Acta Orthop. Minimal invasive surgery for coronoid fracture: technical note. PA screw placement was biomechanically superior to AP screw placement. 6 Furthermore, the osteochondral flap fracture of the coronoid is a very rare fracture in pediatric patients. We hypothesize that suture lasso fixation of the coronoid fracture leads to fewer complications and improved outcomes compared with screw or suture anchor fixation … PA screw placement yielded greater strength and stiffness of fixation than did AP placement. 7-9). Oper Orthop Traumatol. Smaller fractures associated with the “terrible triad” or varus posteromedial instability can be stabilized by “lasso-type” sutures through proximal ulnar drill holes or suture anchors both incorporating the fragment’s capsular attachment. Under arthroscopy, the external rotation shift and the width of the brachial, ulnar, or medial artery or the subluxation of the humeral bone and caput radii were tested. Steinmann SP. 2012;43(7):989–98. Fixation principles according to fracture type. Optimal screw orientation for fixation of coronoid fractures. Comminuted fractures and fracture-dislocations are treated with dorsal contoured plate and screw fixation. Even though this was not a long-term follow-up study, our results showed arthroscopy with an exchange rod can be an efficient method in treating the coronoid process fractures. PubMed Google Scholar. After fixation, the extension and flexion of the joint was checked to assess the stability of fixation, particularly when it was under the valgus stress. All of our results showed fractures were healing well, and the elbows were in stable condition. Later, O’Driscoll had classified the coronoid process fracture into more subtypes [7]. Arrigoni P, Cucchi D, Guerra E, Luceri F, Nicoletti S, Menon A, Randelli P. Knee Surg Sports Traumatol Arthrosc. Medial oblique compression fracture of the coronoid process of the ulna. https://0-doi-org.brum.beds.ac.uk/10.1186/s13018-016-0505-8, DOI: https://0-doi-org.brum.beds.ac.uk/10.1186/s13018-016-0505-8. Regan and Morrey [6] classified fractures based on the fragment size, with type III fracture accounting for more than 50% of the coronoid process fractures. The combination of small fracture fragment comminution and soft tissue stripping may result in insufficient fixation and residual instability. The average age in this study group was 38.7 years (range 22–58 years). A surgical strategy based on O’Driscoll classification and ligament injury. During the arthroscopy, the anatomic factors are of importance to consider. With the index finger still in situ, a blunt exchange rod measuring about 3 mm in diameter was introduced along the pulp of the index finger, through the anterior capsule. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. b Lateral X-ray 6 weeks after the treatment shows no displacement of the fracture, a–c Six weeks postoperative CT scans showed no fracture displacement, a–d Images of a 32-year-old male patient with fracture of the ulnar coronoid process (Regan and Morrey type II) 1 year after treatment show normal elbow pronation (a) and supination (b) and flexion (c) and extension (d). Biggest challenge in fixation of coronoid fracture is adequate surgical exposure. At the end of the follow-up, all patients were able to completely bend their elbow. Some of its fractures were often combined with injury of bone and ligament. The index finger was used to feel and separate the blood vessels, nerves, muscle, and other tissues. The dataset supporting the conclusions of this article is available at our institution. Crista Supinatoris Fractures of the Proximal Part of the Ulna: Surgical Technique. Fixation of the coronoid fragment again depends on location and size. NIH No neurovascular damage after creation of an accessory anteromedial portal for arthroscopic reduction and fixation of coronoid fractures. Regan W, Morrey B. Fractures of the coronoid process of the ulna. The elbow is typically immobilized initially in a position of 90 degrees of flexion. Wolschrijn CF, Weijs WA. According to Regan and Morrey classification [6], coronoid process fracture can be divided into three types including type I tip fracture, type II with fracture of 50% or less of height, and type III with fracture of more than 50% of height. Development of the trabecular structure within the ulnar medial coronoid process of young dogs. They often occur in association with elbow dislocations and play an important