Combined shoulder girdle injury and floating elbow in a pediatric patient secondary to an unusual domestic mechanism: a case report

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Incluido en la revista Ocronos. Vol. IX. N.º 11–Noviembre 2026.

Pág. Inicial: Vol. IX; N.º 11: 28

Autor principal (primer firmante): Aldo Domingo González Pérez

Fecha recepción: 05/10/2026

Fecha aceptación: 01/11/2026

Ref.: Ocronos. 2026;9(11): 28

https://doi.org/10.58842/FDUA5182

Autores:

• Aldo Domingo González Pérez MD 1; Professional category: 1 – Orthopaedic and Trauma surgery Resident at “Dr. José Eleuterio González” University Hospital, Monterrey, Nuevo León, México.
• Alberto Maldonado Olvera MD 1; Professional category: 1 – Orthopaedic and Trauma surgery Resident at “Dr. José Eleuterio González” University Hospital, Monterrey, Nuevo León, México.
• José Alberto Moreno González MD 2; Professional category: 2 – Attending Orthopaedic and Trauma Surgeon at Department of Orthopedics and Traumatology, “Dr. José Eleuterio González” University Hospital, Monterrey, Nuevo León, México.
• Carlos Alberto Acosta Olivo MD, PhD 2; Professional category: 2 – Attending Orthopaedic and Trauma Surgeon at Department of Orthopedics and Traumatology, “Dr. José Eleuterio González” University Hospital, Monterrey, Nuevo León, México.
• Victor Manuel Peña Martínez MD, PhD 3; Professional category: 3 – Chief of Orthopaedic and Trauma Surgery Department at “Dr. José Eleuterio González” University Hospital, Monterrey, Nuevo León, México.

Abstract

• Introduction: Multiple ipsilateral upper-extremity fractures in the pediatric population are uncommon and are usually associated with high-energy mechanisms. Domestic accidents producing this injury pattern are poorly described in the literature.
• Case presentation: A previously healthy 6-year-old boy presented to the emergency department 20 hours after his right upper extremity was caught in an operating clothes wringer. He sustained ipsilateral fractures of the right clavicle, scapula, humerus, radius, and ulna, with no neurovascular compromise. Closed reduction and fixation with titanium elastic nails (TENS) was performed in the humerus, along with open reduction and internal fixation with TENS nails in the radius and ulna; the clavicle and scapula fractures were managed conservatively. At 6 months of follow-up, satisfactory bone healing and remodeling of all fractures were documented, with progressive improvement of the residual humeral deformity and ongoing functional recovery.
• Conclusion: Elastic intramedullary nail fixation for multiple diaphyseal fractures of the pediatric upper limb allows adequate bone healing and functional recovery, even in extensive injury patterns resulting from unusual domestic mechanisms.

Keywords: multiple fractures, TENS, pediatric, upper extremity, domestic trauma, case report.

Introduction

Upper-extremity fractures are among the most common orthopedic injuries in the pediatric population; however, most occur in isolation and affect a single anatomical segment. The simultaneous combination of ipsilateral injuries to the shoulder girdle, humerus, and forearm —including the so-called “floating elbow”— represents an infrequent injury pattern, generally associated with high-energy mechanisms, and is exceptional and scarcely reported in the literature, particularly when it results from domestic mechanisms. ¹⁻ ⁵ In this context, elastic stable intramedullary nailing (Titanium Elastic Nailing System, TENS) has become established as an effective alternative for the treatment of unstable diaphyseal fractures in pediatric patients, while clavicle and scapula fractures are usually managed conservatively given their high potential for bone healing and remodeling. ⁶⁻ ⁹ We therefore present the case of a pediatric patient with ipsilateral fractures of the clavicle, scapula, humerus, radius, and ulna secondary to entrapment of the upper extremity in a centrifugal clothes wringer, treated with a hybrid strategy of surgical and conservative management, with adequate clinical and radiographic evolution at six months of follow-up.

Case presentation

A 6-year-old male patient with no reported personal pathological, family, or surgical history, who lives at home with his parents and 2 siblings, his mother being his primary caregiver. The patient was brought to the emergency department on November 3, 2025 by his mother, who reported that approximately 20 hours before evaluation the patient had accidentally introduced his right upper extremity into an operating centrifugal clothes wringer.

On arrival he was alert and stable; the patient reported severe pain throughout the right upper extremity, from the scapular and clavicular region to the hand. Physical examination revealed marked edema of the right upper extremity with global functional limitation. Deformity and crepitus were also identified at the level of the right clavicle, arm, and forearm. Neurovascular examination showed adequate distal perfusion with intact motor and sensory function at the time of evaluation.

Radiographic studies of the right shoulder, arm, forearm, and hand were obtained, identifying a fracture of the middle third of the right clavicle, a fracture of the body of the right scapula, a diaphyseal fracture of the right humerus, a segmental fracture of the right ulna, and a diaphyseal fracture of the right radius; hand injuries and any joint involvement were ruled out. The clinical history and the mechanism reported by the family were consistent with the clinical and radiographic findings, with no data suggestive of child abuse identified.

