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https://upload.orthobullets.com/topic/1020/images/coronoid fx.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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Question
1 of 13
In scope icon L 5
QID 217935 (Type "217935" in App Search)
Figure A is the AP and lateral radiograph, respectively, of a 45-year-old farmer who presented to your clinic after a fall onto an outstretched hand five days ago. He notes "a bit" of elbow pain, and has had difficulty performing his work duties. The patient has a positive gravity-assisted varus stress test, and the patient states that his elbow "sounds like crispy rice cereal" when he moves it. You bring the patient to the operating room and perform open reduction and internal fixation of the fracture shown. If the elbow remains unstable, which of the following is the insertion of the ligament you should next address surgically?
  • A

Anteroinferior aspect of medial epicondyle

7%

63/928

Crista supinatoris of proximal ulna

47%

436/928

Radial tuberosity

3%

30/928

Sublime tubercle of the ulna

38%

356/928

Tip of the coronoid process

3%

30/928

  • A

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Trauma | Coronoid Fractures
  • Trauma
  • - Coronoid Fractures
18:22 min
5/23/2022
946 plays
5.0
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