SCIENTIFIC ARTICLE

Fixation of Regan-Morrey Type II

Coronoid Fractures: A Comparison of
Screws and Suture Lasso Technique for
Resistance to Displacement
Nicholas P. Iannuzzi, MD,* Adrian G. Paez, BS,* Brent G. Parks, MSc,* Michael S. Murphy, MD*

Purpose The aim of this study was to compare the load to failure and stiffness achieved in
coronoid fractures treated with a posterior-to-anterior screw versus a suture lasso technique.
Methods We performed a biomechanical study using 10 pairs of fresh-frozen cadaveric elbows.
A transverse osteotomy at the midpoint of the coronoid height was created to simulate a Regane
Morrey type II coronoid fracture. The specimens were randomized to screw fixation or suture lasso
fixation. The load to failure and stiffness were then measured using a materials testing machine.
Results Screw fixation provided greater strength and stiffness than suture lasso fixation. Mean
load to failure was 405 N in the screw fixation group compared with a load to failure of 207 N
for suture fixation. Screw fixation resulted in a mean stiffness of 284 kPa/mm compared with
119 kPa/mm after suture fixation.
Conclusions Screw fixation was biomechanically superior to fixation using a suture lasso technique.
For coronoid fractures in which screw or suture fixation is feasible, screw fixation may provide
greater resistance to displacement of the coronoid compared with a suture lasso technique.
Clinical relevance Clinical studies have reported a higher rate of failure after screw fixation
compared with suture lasso fixation; however, this study demonstrated a greater stiffness and
load to failure after screw fixation of type II coronoid fractures. Screw fixation may provide a
stronger fixation construct for fractures of adequate size to support a screw. Further studies
may be warranted to assess the importance of securing the anterior capsule to the coronoid tip
when using a suture lasso construct because this may affect the stability of the elbow after
fixation. (J Hand Surg Am. 2017;42(1):e11ee14. Copyright Ó 2017 by the American Society
for Surgery of the Hand. All rights reserved.)
Key words Coronoid fractures, elbow instability, screw fixation, suture lasso fixation.

“T
From *The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD.
Received for publication February 11, 2016; accepted in revised form November 2, 2016.
No benefits in any form have been received or will be received related directly or
indirectly to the subject of this article.
Corresponding author: Michael Murphy, MD, care of Anne Mattson, The Curtis National
Hand Center, 3333 North Calvert Street, #200 JPB, Baltimore, MD 21218; e-mail: anne.
mattson@medstar.net.
0363-5023/17/4201-0014$36.00/0
http://dx.doi.org/10.1016/j.jhsa.2016.11.003
ERRIBLE TRIAD” INJURIES OF THE elbow often
involve a dislocation of the elbow with a
fracture of the radial head and tip of the
coronoid.1 This constellation of injuries can be diffi-
cult to treat and may lead to persistent instability of the
elbow. To prevent recurrent elbow instability, previ-
ous authors recommended that each component of the
triad be repaired or stabilized.2 In particular, studies
have demonstrated improved elbow stability after
fixation of coronoid fractures involving 50% or more

Ó 2017 ASSH r Published by Elsevier, Inc. All rights reserved. r e11

e12 REGANeMORREY TYPE II CORONOID FRACTURE

of the coronoid tip.3 In our practice, fractures involving

50% of the tip of the coronoid (ReganeMorrey type II)
may be treated using a screw or suture lasso technique.
A recent clinical study by Garrigues and colleagues4
suggested that suture lasso fixation provides greater
clinical stability compared with screw fixation;
however, the small number of patients treated using
screws limited the ability to provide a definitive
recommendation regarding the method of coronoid
fixation. In our practice, the decision to treat
ReganeMorrey type II coronoid fractures using
screws or a suture lasso depends on fragment size and
surgeon preference. The purpose of this study was to
compare screw and suture fixation stability after a
simulated ReganeMorrey type II coronoid fracture in
a cadaver model. We hypothesized that screw fixation
would provide greater stability than a suture lasso.

