shoulder, edited by C. A. Rockwood, Jr., and F. A. Matsen, III. Ed. 2, vol. 1, p. 404. Philadelphia, W. B. Saunders, 1998.)

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Fig. 4-A:: Figs. 4-A and 4-B. Case 12.
Fig. 4-A: Radiograph showing severely displaced fractures of the clavicle and scapula.

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Fig. 4-B: Radiograph made at one year after the injury, showing union of the fractures. The patient was free of pain and had excellent function.

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TABLE I: Data on the Patients

*IA = intra-articular, SB = superior part of scapular body, IB = inferior part of scapular body, LB = lateral part of scapular body, and SN = scapular neck.†The Constant scores are age-adjusted.

Case	Age at Injury (yrs.)	Location (Displacement) of Fracture*		Score			Range of Motion	Pain	Complaint About Appearance	Main Complaint	Overall Satisfaction
Clavicle	Scapula	Herscovici⁹	Rowe¹⁶	Constant†⁴
1	16	Distal (<2 mm)	IB + LB (<5 mm)	16	100	98	Full	None	No	None	Pleased
2	56	Distal (<2 mm)	SN (<5 mm)	16	100	90	Full	Mod.	No	Pain	Dissatis.
3	41	Distal (10 mm)	SN (<5 mm)	16	100	99	Full	None	No	None	Pleased
4	86	Distal (20 mm, comminuted)	IA (7 mm)	14	95	104	Full	Mild	No	Pain	Satis.
5	26	Distal (30 mm, segmental bone loss)	SN + IA + SB + IB (<5 mm)	11	80	80	Full	Severe	Yes	Depression	Unhappy
6	40	Distal + IA (15 mm)	SB + IB + LB (<5 mm)	12	70	78	20° loss of abduct.	Mod.	No	None	Dissatis.
7	18	Distal + IA (25 mm)	SB + IB + LB (<5 mm)	16	100	98	Full	None	No	None	Pleased
8	39	Middle (<2 mm)	IA + SB + IB + LB (<5 mm)	15	100	100	Full	None	No	None	Satis.
9	82	Middle (<2 mm)	SN + LB (<5 mm)	15	95	112	Full	None	Yes	Appearance	Satis.
10	46	Middle (<2 mm)	SN + LB (<5 mm)	10	90	69	Full	Mod.	No	Pain	Satis.
11	44	Middle (<2 mm)	SN + SB (<5 mm, 20°)	16	100	108	Full	Mod.	No	Pain	Satis.
12	32	Middle (10 mm)	SN + IA + IB (10 mm, 20°)	16	100	108	Full	None	No	None	Pleased
13	28	Middle (15 mm)	SN + SB (45°)	16	100	102	Full	None	No	None	Pleased
14	60	Middle (20 mm)	SN + SB (10 mm, 20°)	16	100	120	Full	None	No	None	Pleased
15	25	Middle (20 mm)	SN + LB (<5 mm)	14	90	102	15° loss of flexion	Mild	No	None	Satis.
16	16	Middle (20 mm)	SN + IA + LB (30 mm, comminuted)	16	100	100	Full	None	No	None	Pleased
17	53	Middle (<2 mm)	SN + LB (<5 mm)	13	90	90	Full	Mild	No	None	Satis.
18	24	Proximal (<2 mm)	SN + LB (<5 mm)	13	90	72	Full	Mild	No	Weakness	Dissatis.
19	19	Proximal (<2 mm)	SN + IA (<5 mm)	16	95	100	Full	None	Yes	Appearance	Pleased
20	48	Proximal (10 mm)	SN + SB (20 mm, 45°)	14	95	98	Full	Mild	No	None	Pleased

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TABLE I: Data on the Patients

*IA = intra-articular, SB = superior part of scapular body, IB = inferior part of scapular body, LB = lateral part of scapular body, and SN = scapular neck.†The Constant scores are age-adjusted.

