most published floating clavicle report a dislocation or fracture of one or both ends of the clavicle .
we reported a new framework of this injury in a young triathlon athlete ; medial - end displaced fracture with co - existent double disruption of the superior shoulder suspensory complex ( sssc ) with the anterior shoulder arch wholly disconnected from the nearby structure .
the infrequent publications and the rarity of this type of injuries do nt support the surgeon about the choice of the best possible treatment .
however , if they are involved patients with high functional demands , the authors suggest the surgical management of medial - end clavicle fractures followed by restoration of sssc complex if damaged on more than two locations .
injuries of the lateral aspect of the shoulder are common . in most cases the force applied to the shoulder girdle
is mild , getting an isolated lesions of the acromion - clavicular joint or of the clavicle .
high - energy hit trauma that laterally impacts the shoulder is less common and usually it is often associated to other major damages ( such as ribs fractures , thoracic injuries , vascular or brachial plexus impairment ) .
it is also reported an unusual type of fracture - dislocation named floating clavicle with dislocation of both ends , or with a sternoclavicular dislocation and fracture of the middle - third or the lateral end of the clavicle [ 1 - 5 ] .
( medial - end displaced clavicle fracture with co - existent double disruption of the sssc ) in young triathlete , as a result of a high - velocity sport fall .
a 33-year - old male triathlon athlete , during a bicycle training fell on his right side , hitting his shoulder on the ground , but with no other trauma associated .
he presented an altered sternoclavicular skin profile with a swollen and bruised area on the lateral surface of his shoulder .
he suffered pain in the sternoclaviular joint and in the shoulder , while the abduction and extension of the upper limb was impossible ( pre - operative dash score : 90.9 ) .
the initial radiographs showed an extrarticular displaced fracture of the medialend of the clavicle ( robinson type 1b.1 ) , acromion ( kuhn type ii ) and coracoid process ( ogawa type i ) fractures .
these bone lesions were also confirmed by a computed tomography ( ct ) scan with 3d reconstruction .
the images showed a displaced comminuted extrarticular medial - end clavicle fracture with anterior dislocation , an undisplaced fracture of the coracoid and acromion processes ( fig .
1 and 2 ) . x - ray of the displaced medial - end clavicle fracture a. ct - scan shows the displaced medial - end clavicle fracture and co - existent double distruption of sssc . on the 3rd post - injury day ,
prior to the fixation of sssc injuries , we treated the clavicle . under general anesthesia , with the patient in beach chair position with mayfield headrest , we performed a skin incision directly on the medial - end of the clavicle , respecting the sternoclavicular joint .
we exposed the displaced fracture and fixed bone fragments with a t - shape plate 2.5 mm with 5 locking screws ( intrauma ) .
after the clavicle fixation , we performed percutaneous acromion fracture fixation with two cancellous bone screws with washer ( asnis , stryker 5 mm x 55 and 60 mm length ) ( fig .
we achieved a good clavicle and acromial fixation , while the coracoid process was satisfactorily stable without any other surgical step .
thus , the day after surgery , he started active and passive movements of the elbow , wrist and hand .
one month post - operatively , the patient underwent x - ray that showed fractures in healing .
the patient started water rehabilitation with isometric shoulder exercise , active and passive abduction , adduction , flexion and extension shoulder movement , wall crawl , and elastic resistance exercise .
he referred no difficulty in performing activities which required little efforts , mild difficulty to performing overhead movements and severe difficulty in performing activities which needed high efforts of the shoulder and the arm ( dash score : 52.3 ) .
the patient recovered full rom of the shoulder without stiffness and reported no pain in performing active movements , mild efforts of the shoulder and during sport activities , such as running and riding a bike , but on the other hand , he reported persisted moderate pain during swimming training ( dash score : 29.5 ) .
the clinical evaluation at the follow up 12 months after the operation showed the patient had recovered full shoulder function ( no limitation if compared with contralateral side ) and was able to perform triathlon races with no pain or limitations ( dash score : 11.4 )
most reports of a floating clavicle comprise of a dislocation of both ends of the clavicle , while other authors document a different clinical presentation : thomas et al.1 ) document a patient with a sternoclavicular dislocation associated to the fracture of the middle - third , while serra et al .  
report an anterior sternoclavicular dislocation with a nondisplaced fracture of the lateral end of the clavicle .
our case is an exceptional injury in that it was the result of a high - velocity fall with a displaced medial - end clavicle fracture and a co - existent double disruption of sssc ( acromion and coracoid processes ) without other major lesions .
