Avascular necrosis of shoulder
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Synopsis
Avascular necrosis of the shoulder, also known as osteonecrosis of the humeral head, is an infarction of the humeral head subchondral bone due to the disruption of blood flow, resulting in damage to the articular cartilage and joint.Classic history and presentation: Patients typically present with progressive shoulder pain, stiffness, and weakness without an acute inciting event. This presentation may be secondary to trauma, such as a displaced proximal humerus fracture, or it may be due to atraumatic causes, such as sickle cell anemia or certain medications.
Risk factors: There is an increased risk of avascular necrosis after displaced 3-part and 4-part proximal humerus fractures, with an even higher risk of development with fracture dislocations; these injuries tend to result in a disruption of the blood supply to the bone. Atraumatic risk factors include prolonged corticosteroid use, especially in the setting of systemic lupus erythematosus, homozygous sickle cell disease, alcohol use disorder, decompression illness (Caisson disease), and certain metabolic diseases such as Gaucher disease.
Pathophysiology: The humeral head blood supply is the posterior and anterior circumflex arteries, which can be disrupted by trauma or other conditions that would occlude or disrupt the blood supply.
Grade / classification system: Cruess classification
- Stage 1 – normal x-ray, changes on MRI
- Stage 2 – sclerosis and cystic changes, osteopenia on x-ray
- Stage 3 – crescent sign (subchondral fractures) on x-ray
- Stage 4 – flattening and collapse on x-ray
- Stage 5 – degenerative changes extend to the glenoid on x-ray
Codes
ICD10CM:M87.829 – Other osteonecrosis, unspecified humerus
SNOMEDCT:
203475004 – Avascular necrosis of the head of humerus
Look For
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Diagnostic Pearls
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Differential Diagnosis & Pitfalls
- Proximal humerus fracture
- Osteoarthritis of the glenohumeral joint / shoulder arthritis
- Rotator cuff arthropathy
- Rotator cuff tear
- Clavicle fracture
- Scapular fracture
- Shoulder dislocation (see, eg, anterior shoulder dislocation)
- Glenoid fracture
Best Tests
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Management Pearls
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Therapy
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Drug Reaction Data
Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.Subscription Required
References
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Last Reviewed:04/24/2022
Last Updated:05/08/2022
Last Updated:05/08/2022
Avascular necrosis of shoulder