Case	Age at Injury (yrs.)	Location (Displacement) of Fracture*		Score			Range of Motion	Pain	Complaint About Appearance	Main Complaint	Overall Satisfaction
Clavicle	Scapula	Herscovici⁹	Rowe¹⁶	Constant†⁴
1	16	Distal (<2 mm)	IB + LB (<5 mm)	16	100	98	Full	None	No	None	Pleased
2	56	Distal (<2 mm)	SN (<5 mm)	16	100	90	Full	Mod.	No	Pain	Dissatis.
3	41	Distal (10 mm)	SN (<5 mm)	16	100	99	Full	None	No	None	Pleased
4	86	Distal (20 mm, comminuted)	IA (7 mm)	14	95	104	Full	Mild	No	Pain	Satis.
5	26	Distal (30 mm, segmental bone loss)	SN + IA + SB + IB (<5 mm)	11	80	80	Full	Severe	Yes	Depression	Unhappy
6	40	Distal + IA (15 mm)	SB + IB + LB (<5 mm)	12	70	78	20° loss of abduct.	Mod.	No	None	Dissatis.
7	18	Distal + IA (25 mm)	SB + IB + LB (<5 mm)	16	100	98	Full	None	No	None	Pleased
8	39	Middle (<2 mm)	IA + SB + IB + LB (<5 mm)	15	100	100	Full	None	No	None	Satis.
9	82	Middle (<2 mm)	SN + LB (<5 mm)	15	95	112	Full	None	Yes	Appearance	Satis.
10	46	Middle (<2 mm)	SN + LB (<5 mm)	10	90	69	Full	Mod.	No	Pain	Satis.
11	44	Middle (<2 mm)	SN + SB (<5 mm, 20°)	16	100	108	Full	Mod.	No	Pain	Satis.
12	32	Middle (10 mm)	SN + IA + IB (10 mm, 20°)	16	100	108	Full	None	No	None	Pleased
13	28	Middle (15 mm)	SN + SB (45°)	16	100	102	Full	None	No	None	Pleased
14	60	Middle (20 mm)	SN + SB (10 mm, 20°)	16	100	120	Full	None	No	None	Pleased
15	25	Middle (20 mm)	SN + LB (<5 mm)	14	90	102	15° loss of flexion	Mild	No	None	Satis.
16	16	Middle (20 mm)	SN + IA + LB (30 mm, comminuted)	16	100	100	Full	None	No	None	Pleased
17	53	Middle (<2 mm)	SN + LB (<5 mm)	13	90	90	Full	Mild	No	None	Satis.
18	24	Proximal (<2 mm)	SN + LB (<5 mm)	13	90	72	Full	Mild	No	Weakness	Dissatis.
19	19	Proximal (<2 mm)	SN + IA (<5 mm)	16	95	100	Full	None	Yes	Appearance	Pleased
20	48	Proximal (10 mm)	SN + SB (20 mm, 45°)	14	95	98	Full	Mild	No	None	Pleased

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Thirty-six consecutive patients with a floating shoulder injury were treated at the Regional Medical Center in Memphis, Tennessee, between 1992 and 1996. Patients were excluded if they (1) had died in the hospital secondary to associated injuries (five patients), (2) had sustained a severe head injury that prevented cooperation with physical therapy for more than three months after the injury (four patients), (3) had been lost to follow-up (five patients), or (4) had had an associated ipsilateral proximal humeral fracture that required operative treatment (two patients). Of the remaining twenty patients, who were included in the study, eleven sustained the injury in an automobile accident; two, in a motorcycle accident; three, when they were struck by an automobile as a pedestrian; two, as a result of a gunshot; one, in a fall; and one, as a crush injury.

All fracture patterns consisted of an osseous double disruption of the superior shoulder suspensatory complex, as described by Goss⁷. The ages of the patients ranged from sixteen to eighty-six years and averaged forty years. Eleven dominant and nine nondominant upper extremities were affected. Eighteen injuries were closed, and two were secondary to a gunshot wound. The location of the clavicular fracture was distal in seven patients (including two with intra-articular extension), middle in ten, and proximal in three. Eleven clavicular fractures were displaced ten millimeters or more as measured on the initial radiographs. Of the twenty scapular fractures, two were through the scapular neck only and thirteen involved the scapular neck and some portion of the body. Four of the remaining five scapular fractures not involving the scapular neck were located in the lateral aspect of the body. There was one isolated intra-articular glenoid fracture. Five scapular fractures were displaced more than five millimeters as measured on the initial radiographs (Table I).