usually it is due to a direct trauma with an impact occurred on the lateral side of shoulder and it is of ten associated to other major damages : ribs fractures , thoracic injuries , vascular or brachial plexus impairment [ 2 - 4 ] .
ordinarily a low - energy trauma directed anteriorly may strike only the acromionclavicular joint or clavicle , but if the vector of the force steers posteriorly the acromion , glenoid or scapular spine may be involved . however , high - energy lateral impaction forces can disrupt both the anterior and the posterior arches and usually causes internal lesions[4 , 5 ] . as suggested by scarlat ,
in our case the trauma action began laterally on the shoulder with a vector directed from an external to an internal direction . at the time of the fall
the first one displayed an anterior and superior trend ( antero - superior force : asf ) involving the anterior shoulder arch , thus causing the medial - end clavicle fracture , while the second one took a posterior - inferior direction ( posteror - inferior force : pif ) arousing the acromion , and the base of coracoid process lesions ( co - existent double distruption of sssc ) [ 2 , 5 ] .
the coracoacromial ligament , the acromion - clavicular joint and the connection between coracoid and clavicle ( conoid and trapezoid ligaments ) remained undamaged .
then , the anterior shoulder arch was wholly disconnected from the nearby structure ; in short , it was just floating . to explain the absence of other major lesions and the soft tissue damage , we hypothesized the damping effect played by the lateral shoulder hypertrophic muscles ( deltoid and rotator cuff muscles ) in the young triathlon athlete and secondly the direction and the partition of the trauma forces . furthermore , we hypothesized that that the absence of the ribs fractures was due to the angle of the asf and pif vectors ; they resulted justly tangential to the chest wall , splitting the injury s energy towards the costoclavicular and the scapulothoracic spaces .
the infrequent publications and the rarity of this type of injuries did nt support the surgeon about the choice of the best possible treatment [ 1 , 6 ] .
non - operative treatment has been recommended by many authors for close fractures , though others recommend only clavicular osteosynthesis as a stabilizing procedure ( especially in case of open fractures ) , whereas various papers support a double osteosynthesis of clavicular and scapular fractures , [ 7 , 8 ] .
some authors believe that the stability of the shoulder girdle depends on the integrity of the superior shoulder suspensory complex ( sssc ) .
if sssc is intact and the shoulder girdle is not medially displaced more than 20 mm , a nonsurgical treatment for scapula and all ipsilateral clavicle fractures may be recommended .
however , studies report a worse outcome for patients with sssc double lesion treated with non - surgical management and other authors speak of a better recovery in those who were operated for a lesion of the medial end of the clavicle . in this specific case in order to restore biomechanical function and to ensure the best and fastest recovery of the young triathlon athlete s shoulder it was mandatory to maintain the length of the anterior and the posterior arches .
we chose a stable internal fixation in order to stabilize the displaced medial clavicle fracture and the acromion .
the reason for a surgical management of the clavicle at first was due to avoid possible common sequelae from unstable clavicular fractures , such as nowak et al stated .
we decided not to manage the coracoid process and scapular fractures after evaluating their stability .
although the management of medial - end clavicle fractures is an open debate , most of the authors supports the surgical indication for displaced fractures and in the case of neurovascular compromise ; even in the case of a complete sssc breakage on more than two locations in structures with the ring concept ( such as the pelvis ) some authors agree that it causes instability , and surgical intervention is usually indicated [ 8 - 10 ] . in this paper
we reported a variant type of this injury ( medial - end displaced fracture with co - existent double disruption sssc ) in a young triathlon athlete .
the infrequent publications and the rarity of this type of injuries do nt support the surgeon about the choice of the best possible treatment .
the clinical results described in this case report encourage further studies to draw a standardized surgical approach for the medial clavicle fracture . in case of medial - end clavicle fracture and complete sssc breakage in more than two locations (
the ring concept , such as the pelvis ) the shoulder is unstable and surgical intervention is indicated .
 introduction : most published floating clavicle report a dislocation or fracture of one or both ends of the clavicle.case presentation : we reported a new framework of this injury in a young triathlon athlete ; medial - end displaced fracture with co - existent double disruption of the superior shoulder suspensory complex ( sssc ) with the anterior shoulder arch wholly disconnected from the nearby structure.conclusion:the management of these complex fractures remains an open debate . 
 the infrequent publications and the rarity of this type of injuries do nt support the surgeon about the choice of the best possible treatment . 
 however , if they are involved patients with high functional demands , the authors suggest the surgical management of medial - end clavicle fractures followed by restoration of sssc complex if damaged on more than two locations . 
Introduction:
Case Presentation:
Conclusion:
Introduction
Case Report
Discussion
Conclusion