Fractures Around Shoulder and Elbow Replacements
- Periprosthetic fractures around SHOULDER and ELBOW arthroplasty are an increasingly common complication as these replacements become more frequent; they typically occur in ELDERLY, often OSTEOPOROTIC bone, and management is guided by the same logic as the hip: FRACTURE LOCATION, IMPLANT STABILITY and BONE QUALITY.
- For the SHOULDER (periprosthetic humeral fracture after anatomic or reverse arthroplasty), the location-based classifications describe the fracture RELATIVE TO THE STEM TIP - the WRIGHT & COFIELD system (Type A at/proximal to the tip, Type B around/just distal to the tip, Type C distal/diaphyseal) is the most commonly used and the most RELIABLE, although interobserver agreement across all the shoulder systems is only MODERATE.
- For the ELBOW (periprosthetic fracture after total elbow arthroplasty), the MAYO classification (O'Driscoll & Morrey) grades by location and stem fixation: Type I about the ARTICULATION/columns (condyles), Type II along the STEM (humeral or ulnar component, subdivided by whether the stem is WELL-FIXED or LOOSE), and Type III BEYOND the stem tip; the thin ulna and bone loss make these challenging.
- The TREATMENT PRINCIPLE (Vancouver-style) is: if the implant is WELL-FIXED, treat the fracture (ORIF with plates, cerclage and often a STRUT ALLOGRAFT, or non-operatively for stable proximal/undisplaced patterns); if the implant is LOOSE, REVISE the implant (a longer-stemmed component that bypasses the fracture) with or without additional fixation/graft.
- Because the bone is frequently OSTEOPOROTIC and stock is limited (especially in revision and around the elbow), fixation strategies emphasise LONG plates, MULTIPLE points of fixation, CERCLAGE around the stem, and STRUT ALLOGRAFT to augment the construct; healing rates are good with appropriate, stability-matched treatment.
- Assess the WHOLE construct and the patient: identify the implant type, determine stem fixation (loosening signs), evaluate bone quality and the fracture pattern on radiographs (+/- CT), and rule out INFECTION before any revision.
- “Shoulder periprosthetic humeral fracture: classify by location relative to the STEM TIP (Wright & Cofield A/B/C; the most reliable system).
- “Elbow periprosthetic fracture: Mayo (O'Driscoll-Morrey) - Type I condyles/articulation, Type II along the stem (well-fixed vs loose), Type III beyond the stem.
- “Same principle as the hip (Vancouver): well-fixed implant -> ORIF (+/- strut allograft); loose implant -> revise with a long-stem component.
Treat the fracture: ORIF with a long plate, cerclage and often a strut allograft, or non-operative management for stable, undisplaced or proximal patterns. Keep the well-functioning implant.
Revise the implant with a longer-stemmed component that bypasses the fracture, with or without supplementary fixation/graft - fixing the fracture alone over a loose stem will fail.
Why They Matter & How to Classify
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.


Classifications
| 0 | 1 |
|---|---|
| Type A | At / proximal to the stem tip, extending proximally (around tuberosities/proximal stem) |
| Type B | Around or just distal to the stem tip |
| Type C | Distal to the stem tip (distal humeral diaphysis) |
| 0 | 1 |
|---|---|
| Type I | About the ARTICULATION / columns (condyles) - around the joint, not the stem |
| Type II | Along the STEM (humeral or ulnar) - subdivided by whether the stem is well-fixed or loose |
| Type III | BEYOND the stem tip (diaphyseal) |
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.
Assessment & Management
- Identify the implant (anatomic vs reverse shoulder; linked vs unlinked elbow) and stem fixation (loosening: lucency, subsidence, cement-mantle failure)
- Radiographs (+/- CT) for fracture pattern and location relative to the stem tip
- Assess bone quality/stock; rule out INFECTION before any revision
- Neurovascular exam (e.g. radial nerve with humeral fractures)
- Well-fixed implant: treat the fracture - ORIF (long plate, cerclage, screws) often with a strut allograft; non-operative for selected stable/undisplaced patterns
- Loose implant: revise to a long-stem component bypassing the fracture (+/- fixation/graft)
- Augment the osteoporotic construct (long plates, multiple fixation points, cerclage, strut graft)
- 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.
Evidence & Key Studies
Periprosthetic humerus fractures after shoulder arthroplasty: an evaluation of available classification systems
- Compared four periprosthetic-humerus-fracture classifications (Wright & Cofield, Campbell, Worland, Groh) for reliability across 34 fractures.
- The Wright & Cofield system had the greatest intraobserver and interobserver reliability; all systems showed only moderate interobserver agreement (and moderate agreement on preferred management).
- Highlights the need for a more reliable classification and a standardised treatment algorithm for periprosthetic humerus fractures.
Posterior approach with posterior locking plate and anterior strut allograft for periprosthetic humeral fractures after reverse total shoulder arthroplasty
- In 18 elderly patients with periprosthetic humeral fractures after reverse shoulder arthroplasty, a posterior approach with a posterior plate plus anterior strut allograft and cerclage achieved consolidation in all (mean 4.2 months) with good function.
- Treatment must consider fracture location, displacement and local bone quality; the technique is applicable to Worland B/C-type fractures.
- Strut allograft augmentation is useful for fixation in osteoporotic periprosthetic humeral bone.
According to PubMed, the shoulder classification comparison (Wright & Cofield most reliable; only moderate agreement overall) comes from the cited Kuhn study, and the strut-allograft fixation approach from the cited Vicenti series. The Mayo (O'Driscoll & Morrey) total-elbow-arthroplasty classification and the Vancouver- style 'location + implant stability + bone quality' treatment principle are standard, well-established teaching applied from the hip. (See also our TKA/THA Periprosthetic Fractures and Total Elbow Arthroplasty material.)
Clinical Decision Scenarios
Practise clinical reasoning and management decisions out loud
“An elderly patient with a reverse total shoulder replacement falls and sustains a periprosthetic humeral fracture. How do you classify it, and what determines your treatment?”
“How is the approach to a periprosthetic fracture around a total elbow replacement classified and managed, and why is it challenging?”
Mnemonics & Memory Aids
STEM
Hook:Around a STEM: classify by the tip, judge stability, and augment osteoporotic bone.
FIX-OR-REVISE
Hook:Fixed = fix; loose = revise (long stem) - the same upper-limb Vancouver logic.
General
- Rising with shoulder/elbow arthroplasty; usually osteoporotic elderly bone
- Vancouver-style logic: fracture location + implant stability + bone quality
- Identify implant + stem fixation; CT; exclude infection before revision
Shoulder (humerus)
- Classify relative to stem tip: Wright & Cofield A (at/proximal), B (around/just distal), C (distal)
- Wright & Cofield most reliable; overall agreement only moderate
- Strut allograft augments osteoporotic fixation (Worland B/C); protect radial nerve
Elbow (total elbow arthroplasty)
- Mayo (O'Driscoll-Morrey): I articulation/columns, II along stem (well-fixed vs loose), III beyond stem
- Thin ulna + condylar bone loss -> difficult fixation; strut graft/revision implants
- Type II subdivided by stem fixation
Treatment principle
- Well-fixed implant: ORIF (long plate, cerclage, strut allograft) or non-op (stable patterns)
- Loose implant: revise to long-stem component bypassing the fracture
- Augment osteoporotic bone; optimise the (usually elderly) patient