Acromial and scapular spine fractures after reverse total shoulder arthroplasty

Last revised by Henry Knipe on 1 Feb 2024

Acromial and scapular spine fractures after reverse total shoulder arthroplasty (RTSA) can occur intraoperatively or postoperatively with post-operative stress fractures the most common.

Acromial and scapular spine fractures complicate ~7.5% (range 3.1-11.2%) of RTSAs 1,2.

  • intraoperative fracture: rare and can be treated depending on the location and displacement of the fracture, as well as the stability of the implant, conservatively or with open reduction-internal fixation (ORIF) 1

  • post-operative fracture

    • stress fractures are more common the post-trauma fractures 2

    • the mechanism of fracture in a fall or an event requiring to reach out and grab something to prevent a fall may be from rapid deltoid contraction 1

    • most commonly occur between 3 and 12 months (range 1-94 months) after RTSA 1

Several factors may also increase the risk of acromial fractures after RTSA:

  • the superior screw of the glenoid baseplate is too long or exiting at the scapular spine base may cause increased stress in the scapular spine with fracture 1

  • distalisation and medialisation of the center of rotation causes excessive tension on the deltoid with increased stress on the acromion and scapular spine 1

  • low bone mineral density 3

Three types of acromial fracture are defined by Levy et al. 1

  • type I: small fractures of the anterior acromion

  • type II: fractures through the anterior acromion just posterior to the acromioclavicular joint

  • type III: fractures of the posterior acromion or scapular spine

X-ray is the first-line imaging choice but only has a sensitivity of ~80% 1.

In patients with a high clinical suspicion for scapular fractures, CT is the imaging modality that best identifies fractures not apparent on plain radiographs 1,3.

SPECT-CT can be used for a diagnosis of the stress reaction or non-displaced fracture in the symptomatic patient.

  • conservative management for acute non-displaced fractures of the scapula with nonunion rates as high as 50-75% 1

  • operative management for painful nonunion or displaced fractures with surgical fixation with dual orthogonal plating if possible 1

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