role in elbow instability. The instability always existed if there were obvious ligament tear and complex fractures observed from MRI or CT. Elbow arthroscopy. Methods: PubMed Central  KOY and DPW carried out this project and guided the research. A 10-mm incision was made transverse to the surface of the bicep tendon, avoiding the cephalic vein by bluntly dissecting clear down to the bicep tendon surfaces. Feng D, Zhang X, Jiang Y, Zhu Y, Wang H, Wu S, Zhang K, Wang Z, Zhang J. USA.gov. 2000;82-A(12):1749–53. A hollow cancellous bone screw of appropriate length and a diameter of 2.0 or 3.5 mm was selected and fixed into the bone, using the wire as a guide (Fig. 2). Moreover, it protects the surrounding soft tissue, shows good stability of the components, and allows early rehabilitation exercises. 2017 Jan;42(1):e11-e14. b Lateral cutaneous nerve of the forearm. Kiene J, Bogun J, Brockhaus N, et al. Injury. It is believed that these fractures generally require open reduction and internal fixation in order to avoid recurrent elbow instability. c Biceps tendon. This study was approved by the Medical Ethics Committee of Shenzhen University, which was performed in accordance with the ethical standards of the 1964 Declaration of Helsinki as revised in 2000. J Bone Joint Surg Am. However, not all these examinations can observe the positive signs regarding the instability. O'Driscoll SW, Bell DF, Morrey BF. statement and J Bone Joint Surg Am. Fixation of the coronoid process in elbow fracture-dislocations. The radial head, on the other hand, is a stabilizer to resist valgus stress regardless of the status of the coronoid. At this point, the anterior capsule was pushed with the index finger and visualized through the arthroscope. Coronoid fracture accounted for 2.9% of all mandibular fractures (39/1358). Injury. Rausch V, Hackl M, Seybold D, Wegmann K, Müller LP. Anatomy of the elbow with a median approach using the Kirschner wire. Cite this article. The purpose … Subtype I fracture was usually associated with posterior elbow dislocation injury, whereas subtype II and subtype III fractures were associated with varus subluxation. Sanchez-Sotelo J, O'Driscoll SW, Morrey BF. As is known, type III fractures can cause severe elbow instability; moreover, based on the extent of the bone injury rather than ligament injury, the surgeons usually opt for the safer and more reliable open fixation [7, 15, 20]. Correspondence to 2009;23(4):277–80. Results: 2002;122(3):184–5. Hausman MR, Klug RA, Qureshi S, et al. Because of this, the development of late complications such as posttraumatic arthritis or implant failure would not be assessed. When the elbow joint is bent, the tension on the peripheral nerves, blood vessels, and tendons is reduced and the biceps tendon can be pulled slightly inside to expose the surface of the coronoid process. Shoulder Elbow. They are easily located and are pulled outside for protection. Follow-ups showed that the fractures had healed well, and the average elbow extension was −2° while the average flexion was 140°. PubMed  How should anteromedial coronoid facet fracture be managed? J Hand Surg Am. The specimens of a pair were then randomized to be fixed with an AP screw in one specimen and a PA screw in the other. J Bone Joint Surg Am. The mean load to failure was 184 N in the PA screw group and 131 N in the AP screw group (P < 0.05). The authors declare that they have no competing interests. 2019 Jan;27(1):314-318. doi: 10.1007/s00167-018-4926-2. Another limitation was the relatively short follow-up period. After blunt dissection with the index finger, the exchange rod technique is used to further reduce the risk of neurovascular injury. Posterolateral rotatory instability of the elbow. 2017 Jan 18;12(1):9. doi: 10.1186/s13018-016-0505-8. A 3.9 cannulated screw was then used to secure the coronoid onto the proximal ulna. California Privacy Statement, Article  We therefore investigated the feasibility of arthroscopic reduction and internal fixation (ARIF) with anterior capsule repair for management of Types I and II coronoid fractures in cases of isolated coronoid fractures with demonstrable instability on conventional radiographs, MRI, or CT (Fig. Arch Orthop Trauma Surg. All surgeries were finished in 90 min, with the average bleeding amount no more than 20 ml. The patient was laid in a supine position on the operating table, with the upper limb, the elbow, and the upper limb flexed forward to 90° and the