Periprosthetic fracture of the humerus below an arthroplasty stem - fixation with plate and dodging screws

A lady sustained a fracture below the stem of the humeral prostheses. A repair was attempted at another hospital using a plate and circlage wires. 

However, this fixation did not have adequate purchase on the upper fracture fragment and it failed and became infected. The plate was removed.

After the infection resolved, the patient came to our colleague Jason Hsu who securely repaired the fracture using a long plate and dodging screws that pass anterior and posterior to the stem of the implant.

Comment: Fixation of periprosthetic fractures can be a major challenge.

One of the main issues is getting rotational control of the two fragments, recognizing the torque that can be applied to the distal fragment by the hand and forearm when the elbow is flexed. This is a particular issue when the glenohumeral joint is stiff.

Conversion to a long stemmed prosthesis requires removal of the extant implant, which can be very difficult. Circlage wires may not be effective in controlling rotation, especially if the bone around the fracture site is soft.

When possible we prefer to retain the prosthesis and fix the fracture with dodging screws as shown in this case and here.

Dr Hsu pointed out that the use of a broad plate allows for more flexibility in screw placement.

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