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Images fx.jpg facet fracture 3d ct.jpg tip fracture 3d ct.jpg facet coronoid fracture ap and lateral radiographs.jpg
  • summary
    • Coronoid Fractures are traumatic elbow fractures that are generally pathognomonic for an episode of elbow instability. 
    • Diagnosis can be made using plain radiographs of the elbow. CT studies may be helpful for surgical planning.
    • Treatment may be nonoperative for nondisplaced coronoid tip fractures with a stable elbow. Surgical management is indicated for anteromedial facet fractures or fractures associated with elbow instability.
  • Epidemiology
    • Incidence
      • 10-15% of elbow injuries
  • Etiology
    • Types
      • isolated coronoid fracture
        • less common than previously thought
      • coronoid fracture + associated injuries
        • commonly occur with elbow dislocation
          • associated with recurrent instability after dislocation
    • Mechanism
      • traumatic shear injury
        • typically occurs as distal humerus is driven against coronoid with an episode of severe varus stress or posterior subluxation
        • not an avulsion injury as nothing inserts on tip
    • Pathoanatomy
      • fractures at the coronoid base can amplify elbow instability given that
        • anterior bundle of the medial ulnar collateral ligament attaches to the sublime tubercle 18 mm distal to tip
        • anterior capsule attaches 6 mm distal to the tip of the coronoid
    • Associated conditions
      • posteromedial rotatory instability
        • results from a varus deforming force
      • posterolateral rotatory instability
        • coronoid tip fracture, radial head fracture, and LCL injury
      • olecranon fracture-dislocation
        • usually associated with a large coronoid fracture
      • terrible triad of elbow
        • coronoid fracture (transverse fracture pattern), radial head fracture, and elbow dislocation
  • Anatomy
    • Osteology
      • coronoid tip
        • is an intraarticular structure
        • can be visualized during elbow arthroscopy
      • medial facet
        • important for varus stability
        • provides insertion for the medial ulnar collateral ligament
    • Biomechanics
      • coronoid functions as an anterior buttress of the olecranon greater sigmoid notch
        • important in preventing recurrent posterior subluxation
      • primary resistor of elbow subluxation or dislocation
  • Classification
      • Regan and Morrey Classification
      • Type I
      • Coronoid process tip fracture
      • Type II
      • Fracture of 50% or less of height
      • Type III
      • Fracture of more than 50% of height
      • O'Driscoll Classification
      • - Subdivides coronoid injuries based on location and number of coronoid fragments
        -Recognizes anteromedial facet fractures caused by varus posteromedial rotatory force
  • Presentation
    • Symptoms
      • elbow deformity & swelling
      • elbow pain
      • forearm or wrist pain may be a sign of associated injuries
    • Physical exam
      • inspection & palpation
        • varus or valgus deformity
        • ecchymosis & swelling
        • diffuse tenderness
      • range of motion & instability
        • document flexion-extension and pronation-supination
          • crepitus should be noted
        • varus/valgus instability stress test
          • challenging but important for an accurate diagnosis
      • neurovascular exam
  • Imaging
    • Radiographs
      • recommended views
        • AP and lateral elbow views
      • findings
        • interpretation may be difficult due to overlapping structures
    • CT scan
      • useful for high grade injuries and comminuted fractures
  • Treatment
    • Nonoperative
      • brief period of immobilization, followed by early range of motion
        • indications
          • Type I, II, and III that are minimally displaced with stable elbow
    • Operative
      • ORIF with medial approach
        • indications
          • Type I, II, and III with persistent elbow instability
          • posteromedial rotatory instability
      • ORIF with posterior approach
        • indications
          • olecranon fracture dislocation
          • terrible triad of elbow
      • hinged external fixation
        • indications
          • large fragments
          • poor bone quality
          • difficult revision cases to help maintain stability
  • Techniques
    • ORIF with medial approach
      • approach
        • medial exposure through an interval between two heads of FCU
        • exposure more anteriorly through a split in flexor pronator mass
      • technique
        • cerclage wire or No. 5 suture through ulna drill holes for Type I injuries
        • ORIF with retrograde cannulated screws or plate for Type II or III injuries
        • ORIF with buttress plate fixation or pins and lateral ligament repair for posteromedial rotatory instability
      • postoperative rehabilitation
        • depends on intraoperative exam following the procedure
        • thermoplastic resting splint
          • applied with elbow at 90° and forearm in neutral
          • restrict terminal 30° extension for 2-4 weeks
        • avoid shoulder abduction for 4-6 weeks
          • to prevent varus moment on arm
        • early active motion
          • dynamic muscle contraction may improve gapping of the ulnohumeral joint after surgical repair
    • ORIF with posterior approach
      • approach
        • posterior
      • technique
        • mobilize olecranon fracture to access coronoid fracture for associated olecranon fracture-dislocations
        • repair coronoid fragment first prior to reducing main ulnar fracture
        • olecranon ORIF with dorsal plate and screws
  • Complications
    • Recurrent elbow instability
      • especially medial-sided
    • Elbow stiffness
    • Posttraumatic arthritis
    • Heterotopic ossification
    • Early failure
      • associated with failure to recognize and repair underlying elbow instability
  • Prognosis
    • Complications and reoperation rates are high
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