All fractures were treated, for comfort, with either a sling or a shoulder immobilizer; the choice was largely arbitrary. All patients were weaned from any form of immobilization over a period of three to eight weeks. Early physical therapy was begun as soon as associated injuries allowed, with the period between the injury and the therapy ranging from three days to two weeks. The therapy protocol was initiated with pendulum exercises and progressed as tolerated to passive and active-assisted and active range-of-motion exercises of the shoulder, elbow, wrist, and hand. Resistance exercises were delayed until there was early radiographic evidence of healing.

At an average of twenty-eight months (range, nine to seventy-nine months) postoperatively, the patients were examined by the senior author (S. G. E.), specifically for the purpose of this study, with the scoring systems of Herscovici et al.⁹, Rowe¹⁶, and Constant and Murley⁴. The Herscovici system combines a subjective assessment of pain and lifestyle adjustment with objective measurements of strength and range of motion. The Rowe system represents one of the earliest attempts at standardizing the evaluation of shoulder function. With this system, which was originally designed to evaluate the results of Bankart repairs, stability of the joint is weighted heavily but motion and overall subjective function are also considered. The Constant system scores range of motion, strength, activities of daily living, and pain, all of which are factors reported to be affected by a floating shoulder injury.

Shoulder abduction and flexion were measured, and abduction strength was evaluated with use of two clinical methods. With the first method, the examiner compared the injured side with the uninjured side by providing resistance with both of the patient's shoulders in 90 degrees of abduction. If both shoulders demonstrated complete symmetry of abduction strength, a score of 5 was given. If any asymmetry was detected, a score of 4 was given. With the second method, the patient was asked to hold progressively increasing weight with the shoulder in 90 degrees of abduction. The heaviest weight that the patient could hold was recorded.

Anteroposterior, scapular Y, and axillary lateral radiographs were assessed for fracture-healing and alignment. Photographs of all patients were used to assess residual deformity and the cosmetic result.

The patients also were questioned about pain, their perception of the appearance of the extremity, and their overall satisfaction with the outcome. Pain, which was graded according to the patient's ability to tolerate activity, was considered mild if it occurred only during strenuous activity (such as lifting weights and strenuous outdoor labor), moderate if it occurred during most activities (such as housework, driving an automobile, and carrying groceries), and severe if it occurred during light activities of daily living (such as brushing teeth and combing hair) or rest. Overall satisfaction was determined by whether the patient was pleased, satisfied, dissatisfied, or unhappy with the outcome.

Results

Introduction | Materials and Methods | Results | Discussion | References

Nineteen of the twenty pairs of fractures had united uneventfully by one year. One clavicular nonunion occurred secondary to segmental bone loss from a gunshot wound (Fig. 1-A, Fig. 1-B, and Fig. 1-C). No further treatment was necessary for this patient, who had satisfactory function. At the final evaluation, none of the fractures were found to have displaced compared with the alignment at the initial presentation.

On the basis of the Herscovici rating system⁹, seventeen patients had an excellent result and three had a good result (Table I). According to the Rowe assessment method¹⁶, eighteen had an excellent result, one had a good result, and one had a fair result. The average Rowe score was 95, and the average Constant score was 96. All twenty patients had strength of the injured extremity that was equal to that of the uninjured extremity. Eighteen patients had a full, symmetrical range of shoulder motion. One patient lost 20 degrees of shoulder abduction, and one lost 15 degrees of flexion. Both of these patients had a scapular fracture that was displaced less than five millimeters but a clavicular fracture that was displaced more than ten millimeters.

