Sections

Workup

Radiography

Radiographs of the elbow in the anteroposterior (AP), lateral, and, if required, oblique views should be obtained to provide a clear assessment of the extent of bony injury. Oblique views are especially important in minimally displaced fractures because in a true lateral view, the radial head overlaps the coronoid. To avoid this problem, Greenspan and Norman described the radiocapitellar view, in which the elbow is flexed to 90º and placed flat on the table with the x-ray beam directed obliquely toward the shoulder.^{[23, 24]} This separates the radial head from the coronoid.

Regan and Morrey classified coronoid fractures depending on the size of the fragment, as follows^[15]:

Type 1 - Avulsion of the tip of the coronoid process (see the first image below); some have not considered this to be an avulsion, in that the brachialis is attached to the base of the coronoid
Type 2 - Single or comminuted fragment involving less than 50% of the coronoid (see the second image below)
Type 3 - Single or comminuted fragment involving more than 50% of the coronoid (see the third image below)

$Type 1 coronoid fracture: avulsion fracture at tip$ Type 1 coronoid fracture: avulsion fracture at tip of coronoid.

View Media Gallery

$Type 2 coronoid fracture: unstable elbow fracture$ Type 2 coronoid fracture: unstable elbow fracture dislocation with fracture involving <50% of coronoid height and associated radial head fracture.

View Media Gallery

$Type 3 coronoid fracture: fracture involving >50%$ Type 3 coronoid fracture: fracture involving >50% of coronoid height.

View Media Gallery

O'Driscoll proposed a somewhat more detailed classification that included three main types, each of which had two or three subtypes^[25]:

Type I: Fracture of coronoid tip -- (1) ≤ 2 mm of coronoid height; (2) >2 mm of coronoid height
Type II: Fracture of anteromedial facet -- (1) Anteromedial rim; (2) anteromedial rim and tip; (3) anteromedial rim and sublime tubercle ± tip
Type III: Fracture of coronoid process base -- (1) Coronoid body and base; (2) transolecranon basal coronoid fracture

CT and MRI

Computed tomography (CT) may be useful in complex fracture dislocations to delineate the fracture patterns and for preoperative planning.^{[26, 27]}

Rhyou et al studied rates of associated ligamentous injury in isolated and combined coronoid fractures and found the following^[28]:

Complete lateral ulnar collateral ligament rupture (94.1%)
Complete medial (ulnar) collateral ligament rupture (17.6%)
Medial bone contusion (70.6%)
Lateral bone contusion (17.6%)

For magnetic resonance imaging (MRI) findings in elbows with a radial head fracture, see Kaas et al.^[29]

