Updated: 6/12/2021

Shoulder Periprosthetic Fracture

Review Topic
Videos / Pods
  • summary
    • Shoulder Periprosthetic Fractures are intraoperative or postoperative complications associated with shoulder arthroplasty that can lead to loosening and migration of the prosthesis. 
    • Diagnosis can be made with pain radiographs of the shoulder and humerus. CT scan can help identify loosening of the prosthesis. 
    • Treatment involves ORIF or revision shoulder arthroplasty depending on location of the fracture and stability of the prosthesis. 
  • Epidemiology
    • Incidence
      • 0.6-3% of patients with TSA
    • Demographics
      • typically occurs in patients 50-85 years of age
    • Timing of onset
      • most fractures often occur intraoperative at the time of the original implant
        • consists of 20% of all complications
    • Anatomic location
      • adjacent to the prosthetic stem tip
      • greater tuberosity
        • most commonly occurs during revision total shoulder arthroplasty
    • Risk factors
      • soft tissue contractures
      • osteoporosis
      • endosteal notching
      • aggressive reaming
      • incorrect entry reaming site
        • ideal entry reaming site is 9 mm lateral from anatomic center of rotation
      • use of press fit humeral stems
        • compared to cemented stems
      • revision arthroplasty cases
      • history of instability
      • female sex
      • post-traumatic arthritis
      • increased comorbidity index
      • osteonecrosis
        • corticosteroid-induced > alcohol and post-traumatic
  • Etiology
    • Pathophysiology
      • intraoperative fractures occur most often during revision total shoulder arthroplasty
        • greater exposure required during these procedures
        • increased scarring in the subacromial space and around the rotator cuff
          • increased soft-tissue retraction and greater torque placed on humerus
        • removing previous implant (up to 81% of intraoperative fractures)
          • metaphyseal filling implants -> increased risk of greater tuberosity fractures
            • bone loss from cement removal
            • bone loss from disengagement of the bone-implant interface
          • diaphyseal-engaging stems -> greater tuberosity fractures
            • stress shielding of the metaphysis
          • methods to prevent:
            • clearing soft-tissue from lateral portion of implant
            • use of implant specific removal instruments
            • controlled corticotomy
        • other mechanisms of intraoperative fractures:
          • reaming or broaching (up to 31% of intraoperative fracture)
          • implant trialing or insertion (up to 19% of cases)
          • during exposure (up to 15% of cases)
            • forceful retractor placement
        • primary total shoulder arthroplasty has a lower risk for intraoperative fracture
          • factors associated with primary intraoperative fractures
            • endosteal notching from reaming
            • excessive humeral external rotation during exposure
            • cortical breaching during reaming or broaching
          • especially in ostepenic bone
      • post-operative fractures can occur as a result of a fall or fatigue fracture through a stress riser
        • fall on outstretched hand
          • tip of prosthesis acts as a stress riser
            • most postoperative fractrues as a result occur at or adjacent the tip of the prosthesis stem
        • atraumatic due to prosthetic loosening
          • cortical weakening from implant "rattling" inside medullary canal
      • high risk of nonunion
        • prosthesis disrupts endosteal blood supply impairing fracture revascularization and healing
        • prosthetic stem distracts the two fragments preventing end-to-end healing
    • Associated conditions
      • nonunion
        • osteoporosis
        • RA
        • female sex
        • displacement >2 mm
        • presence of cement at fracture site
  • Classification
      • Wright and Cofield Classification
      • Type A
      • Fracture centered near the tip of the stem and extends proximally
      • Type B
      • Fracture centered near the tip of the stem and extends distally
      • Type C
      • Fracture located distal to the tip of the stem.
  • Presentation
    • History
      • mechanical fall
        • fall on out-stretched hand
      • worsening arm pain
        • present with mechanical loosening of the prosthesis
    • Symptoms
      • common symptoms
        • acute pain in the upper arm
          • prodromal pain maybe present in patients with mechanically loose implants
        • gross deformity
    • Physical exam
      • inspection
        • varus or valgus deformity
        • ecchymosis & swelling
        • shortening of the affected arm
        • diffuse tenderness of the upper arm
      • motion
        • patient may not be able to move affected elbow or shoulder
          • most often due to pain
      • neurovascular
        • examine for radial nerve status
          • high incidence of radial nerve palsy with distal humerus fractures
            • most often neurapraxia and does not require operative management
        • document full neurological and vascular findings
  • Imaging
    • Radiographs
      • orthogonal radiographs of the affected humerus
        • AP, axillary lateral, Grashey, scapular Y views
      • findings
        • fracture involving the prosthetic stem tip
          • usually in an oblique pattern
      • criteria dictating treatment
        • appearance of stem stability
        • zones of lucency around stem
          • suggests lack of bone ingrowth or osteolysis
    • CT
      • indications
        • concern for loose prosthesis
          • fracture pattern on radiographs concerning for mechanical stability of humeral stem
          • prodromal pain consistent with mechanical loosening
        • comminution
      • perform with metal suppression protocol
        • decreased artifact from prosthesis
      • assessment:
        • determine fracture morphology
        • assess remaining bone stock
        • quality of the rotator cuff muscle
        • version of the glenoid if revision is determined necessary
  • Treatments
    • Nonnoperative treatment
      • immobilization
        • indications
          • long oblique or spiral type A or B fractures with a stable prosthesis
          • type C fracture
        • outcomes:
          • union rates <50%
    • Operative treatment