Initial immobilization was performed with a long posterior splint and a sling, and the patient was admitted for definitive management. Four days after admission, closed reduction and internal fixation with elastic intramedullary nails (TENS) was performed in the right humerus, along with open reduction and internal fixation with TENS nails in the right radius and ulna. Given the characteristics of the clavicle and scapular body fractures, as well as the high potential for bone healing expected for the patient’s age, these injuries were managed conservatively with sling immobilization. The surgical procedure was uneventful, with no intraoperative complications.

During the immediate postoperative period the patient remained neurologically and vascularly intact, with significant improvement in pain during the first 24 hours after the procedure. At the two-week follow-up visit, the patient remained neurologically and vascularly intact, with only mild pain during mobilization of the right shoulder and elbow. The surgical wounds showed adequate healing, so the sutures and immobilization splint were removed, and an early rehabilitation program was started.

At three months of follow-up, bone healing of all fractures was documented. Clinically, the patient had full active mobility of the right shoulder without pain at the clavicular or scapular level. Elbow mobility showed active flexion of 80°, active extension of -10°, and active pronation-supination of 45°. Radiographically, fracture healing was observed, with persistence of a residual humeral deformity of approximately 12° of valgus and 6° of recurvatum.

At the six-month evaluation, healing and remodeling of all fractures were observed. The patient had full mobility of the right shoulder, while elbow mobility had improved to active flexion of 100°, full extension, and active pronation-supination of 60°. Radiographically, remodeling of the right humerus was evident, with a decrease in residual deformity to approximately 3° of valgus. The patient is currently continuing his rehabilitation program. On complete assessment, good adherence to follow-up visits was noted, with the family reporting gradual improvement in pain and in the range of motion observed by the patient’s parents, as well as an unrestricted return to activities of daily living.

Discussion

Multiple ipsilateral upper-extremity fractures in pediatric patients are uncommon injuries and are usually related to high-energy mechanisms. ^1–4 The classic pattern described as “floating elbow” corresponds to the association of ipsilateral arm and forearm fractures, producing a functional dissociation of the elbow from the rest of the extremity. ^1,2 Although our patient did not present the classic definition of floating elbow described by Stanitski and Micheli, he did develop an injury pattern with similar biomechanical characteristics, with coexisting ipsilateral fractures of the humerus, radius, and ulna associated with additional shoulder-girdle injuries. This combination represents an even less frequent presentation than those typically described in the literature. ^1,2

Stanitski and Micheli reported that these injuries require careful evaluation due to the risk of loss of alignment and complications derived from segmental instability. ¹ Subsequently, Templeton and Graham emphasized that the coexistence of arm and forearm fractures produces a significant biomechanical disturbance that justifies early stabilization strategies. ² Similarly, our patient presented a displaced diaphyseal humeral fracture associated with diaphyseal radius fractures and a segmental ulna fracture, a situation that prompted surgical stabilization of the most unstable segments with the aim of restoring the structural continuity of the upper limb and facilitating early rehabilitation. ^11,12

Contemporary literature indicates that floating-elbow-type injuries are associated with greater soft-tissue edema, risk of loss of reduction, and potential development of compartment syndrome. ^3,4,19 Fortunately, none of these events occurred in our patient, who maintained neurovascular integrity throughout his course and did not develop complications related to treatment or to the osteosynthesis material used. ^17,18

Regarding the surgical technique used, Gordon and Garg describe elastic intramedullary fixation as an effective option for selected pediatric diaphyseal fractures, as it provides adequate stability with minimal biological aggression. ⁶ Likewise, Fernández et al. reported excellent functional and radiographic outcomes in unstable radius and ulna fractures treated with elastic intramedullary nailing, with high union rates and a low incidence of complications. ⁹ Similarly, Marengo et al. documented satisfactory healing and favorable functional recovery in humeral diaphyseal fractures treated with TENS. ¹⁰ The results observed in our patient are consistent with these reports, as healing of all fractures was achieved without complications and with progressive functional recovery during follow-up.

In contrast, the clavicle and scapular body fractures were managed conservatively. This decision was based on the recommendations described by Rockwood, which establish that most pediatric clavicle fractures have excellent potential for healing and remodeling, with surgical treatment reserved for exceptional situations. ^8,13,14 Likewise, fractures of the scapular body are usually treated non-surgically due to the inherent stability of the shoulder girdle and the good functional outcomes reported. ^8,15,16 Our case is consistent with these observations, as both fractures healed satisfactorily without requiring additional surgical intervention.

Another relevant aspect concerns the possibility of non-accidental trauma. Bullock et al. reported that certain fractures, particularly those located in the shoulder girdle, may be associated with child abuse and should prompt a comprehensive assessment of the clinical context. ^7,20 In our patient, the clinical history, the injury mechanism reported by the family, and the multidisciplinary assessment were consistent with a domestic accident, with no findings suggestive of child abuse identified.