Ten patients reported no pain in the affected shoulder, five had mild pain, four had moderate pain, and one had severe pain. When asked to identify one primary complaint about the result, four patients mentioned pain; two, appearance; one, weakness; and one, depression caused by the injury. The remaining twelve had no complaints. The examiner (S. G. E.) noted asymmetry between the shoulders in eight patients; however, six of these patients failed to notice or were not bothered by the deformity (Fig. 2-A). Two patients complained about a deformity that was not apparent to the examiner (Fig. 2-B). When questioned specifically about the appearance of the injured shoulder, three stated some dissatisfaction, whereas seventeen either noticed no difference between the injured and uninjured sides or were not bothered by whatever difference was present. Nine patients were pleased with the overall outcome, seven were satisfied, three were dissatisfied, and one was unhappy.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

Before 1970, most floating shoulder injuries were treated nonoperatively. This changed after Ganz and Noesberger⁶ noted that scapular fractures that were associated with an ipsilateral clavicular fracture were displaced more often and more severely than scapular fractures that were not associated with an ipsilateral clavicular fracture. They reasoned that when the stabilizing effect of an intact clavicle was lost, the unopposed muscular forces acting on the scapula resulted in displacement (Fig. 3). Since then, treatment recommendations for all ipsilateral fractures of the clavicle and scapula, regardless of the initial displacement, have focused on some form of internal fixation to reduce the risk of eventual scapular displacement. In other words, all floating shoulders, even if minimally displaced, were considered unstable injuries. A generally held belief was that displacement of the scapular neck would alter the relationship of the glenohumeral joint with the acromion and create a functional imbalance^1,6-9,11. However, this functional imbalance was not quantified or specifically tested, to our knowledge. Nevertheless, a number of authors recommended surgical restoration of the shoulder anatomy, despite reports of frequent intraoperative and postoperative complications^10,12,18. In 1991, Ada and Miller¹ advocated operative management, suggesting that displaced fractures of the scapular neck contribute to weakness of shoulder abduction and subacromial pain. However, they could not make direct correlations between the displaced scapular fractures and the symptoms because the symptoms could not be differentiated from those caused by rotator cuff injury.

In 1993, Goss⁷ described the floating shoulder injury as a double disruption of the superior shoulder suspensatory complex. He warned that these disruptions, regardless of the displacement, could result not only in weakness but also in degenerative arthritis and nonunion. A few attempts have been made to evaluate operative treatment of floating shoulder injuries more thoroughly, but those studies involved small series without nonoperative controls^9,12,15.

Herscovici et al.⁹ reported on seven patients with a high-energy, closed floating shoulder injury that was treated with plate fixation of the clavicle. At an average of forty-eight months, they evaluated the patients with a functional grading system of their own design. All seven of the patients had an excellent result, and no surgical complications were reported. According to this functional grading system, seventeen of our twenty patients had an excellent result and three had a good result.

Leung and Lam¹² reported on fifteen patients in whom a floating shoulder injury was treated with internal fixation of both the scapula and the clavicle. They evaluated the results with the Rowe¹⁶ system, according to which eight patients had an excellent result, six had a good result, and one had a fair result; the average Rowe score was 84. However, seven patients had complications: one had a pneumothorax, one required plate removal because of impingement, and five had pain attributed to irritation by the plate. According to Rowe's criteria, eighteen of our patients had an excellent result, one had a good result, and one had a fair result; the average Rowe score was 95.

Rikli et al.¹⁵ used the system of Constant and Murley⁴ to evaluate twelve patients with a floating shoulder injury that was treated with plate fixation of the clavicle. The scores ranged from 69 to 113, which corresponds to an average of 96 adjusted for age. Complications included one wound infection and one case of adhesive capsulitis that required manipulation under anesthesia. Our twenty patients had a similar range of scores (69 to 120) and the same average score, and since they were treated nonoperatively they had no surgical complications.

Abduction weakness, decreased range of motion, and nonunion are the most frequently mentioned complications of nonoperative treatment, although the prevalences of these complications have not been defined. Ramos et al.¹⁴ reported that, of thirteen patients with nonoperative treatment of ipsilateral fractures of the scapula and clavicle, all had union and twelve had an excellent or good functional result. Nine of the thirteen patients had a full range of shoulder motion, and ten had grade-5 muscle strength. In our series, no patient had a decrease in abduction strength. Eighteen of the twenty patients had a full, symmetrical range of shoulder motion (Fig. 4-A and Fig. 4-B), and the other two patients lost 20 degrees or less of motion. It is unclear whether this loss of motion resulted directly from the injury or from inadequate rehabilitation. There was only one nonunion, a result of segmental bone loss from a gunshot wound. Most (twelve) of the patients had no complaints about either the function or the appearance of the shoulder. Sixteen were at least satisfied with the overall outcome, and almost half stated that they were pleased with the outcome.