      • conversion to prosthetic stem spanning fracture site by two cortical diameters
        • indications
          • intraoperative type A fractures
      • conversion to proximally porous coated long stem prosethesis spanning fracture site by two to three cortical diameters
        • indications
          • intraoperative type B fractures
          • intraoperative type C fractures
      • open reduction and internal fixation
        • indications
          • intraoperative fractures
            • type C unamenable to long stem prosthesis
          • postoperative fractures
            • transverse type A and B fractures with stable prosthesis
            • type C that has failed nonsurgical management
            • patients unable to tolerate nonoperative management
      • revision arthroplasty with supplementary fixation
        • indications
          • presence of a loose prosthesis with any fracture type
        • long stem prosthesis
          • poor bone stock
          • bypass fracture by two cortical diameters
        • short stem prosthesis
          • good bone stock
          • convert to a shorter stem prosethesis than original and apply supplementary fixation
  • Techniques
    • Immobilization
      • coaptation splint followed by functional bracing
      • hydrostatic pressure created by brace stabilizes fracture site
      • higher risk of nonunion with type A and B fractures
    • Conversion to prosthetic stem spanning fracture site by two cortical diameters
      • removal or original stem
      • placement of longer stem engages distal fragment and improves fracture alignment
      • +/- supplementary fixation depending on fracture stability
    • Conversion to proximally porous coated long stem prosethesis spanning fracture site by two to three cortical diameters
      • proximal porous coating allows for metaphyseal stability
      • distal fragment cemented to stem tip
      • techniques:
        • pack cement into the distal canal to allow for distal stem fixation
        • avoid proximal cement extrusion into fracture site
        • use cortical strut grafting with cerclage cables in cases of bone deficiency
        • olecranon fossa may prevent successful treatment with this method
    • Open reduction and internal fixation
      • techniques:
        • approaches:
          • anterolateral approach to the humerus
            • can be extended from deltopectoral approach used for the index procedure
              • tip of coracoid process
              • curve along the deltopectoral groove
              • continue incision along lateral border of biceps brachii
            • develop interval between biceps and brachialis muscle
            • divide brachialis muscle longitudinally at midline and elevate subperiosteally to expose distal aspect humerus
              • medial fibers innervated by musculocutaneous nerve
              • lateral fibers innervated by radial nerve
            • preserve as much soft tissue attachment to the humerus as possible
            • place appropriate sized plate
              • usually 4.5 mm LC-DCP plate
              • screw fixation distal to stem
              • cerclage cables proximal to stem tip
          • posterolateral approach
            • good for distal postoperative fracture with stable prosthesis
      • greater tuberosity and calcar fractures
        • suture or cable fixation
      • hydbrid locking plates with cerclage cables have been used for postoperative fractures
        • plate placed eccentrically on humerus to allow locking screws to miss humeral stem
          • allows bicortical fixation around the stem
        • use of cerclage cables for added stability
        • alternatively can use dual plate constuct or 3.5 mm attachment plates for bicortical fixation
      • can combine with allograft augmentation for fractures with deficient cortices
        • can use cortical strut allograft and fix with cerclage cables
          • 2 hemicylinders can be used to form a sarcophagus around prosthesis
    • Revision arthroplasty with supplementary fixation
      • type of revision prosethesis is dependent on the quality of bone stock
        • poor bone stock
          • conversion to long-stemmed prosthesis
          • bypasses fracture site by at least two to three cortical diameters
          • can be augmented with allograft to enhance bone stock
        • good bone stock
          • conversion to short-stemmed prosthesis
            • stem ends more proximal than original prosthesis
          • apply supplementary fixation to fracture site
          • shorter stem impants prevents stem tip from distacting the fracture site
  • Complications
    • Nonunion
    • Delayed union
    • Glenohumeral stiffness
    • Radial nerve injury
      • can be secondary from the fracture
      • iatrogenic from fixation with cerclage cables
        • instrumentation proximal to the inferior edge of the latissimus dorsi insertion may reduce the risk of iatrogenic radial nerve injury
  • Prognosis
    • High union rates when appropriately treated
      • time to union 2-8 months
    • Significant decrease in shoulder ROM
Flashcards (1)
1 of 1
Questions (2)

(OBQ18.205) A 69-year-old patient presents with the injury shown in Figures A and B. A deltopectoral approach is used for open reduction and internal fixation of the fracture. Which of the following is the most likely complication that might occur when cable fixation is placed 4 cm inferior to the insertion of the latissimus dorsi?

QID: 213101

Iatrogenic median nerve injury



Axillary nerve neurapraxia



Subscapularis tendon injury



Iatrogenic radial nerve injury



Incarceration of the brachial artery



L 4 A

Select Answer to see Preferred Response

(OBQ18.63) A 60-year-old patient fell down a flight of stairs and injured their right arm. Since the fall they are unable to move their extremity due to pain. Prior to the fall, the patient denied any pain in the shoulder or upper arm. Currently, the patient is neurovascularly intact. Figures A and B are the radiographs at the time of presentation. What is the best treatment option for this patient?

QID: 212959

Revision rTSA with cemented long-stem prosthesis



Revision rTSA with cementless long-stem prosthesis



ORIF with hybrid locking plate and cerclage cables



ORIF with lag screw fixation and neutralization plating



Nonoperative treatment



L 2 A

Select Answer to see Preferred Response

Evidence (7)
Private Note