Treatment & Management

Hartzler RU, Morrey BF. Coronoid fractures. Morrey BF, Sanchez-Sotelo J, Morrey ME, eds. Morrey's the Elbow and Its Disorders. 5th ed. Philadelphia: Elsevier; 2018. 428-39.
Ring D, Horst TA. Coronoid Fractures. J Orthop Trauma. 2015 Oct. 29 (10):437-40. [QxMD MEDLINE Link].
Kovacevic D, Vogel LA, Levine WN. Complex Elbow Instability: Radial Head and Coronoid. Hand Clin. 2015 Nov. 31 (4):547-56. [QxMD MEDLINE Link].
Ohl X, Siboni R. Surgical treatment of terrible triad of the elbow. Orthop Traumatol Surg Res. 2021 Feb. 107 (1S):102784. [QxMD MEDLINE Link].
Ring D, Jupiter JB. Fracture-dislocation of the elbow. Hand Clin. 2002 Feb. 18 (1):55-63. [QxMD MEDLINE Link].
Ring D, Jupiter JB, Zilberfarb J. Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am. 2002 Apr. 84 (4):547-51. [QxMD MEDLINE Link].
Ring D. Fractures of the coronoid process of the ulna. J Hand Surg Am. 2006 Dec. 31 (10):1679-89. [QxMD MEDLINE Link].
Wells J, Ablove RH. Coronoid fractures of the elbow. Clin Med Res. 2008 May. 6 (1):40-4. [QxMD MEDLINE Link]. [Full Text].
Steinmann SP. Coronoid process fracture. J Am Acad Orthop Surg. 2008 Sep. 16 (9):519-29. [QxMD MEDLINE Link].
Mathew PK, Athwal GS, King GJ. Terrible triad injury of the elbow: current concepts. J Am Acad Orthop Surg. 2009 Mar. 17 (3):137-51. [QxMD MEDLINE Link].
Forthman C, Henket M, Ring DC. Elbow dislocation with intra-articular fracture: the results of operative treatment without repair of the medial collateral ligament. J Hand Surg Am. 2007 Oct. 32 (8):1200-9. [QxMD MEDLINE Link].
Cage DJ, Abrams RA, Callahan JJ, Botte MJ. Soft tissue attachments of the ulnar coronoid process. An anatomic study with radiographic correlation. Clin Orthop Relat Res. 1995 Nov. (320):154-8. [QxMD MEDLINE Link].
Morrey BF. Complex instability of the elbow. Instr Course Lect. 1998. 47:157-64. [QxMD MEDLINE Link].
Closkey RF, Goode JR, Kirschenbaum D, Cody RP. The role of the coronoid process in elbow stability. A biomechanical analysis of axial loading. J Bone Joint Surg Am. 2000 Dec. 82 (12):1749-53. [QxMD MEDLINE Link].
Regan W, Morrey B. Fractures of the coronoid process of the ulna. J Bone Joint Surg Am. 1989 Oct. 71 (9):1348-54. [QxMD MEDLINE Link].
Antuña S, Alvarez EDT, Barco R, Morrey BF. Radial head fracture: general considerations, conservative treatment, and radial head resection. Morrey BF, Sanchez-Sotelo J, Morrey ME, eds. Morrey's The Elbow and Its Disorders. 5th ed. Philadelphia: Elsevier; 2018. 375-87.
Egol KA, Immerman I, Paksima N, Tejwani N, Koval KJ. Fracture-dislocation of the elbow functional outcome following treatment with a standardized protocol. Bull NYU Hosp Jt Dis. 2007. 65 (4):263-70. [QxMD MEDLINE Link].
Kälicke T, Muhr G, Frangen TM. Dislocation of the elbow with fractures of the coronoid process and radial head. Arch Orthop Trauma Surg. 2007 Dec. 127 (10):925-31. [QxMD MEDLINE Link].
Adams JE, Hoskin TL, Morrey BF, Steinmann SP. Management and outcome of 103 acute fractures of the coronoid process of the ulna. J Bone Joint Surg Br. 2009 May. 91 (5):632-5. [QxMD MEDLINE Link].
Rodriguez-Martin J, Pretell-Mazzini J, Andres-Esteban EM, Larrainzar-Garijo R. Outcomes after terrible triads of the elbow treated with the current surgical protocols. A review. Int Orthop. 2011 Jun. 35 (6):851-60. [QxMD MEDLINE Link].
Lill H, Korner J, Rose T, Hepp P, Verheyden P, Josten C. Fracture-dislocations of the elbow joint--strategy for treatment and results. Arch Orthop Trauma Surg. 2001. 121 (1-2):31-7. [QxMD MEDLINE Link].
Blasier RD. Intra-articular flap fracture of the olecranon in a child. A case report. J Bone Joint Surg Am. 1989 Jul. 71 (6):945-7. [QxMD MEDLINE Link].
Greenspan A, Norman A, Rosen H. Radial head-capitellum view in elbow trauma: clinical application and radiographic-anatomic correlation. AJR Am J Roentgenol. 1984 Aug. 143 (2):355-9. [QxMD MEDLINE Link].
Greenspan A, Norman A. Radial head-capitellum view: an expanded imaging approach to elbow injury. Radiology. 1987 Jul. 164 (1):272-4. [QxMD MEDLINE Link].
O'Driscoll SW, Jupiter JB, Cohen MS, Ring D, McKee MD. Difficult elbow fractures: pearls and pitfalls. Instr Course Lect. 2003. 52:113-34. [QxMD MEDLINE Link].
Guitton TG, van der Werf HJ, Ring D. Quantitative measurements of the volume and surface area of the radial head. J Hand Surg Am. 2010 Mar. 35 (3):457-63. [QxMD MEDLINE Link].
Lindenhovius A, Karanicolas PJ, Bhandari M, van Dijk N, Ring D, Collaboration for Outcome Assessment in Surgical Trials. Interobserver reliability of coronoid fracture classification: two-dimensional versus three-dimensional computed tomography. J Hand Surg Am. 2009 Nov. 34 (9):1640-6. [QxMD MEDLINE Link].
Rhyou IH, Lee JH, Kim KC, Ahn KB, Moon SC, Kim HJ, et al. What Injury Mechanism and Patterns of Ligament Status Are Associated With Isolated Coronoid, Isolated Radial Head, and Combined Fractures?. Clin Orthop Relat Res. 2017 Sep. 475 (9):2308-2315. [QxMD MEDLINE Link].
