Periprosthetic Fractures of Shoulder & Elbow Arthroplasty

As shoulder and elbow arthroplasty become more common (especially reverse total shoulder arthroplasty and total elbow arthroplasty for fracture and arthritis in the elderly), periprosthetic fractures around these implants are an increasingly frequent and challenging complication. They usually occur in osteoporotic bone with limited bone stock, often intra-operatively or from a low-energy fall. The key to management - exactly as at the hip - is to characterise the fracture location, the implant stability, and the bone quality.

For the shoulder, multiple classification systems exist (Wright & Cofield, Campbell, Worland, Groh); the Wright & Cofield system has the best intra- and interobserver reliability, but agreement across all systems - and on the preferred treatment - is only MODERATE, so the classification guides, but does not replace, individualised assessment of stem fixation and bone quality.

• Shoulder (humerus): a Type C (distal, well below a well-fixed stem) is usually ORIF like a humeral shaft fracture; a fracture around a loose stem needs revision with a long stem; strut allograft (e.g. via a posterior approach with a plate) is valuable in osteoporotic bone and for Worland B/C-type patterns. Protect the radial nerve.
• Elbow: Type II fractures hinge on stem fixation - a well-fixed stem allows ORIF, a loose stem needs component revision; the thin ulna and condylar bone loss make fixation difficult, and strut allograft / revision implants are often required.
• Always treat within overall patient optimisation (the typical patient is elderly with osteoporosis and comorbidities) and exclude infection.