Although this series is small and lacks operatively treated patients for comparison, we believe that it offers an effective counterpoint to reports on operative treatment, all of which are of even smaller series and also lack controls. In our series of twenty patients, the results of nonoperative treatment of floating shoulder injuries were as good as or better than those reported after surgical treatment, regardless of the criteria used for evaluation. While this cohort offers a good representation of displaced clavicular fractures, most of the scapular fractures were minimally displaced. Additional studies are needed to investigate the results of nonoperative treatment of floating shoulders with a severely displaced scapular fracture. Five of our patients, however, had severe displacement of both the scapula and the clavicle, and their outcomes were comparable with those of the patients with minimally displaced fractures.

It appears that many floating shoulder injuries are not as unstable as was previously thought and do not require operative fixation. None of the three functional assessments that were used in the present study identified poor outcomes. Thus, it is difficult to identify factors that might predict which fractures will do well with nonoperative treatment and which will have a better result with surgery. Operative treatment may have a role for some floating shoulder injuries, but at this time it is unclear which patients require such treatment. Until these patients can be identified, we believe that nonoperative treatment of floating shoulder injuries, especially those that are minimally displaced (less than five millimeters), is appropriate because good results can be obtained without the risks associated with operative fixation.

References

Introduction | Materials and Methods | Results | Discussion | References

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Butters, K. P.: The scapula. In The Shoulder, edited by C. A. Rockwood, Jr., and F. A. Matsen, III. Ed. 2, vol. 1, pp. 391-427. Philadelphia, W. B. Saunders, 1998.

Constant, C. R.,Murley, A. H. G.. A clinical method of functional assessment of the shoulder. Clin. Orthop.,214: 160-164. 1987;214160 1987 [PubMed]

Crenshaw, A. H., Jr.: Fractures of shoulder girdle, arm, and forearm. In Campbell's Operative Orthopaedics, edited by S. T. Canale. Ed. 9, vol. 3, p. 2282. St. Louis, Mosby-Year Book, 1998.

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

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Kavanagh, B. F., Bradway, J. K.,Cofield, R. H.. Open reduction and internal fixation of displaced intra-articular fractures of the glenoid fossa. J. Bone and Joint Surg.,75-A: 479-484. April 1993;75-A479 1993

Leung, K. S.,Lam, T. P.. Open reduction and internal fixation of ipsilateral fractures of the scapular neck and clavicle. J. Bone and Joint Surg.,75-A: 1015-1018. July 1993;75-A1015 1993

Magerl, F.. Osteosynthesen im Bereich der Schulter. Pertuberkulüre Humerusfrakturen, Skapulahalsfrakturen. Helvetica Chir. Acta,41: 225-232. 1974;41225 1974

Ramos, L., Mencia, R., Alonso, A.,Ferrández, L.. Conservative treatment of ipsilateral fractures of the scapula and clavicle. J. Trauma,42: 239-242. 1997;42239 1997 [PubMed]

Rikli, D., Regazzoni, P.,Renner, N.. The unstable shoulder girdle: early functional treatment utilizing open reduction and internal fixation. J. Orthop. Trauma,9: 93-97. 1995;993 1995 [PubMed]

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Topics

fracture ; asthenia ; clavicle ; range of motion ; scapula ; gunshot wounds ; shoulder region ; clavicle fractures ; scapula fractures ; shoulder injury

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Scott G. Edwards, A. Paige Whittle, George W. WoodII; Nonoperative Treatment of Ipsilateral Fractures of the Scapula and Clavicle*. The Journal of Bone & Joint Surgery. 2000 Jun;82(6):774-774.

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