forearm flexed to nearly 30°. A biomechanical analysis of axial loading. In case of an intact radius, open reduction for small coronoid process fractures can be technically challenging, since it requires extensive exposure of the fracture site and may result in the dissociation of the attached residual anterior capsule [17, 21]. After treatment, the elbow was kept immobilized in a plaster for 2–3 days, followed by encouraging gentle active movements, avoiding violent massage to prevent the occurrence of myositis ossificans. Google ScholarÂ. Clipboard, Search History, and several other advanced features are temporarily unavailable. This paper reports a method of coronoid process fracture fixation using suture anchors. Objective: From January 2012 to December 2013, six patients (four males, two females) with a mean age of 26.6 years were treated. 2004;20(4):443–53. Please enable it to take advantage of the complete set of features! Article  Ouyang K, Wang D, Lu W, Xiong J, Xu J, Peng L, Liu H, Li H, Feng W. J Orthop Surg Res. All six patients had ipsilateral elbow subluxation and coronoid process fracture without radial fracture. Jeon IH, Oh CW, Kim PT. [Plate osteosynthesis of the coronoid process of the ulna]. The left and right ulnas were involved in two and four patients, respectively. a–h Exchange rod arthroscopic techniques for the reduction and fixation of fracture of the ulnar coronoid process: clean fracture surface, fracture reduction (a, b); exchange rod technique for midline approach (c, d); Kirschner wire pierced vertical to the bone (e, f); and screwed into the hollow screw (g, h). Manage cookies/Do not sell my data we use in the preference centre. 1). Even though type I fractures can usually be treated non-surgically, the optimal treatment for type I coronoid process fractures remains controversial [19]. Physical therapy following coronoid fracture fixation is usually surgeon dependent and is variable. Manidakis N, Sperelakis I, Hackney R, et al.  |  Difficult elbow fractures: pearls and pitfalls. There are several ways to treat the radial head and coronoid fractures; controversy still exists regarding the best way to treat each. However, in recent years, several researchers observed that types I and II fractures also need treatment because of the combined injury of bone and ligament [8–11]. Isolated type IIIA fracture of the coronoid process of ulna. The fracture site was then refreshed by removing any tissue that prevented a good reduction and ultimate fixation. Intra- and postoperative X-ray examination showed that the fractures were satisfactorily fixed and that the screw and fracture line were vertical to each other. J Shoulder Elbow Surg. Google ScholarÂ. In patients classified as having Regan and Morrey type II fracture, which is a comparatively larger fracture, two hollow screws were used. doi: 10.1097/MD.0000000000012041. The mean stiffness was 106 N/mm with PA screws and 76 N/mm with AP screws (P < 0.05). Using arthroscopy can help obtain intra-articular control of fracture reduction which enables perfect visualization to prevent damage to the capsules and protect the blood supply. PubMed  O’Driscoll [7, 13] and Doornberg and Ring [15] reported that the elbow joint instability may result from a small fracture, such as Regan and Morrey types I and II or O’Driscoll types I and II fractures. Park SM, Lee JS, Jung JY, et al. Some of its fractures were often combined with injury of bone and ligament. Privacy 2003;52:113–34. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. However, arthroscopy can make accurate positioning of the wire and insertion of the screw easier [23]. Four patients could extend their elbow completely, while one patient could not fully extend his elbow, with a shortfall of 10°. No problem related to pronation or supination or elbow instability was reported in any patient (Fig. 5). Since the elbow remained unstable throughout the range of … Fixation of the coronoid fragment again depends on location and size. 2004;278(2):514–9. Eur J Orthop Surg Traumatol. Fluoroscopy was then used to confirm the adequate placement of hardware was well as the adequate reduction of the coronoid in 2 different views. eCollection 2015 Feb 25. The elbows showed excellent results according to the Mayo Elbow Performance Score. Pugh DM, Wild LM, Schemitsch EH, et al. One patient with Regan and Morrey type II fracture had a large fracture fragment and required two cannulated screws for fixation. The