MATERIALS AND METHODS

Ten matched pairs of fresh-frozen cadaver elbows
were used as a convenience sample. Specimens were
visually inspected for any signs of previous trauma or
arthritis about the elbow, and any specimens with signs
of previous injury were excluded. The elbows were
skeletonized, and the proximal ulna and distal humerus
were isolated and removed for testing. In the ulna, a
ReganeMorrey type II fracture involving 50% of the
coronoid process was created using a method previ-
ously described by Moon et al.5 The coronoids were
measured using calipers and a TPS saw (Stryker,
Kalamazoo, MI) was used to create an osteotomy at
50% of the height of the coronoid. We used an osteo-
tome to complete the fracture to simulate interdigita-
tion between fragments present in a typical injury. The
specimens were then randomized to fixation by either
posterior-to-anterior screw or suture fixation. Before
the osteotomy of the coronoid, we drilled a 2.0-mm
hole from the dorsal ulna into the coronoid to permit
later screw fixation. Coronoid osteotomy was then
performed, and reduction between the coronoid and
proximal was maintained with a point-to-point reduc-
tion clamp. A 2.7-mm self-tapping cortical screw was
then inserted bicortically across the fracture. To sta-
bilize the specimens with suture fixation, two 2.0-mm
drill holes were made through the dorsal ulna and
coronoid before osteotomy. After the osteotomy, a
Hewson suture passer (Smith & Nephew, Andover,
MA) was used to pass number 2 Ethibond suture
(Ethicon, Somerville, NJ) around the fragment. The
suture was tied using a series of 5 alternating knots.
After securing the coronoid fragments, the speci-
mens were prepared to load in a materials testing
FIGURE 1: Cadaveric specimen being tested after fixation using
a suture lasso technique.
machine (MTS, Eden Prairie, MN). In the distal ulna,
1.6-mm (0.062-in) K-wires were placed orthogonally
with subsequent embedding in polyester resin
(BONDO; 3M, St. Paul, MN) within polyvinyl-
chloride pipe. Similarly, the proximal portion of the
humerus was pinned with 1.6-mm K-wires and
embedded in polyvinylchloride pipe with polyester
resin. The ulna and humerus were placed in an
extended position (Fig. 1) and a load was applied
parallel to the olecranon osteotomy. Specimens were
loaded at a rate of 10 mm/min until gross fracture or
displacement greater than 2 mm occurred at the
osteotomy site, similar to the criteria used by Moon
et al.5 The load to failure (N) and stiffness (kPa per
millimeter of displacement) were recorded continu-
ously at a rate of 10 Hz for each construct. Results
were averaged for each group and average results were
compared using a 2-tailed t test to determine whether
any observed differences were statistically significant.
RESULTS
Average age of the specimens was 71 years (range,
53e86 years). The paired elbows belonged to 9 male
cadavers and 1 female. Screw fixation demonstrated
significantly greater loads to failure, defined as 2 mm

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 REGANeMORREY TYPE II CORONOID FRACTURE e13

displacement, and stiffness compared with suture

fixation. Screw fixation resulted in an average load to
failure of 405 N (range, 204e581 N) compared with
an average load to failure of 207 N (range, 113e294
N) for suture fixation (P < .05) (Fig. 2). Screw fix-
ation also demonstrated greater stiffness. One milli-
meter of displacement at the fracture required 284
kPa (range, 122e404 kPa) of force after screw fixa-
tion, whereas 119 kPa (range, 22.4e271 kPa) of force
created similar displacement in the suture fixation
model (P < .05) (Fig. 3). All constructs failed as a
result of displacement of the coronoid fragment
around intact fixation. Suture constructs stretched but
did not break in all cases, whereas screws either bent
FIGURE 2: Load at 2 mm of displacement.
or pulled out from the bone in all cases.

