Coronoid fracture

Presenter: Dr Ramin Maharjan

First year Resident,
Department of Orthopaedics
PAHS
Moderator: Dr Abhishek Kumar Thakur

2078/08/02
Contents
• Relevant Anatomy
• Epidemiology
• Classification
• Mechanism of injury
• Clinical features
• Radiological features
• Treatment
• Complications
Relevant Anatomy
 Relevant Anatomy
coronal view

‘‘Coronoid’’ : HOOK
- Trianglular shape
- Apex
- Base
Medial view
- Articular surface
- Ulnar tuberosity

Lateral view
Attachment
Why is coronoid important?
• Provides anterior buttress

• Anterior capsule and brachialis attach

• Anterior bundle of MCL attaches

• Fractures of the coronoid are highly suggestive of elbow instability

Classification
• Regan and Morrey classification
• O’Driscoll classification
 Regan and Morrey classification

• Type I: fracture of the intraarticular tip of the

coronoid (no long-term instability);

• Type II: fracture - involving half or less of the

coronoid (may significantly affect
ulnohumeral stability); and

• Type III: fracture involving more than half of

the coronoid process (often associated with
posterior instability)
Epidemiology

• Accounts for 10-15% of elbow injuries

• Associated with approximately 10 to 15% elbow dislocation

Etiology
• Almost always traumatic; high-velocity activity,

• Motor vehicle accidents are the most common cause of proximal ulna
fractures.

• They are often the result of an associated elbow dislocation.

• Coronoid fractures are believed to occur due to a shearing force when

elbow experiences excess stress.
Mechanism of Injury
Coronoid Tip Type 1:
Terrible Triad
• Elbow dislocation + Radial head # + Transverse coronoid tip #
• PLRI mechanism
1. Ulnar LCL disruption
2. Radial head impacts Capitellum 
Radial head #
3. Coronoid contacts trochlea or Ant.
Capsule avulsion  Coronoid tip #
Capsuloligamentous injury from lateral to
medial side – HORI cycle
Coronoid AM Facet Type 2: Posteromedial Rotatory Instability (PMRI)
Fall on outstretched hand with flexed elbow
1. LCL injury
2. Medial coronoid impacts medial trochlea
• Produce subluxation rather than dislocation
(disruption injury)
• Determinant of stability: Sublime tubercle
involvement
PMRI mechanism

Significant varus forces on the elbow can lead to fractures of the anteromedial facet of the coronoid.
Coronoid base type 3: Olecranon fracture-dislocation
• Elbow dislocation + Trans-olecranon # + Basal coronoid #
• Direct blow on Elbow  Distal humerus drives through proximal ulna

direct posterior injury mechanism

Clinical features
• Symptoms • Range of motion & instability
• Elbow deformity & swelling • Document flexion-extension and
• Elbow pain pronation-supination
• Forearm or wrist pain may be a sign of • Crepitus should be noted
associated injuries • Varus/valgus instability stress test

• Physical exam • Neurovascular exam

• Inspection & palpation
• Varus or valgus deformity
• Ecchymosis & swelling
• Diffuse tenderness
Imaging
• X-ray elbow: AP, Lateral +/- Oblique
• True lateral: Radial head overlaps coronoid (confused as radial head #)
• Radiocapitellar view: Separates radial head from coronoid
• AP: In AM coronoid # - progressive narrowing of joint space from lateral to
medial betn. Medial trochlea & coronoid
• CT with 3d reconstruction
• MRI
Radiocapitellar view
Non-Operative Treatment
Indication: Pugh et.al -
• Motion of humeroulnar and humeroradial joint reaches to concentric reduction
• Range of elbow extension reaches 30 degrees; joint has adequate stability
• Radial head fracture doesn’t present dislocation or has mild dislocation (<25%)
which doesn’t impact functional activity of forearm
• Fragment of coronoid fracture is small

Treatment:
• Long arm posterior plaster splint in neutral rotation and sling immobilization
• Short period of immobilization followed by Elbow ROM
Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD. Standard surgical protocol to treat elbow dislocations with radial
head and coronoid fractures. J Bone Joint Surg Am 2004; 86: 1122-1130.
Operative Treatment
Indication:
• Displaced fracture at any level
• Associated elbow instability

Treatment:
• Initial: Long arm plaster splint with sling
• Encourage wrist and finger ROM
• Elective ORIF  If ? About stability  Hinged
fixator X 6weeks
Options:
1. Type 1: Capsular suture repair
2. Type 2:
• Screws (AP or PA)
• Pass sutures through capsule and tie over drill holes in ulna
3. Anteromedial fragment:
• Medial approach/buttress plate
4. Unrepairable:
• Reconstruct with radial head, iliac crest or allograft
Suitable approaches:
1. Lateral (Kocher or Kaplan): Non-communited coronoid fractures
that can be fixed with screw alone (single approach for both
coronoid and radial head)

2. Medial (Taylor and Scham or Hotchkiss): Comminuted and/or

anteromedial coronoid fractures (allow internal fixation with
whatever method necessary)

3. Anterior approach: Not widely accepted

Lasso suture repair and Lag screws
a. Prepare tendon

b. Drill holes for sutures

c. Reduction & fixation

d. Reduction of larger,
simple coronoid #
Larger type II coronoid # & Type III coronoid
#
• McKee and colleagues published standard protocol to t/t elbow
dislocations with radial head & coronoid #:
1. Fix (<3 fragments) or replace the radial head (>3 fragments)
2. Reattach the LCL
3. With or without coronoid fixation
4. MCL repair in unusual case that the elbow is still subluxating or
dislocating
Postoperative rehabilitation
• 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
Complications
• Instability
• Insufficient reduction
• Nonunion
• Secondary displacement
• AVN coronoid fragment
• Early arthrosis
• Heterotopic bone formation:
• 20% in Type II fractures
• 80% in Type III fractures
• Postoperative stiffness (immobilization shouldn’t exceed >3 wks)
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.
References:

• Rockwood and Green’s Fractures in Adults 8th Edition

• Campbell’s Operative orthopaedics 13th Edition
• AO principle of fracture management 3rd Edition
• Schneeberger, A. G. (n.d.). The Treatment of Coronoid Fractures and their
Complications. Treatment of Elbow Lesions, 89–97. doi:10.1007/978-88-470-
0591-4_8
• Orthobullets
• THANK YOU