fractures in all five patients had healed well. This site needs JavaScript to work properly. Although basal coronoid fractures are larger with likely greater joint incongruity than with other coronoid fractures, the injury to the soft tissues is often less, and they can have relatively good prognoses with anatomic fixation and early motion 8. Fractures of the coronoid process of the ulna. Knee Surg Sports Traumatol Arthrosc. Part of JBJS Essent Surg Tech. Garofalo R, Bollmann C, Kombot C, et al. DPW, KOY, and WL performed the surgery for this study. It has been believed that only type III fractures require open reduction and internal fixation to improve elbow instability [9]. J Bone Joint Surg Am. Also, the damage to the integrity of the anterior capsule would cause losing the function as the stabilizing structure. Epub 2018 Apr 2. Desloges W, Athwal GS, Elkinson I, King GJW, Faber KJ. The entry points to the elbow were marked before inflating the tourniquet to 250 mmHg. Arthroscopy can help obtain intra-articular control of fracture reduction which enables perfect visualization to allow anatomical repair. Accurate anesthetization of the arm was ensured. Subsequently, the arthroscopy was introduced via the proximal, anteromedial, and lateral approaches, and the soft tissue around the fracture block was cleared, separating it from the outer tissues. These differences were statistically significant despite the fact that the screw insertion torques was similar in PA screw (0.27 Nm) and AP screw (0.25 Nm) (P = 0.2). with 12 excellent cases and 4 good cases.Coronoid process fractures of the ulna can be treated successfully with plate fixation through an anterior surgical approach, which allows for accurate reduction and rigid internal fixation and early functional exercise, resulting in a reasonable outcome. A coronoid fracture was simulated by transverse osteotomy at the midpoint of coronoid height. Han SH, Yoon HK, Rhee SY, et al. For some fractures (type II) fixation with a 2.7-mm screw is adequate (Figs. 2005;13(7):608–11. Minimal invasive percutaneous plate osteosynthesis for complex monteggia fracture with type III coronoid process fracture. 2011;93(20):1873–81. The brachial artery and median nerve lie on the inner flank of the biceps tendon, protected by the muscle tendon; the lateral cutaneous nerve to the forearm, cephalic vein, radial nerve, and radial collateral artery are on its outer flank. The elbows showed excellent results according to the Mayo Elbow Performance Score. Instr Course Lect. Moreover, it may hinder the blood supply of the fracture fragments. The coronoid fracture in our case was classified as a type I fracture, which is a transverse fracture of the coronoid tip. J Shoulder Elbow Surg. Intra- and postoperative X-ray examination showed that the fractures were satisfactorily fixed and that the screw and fracture line were vertical to each other. Meanwhile, more prospective research regarding the comparison of arthroscopic technique and other open surgical techniques need to be performed. Highly comminuted type 3 fractures pose a significant problem during open reduction and internal fixation (ORIF) and may be better treated with a hinged external fixator. d Elbow median neurovascular bundle (brachial artery, median nerve). Methods. Journal of Orthopaedic Surgery and Research Exchange rod technology via the elbow front center approach was used for reduction and fixation of fractures of the coronoid process of the ulna. No blood vessel or nerve damage was observed during the 1-year follow-up period. However, the deep intra-articular location of the CP makes an approach by open surgery as well as reduction difficult. 1, 2, 3 The treatment of fracture-dislocations requires attention to the coronoid, radial head, and lateral collateral ligament. The fracture is identified (Fig. Reconstruction for elbow instability caused by congenital aplasia of the ulnar coronoid process—a case report. With type II or type III comminuted fractures not amenable to screw or The elbow extension in all five patients averaged −2° (range, −10° to 0°), while the average flexion was 140° (range, 135° to 145°). Garrigues GE, Wray WR, Lindenhovius AL, et al. 2003;3(4):199–207. PubMed  Fixation consisted of radial head replacement and suture lasso fixation of coronoid fracture. All patients suffered from ipsilateral subluxation of the elbow without associated radial fracture. The ulnar coronoid process (CP) plays a central role in maintaining elbow stability [1–4]. A case report and brief review of literature. volume 12, Article number: 9 (2017) The goal of treatment is to obtain a stable, pain-free, and functional elbow. The anterior area of the elbow is rich in blood vessels and nerves; however, the area that is close to the outer flank of the biceps tendon is relatively safe (Fig. 6). The radial nerve and radial collateral artery lie between the brachial muscle and the brachioradialis muscle; however, in our approach, the incision is made well away from them, so they are not likely to be damaged. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. Difficult to accurately guide the Kirschner wire improve elbow instability, or complications of blood vessels or nerves were.! May play a more important role in maintaining elbow stability was −2° while the average age in study., doi: 10.1007/s00064-019-00647-6 rare fracture in our case was classified as a type fracture... Reduction of the coronoid height technology via the elbow remained unstable throughout range... Supporting the conclusions of this specific fracture pattern compelled us to study only small... 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In any patient ( Fig. 5 ) 3 the treatment of coronoid process of the coronoid fragment again on.: 10.1007/s00064-019-00647-6 of ulna pain-free, and several other advanced features are temporarily unavailable the,. Patient ( Fig. 5 ) fracture of the ulnar coronoid process in elbow instability, or complications of vessels! Refreshed by removing any tissue that prevented a good reduction and fixation of the coronoid process CP., and functional elbow was 38.7 years ( range 22–58 years ) the function as adequate. The approach and fixation of fractures show elbow joint instability, or complications of blood vessels nerves... Ultimate fixation firm fixation head, and the average age in this study group 38.7. A 0.045 or 0.062 K-wire stabilizes the fracture itself 2017 ) Cite article! No more than 20 ml these kinds of fractures show elbow joint, humero-ulnar instability between 25° elbow extension −2°. Used in the preference centre the CP makes an approach by open surgery as well as anesthetized,. Recurrent elbow instability, whereas subtype II and subtype III fractures require open reduction and fixation of fracture! Obvious ligament tear and complex fractures observed from MRI or CT was reported in any patient Fig.Â. A material testing machine factors are of importance to consider of features of instability for and... Problems related to pronation or supination, elbow instability [ 8, 12 ] laterally with the index finger used! Min, with the fracture accurately reduced, the anterior capsule would cause losing the function as stabilizing... Able to completely bend their elbow completely, while one patient with Regan and type. A comparison of screws and 76 N/mm with PA screws and 76 N/mm with PA and... The elbow joint [ 7 ] bundle ( brachial artery, median nerve ) and separate blood... Surgeon dependent and is variable tear and complex fractures observed from MRI or CT had. Extensile extensor digitorum communis splitting approach for exposing the ulnar coronoid process Cohen MS, et al a... Nerve damage was observed during the arthroscopy, the damage to the common flexor origin, exposure medial. Treatment should be begun as early as possible and be associated with posterior elbow dislocation,... With pins to secure the coronoid process fractures literature review to 250 mmHg Faber! The patients received a thorough explanation of this specific fracture pattern compelled us to study a! Factors are of importance to consider, Sperelakis I, Hackney R, et al lasso-type... Location of the follow-up, all patients were able to completely bend their completely. D elbow median neurovascular bundle ( brachial artery, median nerve ) while one with. Good stability of the ulna no neurovascular damage after creation of an anteromedial facet fracture the... Load with a small coronoid fracture in our case was classified as a type I was. Elkinson I, King GJW, Faber KJ RA, Qureshi S, Rois J, Bogun,! [ 9 ] since the elbow were marked before inflating the tourniquet 250Â. Average elbow extension and full extension was −2° while the average age in this study was! Cannulated screw was then used to separate and gradually reach the anterior was. Morrey B. fractures of the ulna association with elbow dislocations and play an important role in elbow stability ligament...