DISCUSSION
This study demonstrated that screw fixation of
ReganeMorrey type II coronoid fractures provides
almost double the strength and stiffness of a suture
lasso technique. Strengths of this study include the use
of paired cadaveric specimens and a uniform fracture
model. These factors control for variations in bone
mineral density and fracture size or configuration that
may be seen in clinical practice. A single surgeon
performed the osteotomies and fixation to ensure uni-
form technique, and all soft tissue stabilizers around
the elbow were removed to eliminate confounding
variables and ensure that the coronoid was the primary
FIGURE 3: Stiffness for both constructs.
structure being tested.
Despite these efforts, the cadaveric model used in
this study has limitations. Elimination of soft tissues
from around the elbow prevents incorporation of the the sutures loosened but did not break. It is possible
anterior capsule of the elbow into the suture lasso that a different suture material or method of tying
technique. It is unknown how much additional stability knots would prevent loosening, but the method tested
would be gained from incorporating soft tissue into the is consistent with clinical practice at our institution
suture lasso; however, it is unlikely that incorporation and similar to the technique described by Garrigues
of the anterior capsule would double the strength and et al.4 With regard to screw fixation, a previous study
stiffness of the coronoid fixation construct. by Moon et al5 demonstrated improved strength and
Additional limitations of this study include the use stiffness of coronoid fixation using a single posterior-
of predrilled holes and of only one suture material to-anterior screw, and the current authors used this
and screw configuration. Predrilling holes before model to guide this comparison. In clinical practice,
creating an osteotomy permits ideal fixation that may however, there are occasions when 2 screws may be
not be possible in the clinical setting. It is likely that used to establish fixation of coronoid fractures. Use
any fixation achieved in clinical practice would be of multiple, smaller screws, if possible, may impart
less resistant to displacement than that demonstrated greater stability compared with a single screw or
in the current study, but the use of predrilled holes suture fixation. The authors also acknowledge that
also provides reproducible reduction and fixation, screw fixation may not always be feasible. In
which reduces variability and allows direct compar- comminuted fractures of the coronoid, there may be
ison between suture and screw fixation. insufficient bone for screw fixation; in those cases, a
We limited testing to one suture material and one suture lasso construct can help incorporate and
screw configuration using a single screw. In testing, stabilize the fragments.

J Hand Surg Am. r Vol. 42, January 2017

e14 REGANeMORREY TYPE II CORONOID FRACTURE
Further limitations of this study include the lack of
cyclic testing and the use of a constrained testing
apparatus. Although cyclic load to failure may
simulate the forces experienced by the coronoid
during range of motion of the elbow, the current
model used a static load to failure to simulate a
“worst-case” scenario in which we tried to determine
the maximum amount of force the coronoid could
withstand before failure. In preparation for this study,
the authors were unable to find reliable data regarding
standard physiological forces across the elbow joint.
We therefore used static force to failure as our model
with the understanding that this information could
help guide future studies using cyclic forces. The use
of a constrained testing apparatus is another limita-
tion of the study, in that this constrained model does
not permit the multiple degrees of freedom found in a
normal elbow. The constrained nature of the testing
apparatus particularly limits dorsal subluxation of the
ulna, which in turn means that the stable, intact
portion of the coronoid assumes some of the load
noted in our model. The result of this constraint is
that the force required to create failure of the fixation
may be artificially higher than that seen in a clinical
case of a terrible triad injury. The authors believe that
this artificially high number is mitigated by using
matched pairs of elbows and a uniform fracture
model involving 50% of the height of the coronoid.
Therefore, although the force required for failure is
relatively high in the current study, the difference in
force required for failure between groups remains
valid. Despite these limitations, the authors think that
this study demonstrates a noteworthy increase in
fracture stability imparted by screws compared with
suture lasso fixation.
The results of the current study are interesting in
light of the study by Garrigues and colleagues.4 In
our study, screws appear to provide more biome-
chanical stability in the setting of ReganeMorrey
type II coronoid fractures; however, Garrigues et al
reported a higher rate of recurrent clinical instability
in patients treated with screws as opposed to suture.
Garrigues et al noted instability in 1 of 28 elbows
J Hand Surg Am.
after suture fixation of the coronoid and lateral ulnar
collateral ligament (LUCL) repair (4%), compared
with 1 of 5 elbows treated with screw fixation of the
coronoid and LUCL repair (20%). Garrigues et al
noted that one of the main limitations of their study
was the small number of patients treated with screw
fixation. It is possible that the single incidence of
instability after screw fixation and LUCL repair
would have been offset if a greater number of patients
had been treated using screw fixation of the coronoid.
It is also possible that securing the anterior capsule
with a suture construct may have conferred additional
stability in the setting of terrible triad injuries.
Further study is warranted regarding the role that
soft tissue structures, particularly the anterior capsule,
have in imparting elbow stability after terrible triad
injuries of the elbow. Although the clinical effec-
tiveness of screw fixation and suture lasso fixation in
providing stability of the elbow remains unresolved,
the authors believe that, where feasible, the improved
biomechanical stability imparted by screw fixation
supports the use of screws in ReganeMorrey type II
coronoid fractures in the setting of unstable fracture-
dislocations about the elbow.
ACKNOWLEDGMENTS
This study was funded by the Raymond M. Curtis
Research Foundation, the Curtis National Hand
Center, Baltimore, MD.
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to treat elbow dislocations with radial head and coronoid fractures.
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3. Schneeberger AG, Sadowski MM, Jacob HA. Coronoid process and
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