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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Shoulder arthroplasty for post-fracture deformity in the presence of a locking plate

Yesterday our OR schedule included two very active ladies who had the following features in common (1) ORIF with a locking plate,  (2) post-fixation collapse of the humeral head, and (3) extremely stiff painful shoulders. Our desire is to avoid stress risers that might predispose the shaft to fracture as they resumed their heli-skiing and other activities.
Our approach was to retain the plate, removing and/or shortening screws as necessary for insertion of the stem of the humeral component and to use impaction grafting rather than cement to fix the prosthetic stem.
Here are the preop and post op films from the first case

And from the second case

These cases demonstrate the versatility of impaction grafting in minimizing the risk of periprosthetic fratures.

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Use the "Search the Blog" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery.

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Revision surgery for failed shoulder replacement arthroplasty due to humeral fracture - our approach, Part 8

Fracture of the humeral shaft is a recognized cause of shoulder arthroplasty failure. The risk for such a fracture is increased in individuals with poor bone quality or with an increased risk of falling because of poor eyesight, balance problems, confusion, or muscle weakness. The risk is also increased when there has been weakening of the humeral shaft from reaming, as explained in a previous post, or from loosening of the humeral component. Our experience indicates that humeral fracture risk is lessened when endosteal reaming is minimized and when impaction autografting is used to secure the stem in the humeral shaft.


The diagnosis of shaft fracture is revealed by high quality anteroposterior and lateral views that span the entire humerus.  

If the component is not loose, it can be difficult to remove in the presence of a fracture. In this situation, we prefer to leave the prosthesis in place and fix the fracture using a plate placed so that the screws in the proximal fragment pass through the cortical bone either anterior or posterior to the stem of the prosthesis. 

If good fixation in the proximal fragment cannot be achieved with screws, circlage around the plate may be used, but extreme care must be used to avoid circlaging the radial nerve posteriorly and to avoid crushing the bone with excessive tightening of the wires.

If the humeral prosthesis is loose, it may be removed and replaced with a long stem prosthesis fixed with cement or bone graft and supplemented with circlage fixation, again taking care to protect the radial nerve.

In all cases of humeral fracture, we prefer to us autogenous bone graft or cancellous allograft around the fracture site. 

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You may be interested in some of our most visited web pages including: shoulder arthritis, total shoulder, ream and run, reverse total shoulder, revision surgery for failed shoulder joint replacement, and rotator cuff surgery.