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Coronoid Fracture Treatment & Management

  • Author: Nirmal Tejwani, MD, MPA; Chief Editor: Harris Gellman, MD  more...
 
Updated: Nov 02, 2015
 

Medical Therapy

Nonoperative treatment is indicated for type 1 and type 2 injuries. This includes closed reduction of the dislocation and splinting it in a moderate degree of flexion for a short period (< 3 wk) before starting a program of protected mobilization of the elbow.

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Surgical Therapy

See Indications, above.

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Preoperative Details

Adequate preoperative imaging studies should be carried out to ascertain the exact fracture anatomy. Skin condition must be evaluated because severe soft-tissue injury and swelling may be present.

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Intraoperative Details

The coronoid can be approached posteromedially through a posterior midline incision after lifting the ulnar origin of the extensor carpi ulnaris (ECU) subperiosteally.

In cases of a Monteggia fracture-dislocation, the coronoid may be approached through the interval between the ECU and the anconeus laterally and the flexor carpi ulnaris (FCU) medially. The radial head may be approached between the anconeus medially and the ECU laterally. This will help prevent formation of a synostosis between the radius and the ulna.

After exposing the fracture site and cleaning the edges, the fragment is anatomically reduced and fixed by means of an interfragmentary screw (from posterior to anterior, or from anterior to posterior if the fragment is small or osteoporotic). The fracture may also be stabilized using heavy nonabsorbable sutures or suture anchors.[30, 31]

The results from one study noted that suture lasso fixation of coronoid fractures for terrible triad injuries results in fewer complications and greater stability compared with screw or suture anchor fixation techniques. A higher rate of implant failure was noted with internal screw fixation, while the suture anchor technique resulted in a higher rate of malunion and nonunion.[32]

In patients with highly comminuted coronoid fractures, reconstruction using a piece of the radial head (Esser technique) or a piece of the olecranon (Moritomo technique) has been described.[33]

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Postoperative Details

The elbow is immobilized at 90° of flexion in a well-padded posterior splint. The neurovascular status of the upper limb is monitored closely for the fist 24 hours. At the earliest sign of neurovascular dysfunction, encircling dressing and bandages should be loosened and compartment pressures should be measured.

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Follow-up

The elbow is immobilized for about a week, and then a protected mobilization program in a hinged orthosis is initiated, which prevents varus-valgus stresses on the elbow. Brace use is continued for approximately 4-6 weeks to allow the ligaments to heal.

Prophylaxis against heterotopic ossification is initiated the day after surgery. The authors prefer to use indomethacin (75 mg PO) for 3 weeks following the surgery.

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Complications

Complications include the following:

  • Neurovascular injury
  • Stiffness
  • Heterotopic ossification
  • Instability and recurrent dislocation
  • Posttraumatic arthritis of the elbow
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Outcome and Prognosis

The prognosis for a complex fracture dislocation of the elbow is definitely poorer than that for a simple elbow dislocation, which has been shown to have good long-term results.[34, 35, 36, 37, 38]

Prognostic factors include the following:

  • Size of the fragment: type 3 fractures have the worst prognosis, with only 20% having good results in the series presented by Regan et al [8]
  • The degree of damage to the articular cartilage at the time of injury
  • The extent of soft-tissue injury [39]
  • The stability obtained at the time of reduction
  • The duration of immobilization [40]
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Future and Controversies

In the past, coronoid fractures were treated with a longer period of immobilization (3-4 wk) in greater degrees of flexion, and this was believed to be a better alternative than operative treatment. However, with increasing understanding of the contribution of the coronoid to stability of the elbow, the trend increasingly is toward operative stabilization of these injuries and initiation of an early, protected range-of-motion program to avoid the most dreaded complication of these injuries, which is stiffness.

However, after studying 58 patients over an 8-year period, Kiene et al concluded that surgical therapy cannot be statistically justified, particularly if the patient underwent therapy with an external fixator, immobilization for more than 3 weeks, and complications and unstable osteosyntheses.[41]

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Contributor Information and Disclosures
Author

Nirmal Tejwani, MD, MPA Professor of Orthopedic Surgery, New York University Hospital for Joint Diseases; Chief of Orthopedic Trauma, Bellevue Hospital

Nirmal Tejwani, MD, MPA is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Orthopaedic Trauma Association, AO Foundation

Disclosure: Received honoraria from Stryker for speaking and teaching; Received honoraria from Zimmer for speaking and teaching; Received royalty from Biomet for other.

Coauthor(s)

Mihir M Thacker, MBBS, MS(Orth), DNB(Orth), FCPS(Orth), D'Ortho Associate Professor of Orthopedic Surgery and Pediatrics, Jefferson Medical College of Thomas Jefferson University; Consulting Staff, Department of Pediatric Orthopedic Surgery, Alfred I duPont Hospital for Children; Orthopedic Oncologist, Helen F Graham Cancer Center and Christiana Care Health Services

Mihir M Thacker, MBBS, MS(Orth), DNB(Orth), FCPS(Orth), D'Ortho is a member of the following medical societies: Children's Oncology Group, Medical Council of India, Musculoskeletal Tumor Society, Pediatric Orthopaedic Society of North America, Limb Lengthening and Reconstruction Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Robert J Nowinski, DO Clinical Assistant Professor of Orthopaedic Surgery, Ohio State University College of Medicine and Public Health, Ohio University College of Osteopathic Medicine; Private Practice, Orthopedic and Neurological Consultants, Inc, Columbus, Ohio

Robert J Nowinski, DO is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, Ohio State Medical Association, Ohio Osteopathic Association, American College of Osteopathic Surgeons, American Osteopathic Association

Disclosure: Received grant/research funds from Tornier for other; Received honoraria from Tornier for speaking and teaching.

Chief Editor

Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine, Clinical Professor, Surgery, Nova Southeastern School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, Arkansas Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

Steven I Rabin, MD Clinical Associate Professor, Department of Orthopedic Surgery and Rehabilitation, Loyola University, Chicago Stritch School of Medicine; Medical Director, Orthopedic Surgery, Podiatry, Rheumatology, Sports Medicine, and Pain Management, Dreyer Medical Clinic; Chairman, Department of Surgery, Provena Mercy Medical Center

Steven I Rabin, MD is a member of the following medical societies: AO Foundation, American Academy of Orthopaedic Surgeons, American Fracture Association, Orthopaedic Trauma Association

Disclosure: Nothing to disclose.

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Elbow joint, anterior view.
Elbow joint, posterior view.
 
 
 
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