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https://upload.orthobullets.com/topic/1020/images/coronoid fx.jpg
https://upload.orthobullets.com/topic/1020/images/anteromedial facet fracture 3d ct.jpg
https://upload.orthobullets.com/topic/1020/images/regan and morrey classification of coronoid fractures.jpg
Introduction
  • Coronoid fractures are pathognomonic of an episode of elbow instability
    • may be
      • 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
  • Epidemiology
    • incidence
      • 10-15% of elbow injuries
  • Associated conditions
    • posteromedial rotatory instability
      • coronoid anteromedial facet fracture and LCL disruption    
      • 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
  • Prognosis
    • complications and reoperation rates are high
Anatomy
  • Coronoid 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
  • Coronoid 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  
image
 
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
 

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(SBQ11UE.98) A 25-year-old male sustains a closed elbow dislocation after falling during a soccer game. Two months later, the patient continues to complain of pain and instability. Radiographs and physical exam are concerning for posteromedial instability. Which of the following fracture patterns is most consistent with this diagnosis? Review Topic

QID: 4333
1

Coronoid tip

10%

(418/4289)

2

Coronoid anteromedial facet

82%

(3534/4289)

3

Radial head

4%

(173/4289)

4

Olecranon

1%

(57/4289)

5

Capitellar impaction injury

2%

(91/4289)

ML 2

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