Kaas L, Turkenburg JL, van Riet RP, Vroemen JP, Eygendaal D. Magnetic resonance imaging findings in 46 elbows with a radial head fracture. Acta Orthop. 2010 Jun. 81 (3):373-6. [QxMD MEDLINE Link].
Papatheodorou LK, Rubright JH, Heim KA, Weiser RW, Sotereanos DG. Terrible triad injuries of the elbow: does the coronoid always need to be fixed?. Clin Orthop Relat Res. 2014 Jul. 472 (7):2084-91. [QxMD MEDLINE Link]. [Full Text].
Klug A, Nagy A, Hagebusch P, Fischer S, Gramlich Y, Hoffmann R. Coronoid tip fractures in terrible triad injuries can be safely treated without fixation. Arch Orthop Trauma Surg. 2023 Aug. 143 (8):5055-5064. [QxMD MEDLINE Link].
Chan K, MacDermid JC, Faber KJ, King GJ, Athwal GS. Can we treat select terrible triad injuries nonoperatively?. Clin Orthop Relat Res. 2014 Jul. 472 (7):2092-9. [QxMD MEDLINE Link]. [Full Text].
Kim BS, Kim DH, Byun SH, Cho CH. Does the Coronoid Always Need to Be Fixed in Terrible Triad Injuries of the Elbow? Mid-Term Postoperative Outcomes Following a Standardized Protocol. J Clin Med. 2020 Oct 29. 9 (11):[QxMD MEDLINE Link]. [Full Text].
Watters TS, Garrigues GE, Ring D, Ruch DS. Fixation versus replacement of radial head in terrible triad: is there a difference in elbow stability and prognosis?. Clin Orthop Relat Res. 2014 Jul. 472 (7):2128-35. [QxMD MEDLINE Link]. [Full Text].
Giannicola G, Sacchetti FM, Greco A, Cinotti G, Postacchini F. Management of complex elbow instability. Musculoskelet Surg. 2010 May. 94 Suppl 1:S25-36. [QxMD MEDLINE Link].
Kiene J, Wäldchen J, Paech A, Jürgens Ch, Schulz AP. Midterm Results of 58 Fractures of the Coronoid Process of the Ulna and their Concomitant Injuries. Open Orthop J. 2013. 7:86-93. [QxMD MEDLINE Link]. [Full Text].
Hanks GA, Kottmeier SA. Isolated fracture of the coronoid process of the ulna: a case report and review of the literature. J Orthop Trauma. 1990. 4 (2):193-6. [QxMD MEDLINE Link].
Kumar D, Sodavarapu P, Kumar K, Hooda A, Neradi D, Bachchal V. Functional Outcome of Surgically Treated Isolated Coronoid Fractures With Elbow Dislocation in Young and Active Patients. Cureus. 2020 Oct 10. 12 (10):e10883. [QxMD MEDLINE Link]. [Full Text].
Lu S, Wang Y, Rui B, Ding J. Comparison of different treatment approaches for coronoid process fracture in terrible triad injury: a multicenter, randomized controlled study. Int Orthop. 2023 Aug. 47 (8):2103-2111. [QxMD MEDLINE Link].
Sotereanos DG, Darlis NA, Wright TW, Goitz RJ, King GJ. Unstable fracture-dislocations of the elbow. Instr Course Lect. 2007. 56:369-76. [QxMD MEDLINE Link].
Ye H, Yang Y, Xing T, Tan G, Jin S, Zhao Z, et al. Anatomical and Biomechanical Stability of Single/Double Screw-Cancellous Bone Fixations of Regan-Morry Type III Ulnar Coronoid Fractures in Adults: CT Measurement and Finite Element Analysis. Orthop Surg. 2023 Apr. 15 (4):1072-1084. [QxMD MEDLINE Link]. [Full Text].
Pai V, Pai V. Use of suture anchors for coronoid fractures in the terrible triad of the elbow. J Orthop Surg (Hong Kong). 2009 Apr. 17 (1):31-5. [QxMD MEDLINE Link].
Clarke SE, Lee SY, Raphael JR. Coronoid fixation using suture anchors. Hand (N Y). 2009 Jun. 4 (2):156-60. [QxMD MEDLINE Link]. [Full Text].
Wang C, Zhang C, Zhou D, Lu D, Li Z, Duan N, et al. A novel and superior Lasso-plate technique in treatment for coronoid process fracture in the terrible triad of elbow. Sci Rep. 2023 Jul 19. 13 (1):11656. [QxMD MEDLINE Link]. [Full Text].
Garrigues GE, Wray WH 3rd, Lindenhovius AL, Ring DC, Ruch DS. Fixation of the coronoid process in elbow fracture-dislocations. J Bone Joint Surg Am. 2011 Oct 19. 93 (20):1873-81. [QxMD MEDLINE Link].
Giannicola G, Polimanti D, Gumina S, Cinotti G. Use of fine-threaded K-wires in the treatment of coronoid fractures in complex elbow instability. Orthopedics. 2013 Oct 1. 36 (10):e1233-8. [QxMD MEDLINE Link].
Ouyang K, Wang D, Lu W, Xiong J, Xu J, Peng L, et al. Arthroscopic reduction and fixation of coronoid fractures with an exchange rod-a new technique. J Orthop Surg Res. 2017 Jan 18. 12 (1):9. [QxMD MEDLINE Link]. [Full Text].
Moritomo H, Tada K, Yoshida T, Kawatsu N. Reconstruction of the coronoid for chronic dislocation of the elbow. Use of a graft from the olecranon in two cases. J Bone Joint Surg Br. 1998 May. 80 (3):490-2. [QxMD MEDLINE Link].
Gray AB, Alolabi B, Ferreira LM, Athwal GS, King GJ, Johnson JA. The effect of a coronoid prosthesis on restoring stability to the coronoid-deficient elbow: a biomechanical study. J Hand Surg Am. 2013 Sep. 38 (9):1753-61. [QxMD MEDLINE Link].
Zhao S, Zeng C, Yuan S, Li R. Reconstruction of coronoid process of the ulna: a literature review. J Int Med Res. 2021 Apr. 49 (4):3000605211008323. [QxMD MEDLINE Link]. [Full Text].