Finally, follow-up at six months demonstrated satisfactory healing and remodeling of all fractures, including those managed conservatively. A particularly relevant finding was the progressive remodeling of the residual humeral deformity, which decreased from 12° of valgus at three months to 3° of valgus at six months. This behavior confirms the substantial bone remodeling potential present in pediatric patients and supports the selective stabilization strategy used in our case. The combination of elastic intramedullary fixation in the unstable segments and conservative treatment of the shoulder-girdle injuries allowed restoration of the biomechanical continuity of the upper limb, with adequate clinical and radiographic evolution, constituting an effective therapeutic alternative for this type of complex injury.

To our knowledge, we did not identify previous reports describing this injury pattern secondary to a domestic accident in a pediatric patient, which highlights the clinical and academic interest of the present case. The main lesson of this case is that the combination of elastic intramedullary fixation of unstable diaphyseal segments together with selective conservative treatment of shoulder-girdle injuries constitutes a safe and effective strategy for achieving bone healing and functional recovery in complex injury patterns of the pediatric upper limb.

Limitations

The main limitation of this report is its single-case nature and the follow-up period, which means the results cannot be extrapolated to all patients with similar injury patterns. Nevertheless, the clinical and radiographic evolution observed provides useful information on the management of extensive upper-extremity injuries in the pediatric population.

Patient and family perspective

When interviewed at the last follow-up visit, the parents reported being satisfied with the care provided from arrival at the emergency department through hospital discharge, as well as throughout all outpatient follow-up visits. Regarding recovery, the parents reported perceiving substantial gradual improvement in both pain and functionality, evidenced by the patient’s unrestricted return to daily activities.

Conclusions

Elastic intramedullary nail fixation for multiple diaphyseal fractures of the pediatric upper limb allows adequate bone healing and functional recovery, even in extensive injury patterns resulting from unusual domestic mechanisms.

Ethical considerations

Informed consent was obtained from the parents for publication of the clinical case and the corresponding images. The patient’s identity was preserved at all times.

Bibliography

1. Stanitski CL, Micheli LJ. Simultaneous ipsilateral fractures of the arm and forearm in children. Clin Orthop Relat Res. 1980;(153):218-222.
2. Templeton PA, Graham HK. The floating elbow in children: simultaneous supracondylar fractures of the humerus and of the forearm in the same upper limb. J Bone Joint Surg Br. 1995;77(5):791-796.
3. Harrington P, Sharif I, Fogarty EE, Dowling FE, Moore DP. Management of the floating elbow injury in children. Arch Orthop Trauma Surg. 2000;120(3-4):205-208.
4. Baghdadi S, Shore BJ, et al. Pediatric floating elbow injuries are not as problematic as they were once thought to be: a systematic review. J Pediatr Orthop. 2020;40(8):380-386.
5. Illingworth KD, Meisel E, Skaggs DL. The pediatric floating elbow. Oper Tech Orthop. 2018;28(1):1-6.
6. Gordon JE, Garg S. Pediatric humerus fractures: indications and technique for flexible titanium intramedullary nailing. J Pediatr Orthop. 2010;30(Suppl 2):S73-S76.
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11. Blumberg TJ, Bremjit P, Bompadre V, Steinman S. Forearm fixation is not necessary in the treatment of pediatric floating elbow. J Pediatr Orthop. 2018;38(2):82-87.
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13. O’Neill BJ, Molloy AP, Curtin W. Conservative management of paediatric clavicle fractures. Int J Pediatr. 2011;2011:172571.
14. Markes AR, Garcia-Lopez E, Halvorson RT, Swarup I. Management of displaced midshaft clavicle fractures in pediatrics and adolescents: operative vs nonoperative treatment. Orthop Res Rev. 2022;14:373-381.
15. Bartoníček J, Naňka O. History of diagnostics and treatment of scapular fractures in children and adolescents and its clinical importance. Arch Orthop Trauma Surg. 2022;142(6):1067-1074.
16. Naňka O, Bartoníček J, Havránek P. Diagnosis and treatment of scapular fractures in children and adolescents. JBJS Rev. 2022;10(2):e21.00132.
17. Nisar A, Bhosale A, Madan SS, Flowers MJ, Fernandes JA, Jones S. Complications of elastic stable intramedullary nailing for treating paediatric long bone fractures. J Orthop. 2013;10(1):17-24.
18. Cumming D, Mfula N, Jones JWM. Paediatric forearm fractures: the increasing use of elastic stable intra-medullary nails. Int Orthop. 2008;32(3):421-423.
19. Pallan TG, Elkins JT, Dunham AM, Jauregui JJ, Abzug JM. Compartment syndrome of the pediatric upper extremity: current concepts. Children (Basel). 2025;12(12):1696.
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Figures and tables

Table 1. Clinical case timeline

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Figure 1. Initial radiographs

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Figure 2. Postoperative radiographs

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Figure 3. Radiographs at 3 months of follow-up

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Figure 4. Radiographs at 6 months of follow-up

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Anexos: PDF

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