Media Gallery

Elbow joint, anterior view.
Elbow joint, posterior view.
Type 2 coronoid fracture: unstable elbow fracture dislocation with fracture involving <50% of coronoid height and associated radial head fracture.
Type 3 coronoid fracture: fracture involving >50% of coronoid height.
Type 1 coronoid fracture: avulsion fracture at tip of coronoid.
Status post open reduction and internal fixation of coronoid with plate-and-screw construct. Courtesy of Kenneth Egol, MD.
Status post open reduction and suture fixation of coronoid, as evidenced by drill holes in proximal ulna. Sutures are used as a lasso to capture coronoid fragment, passed through ulnar drill holes, and tied over posterior ulna bony bridge. Patient is also status post radial head replacement for comminuted radial head fracture. This is an example of typical operative management of "terrible triad" elbow injuries.
Second example of plate-and-screw constructs for fixation of type 3 coronoid fracture. Courtesy of Kenneth Egol, MD.
Chronic elbow fracture dislocation presentation films with type II coronoid fracture (left) and fixation films (right). Fixation consisted of radial head replacement and suture lasso fixation of coronoid fracture. Since the elbow remained unstable throughout the range of motion, a hinged external fixator was placed.

of 9

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, AO Foundation, Orthopaedic Trauma Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Orthopedic Trauma Association Board of directors.<br/>Received honoraria from Stryker for speaking and teaching; Received honoraria from Zimmer for speaking and teaching; for: Stryker; Zimmer.

Coauthor(s)

Nicole Stevens, MD Resident Physician, Department of Orthopedics, NYU Langone Medical Center

Nicole Stevens, MD is a member of the following medical societies: American Medical Student Association/Foundation, Pennsylvania Medical 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

Murali Poduval, MBBS, MS, DNB Orthopaedic Surgeon, Senior Consultant, and Subject Matter Expert, Tata Consultancy Services, Mumbai, India

Murali Poduval, MBBS, MS, DNB is a member of the following medical societies: Association of Medical Consultants of Mumbai, Bombay Orthopedic Society, Indian Orthopedic Association, Indian Society of Hip and Knee Surgeons

Disclosure: Nothing to disclose.

Additional Contributors

Steven I Rabin, MD, FAAOS Clinical Associate Professor, Department of Orthopedic Surgery and Rehabilitation, Loyola University, Chicago Stritch School of Medicine; Medical Director, Musculoskeletal Services, Dreyer Medical Clinic

Steven I Rabin, MD, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Fracture Association, American Orthopaedic Association, AO Foundation, Chicago Metropolitan Trauma Society, Illinois Association of Orthopaedic Surgeons, Limb Lengthening and Reconstruction Society, Mid-America Orthopaedic Association, Orthopaedic Trauma Association

Disclosure: Nothing to disclose.

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.

Coronoid Fracture Workup

Radiography

CT and MRI

References

Tables

Contributor Information and Disclosures

What would you like to print?