Coronoid Fracture Research Articles

Fracture Patterns, Outcomes, and Complications of Terrible Triad Injury in Elderly Patients

Fracture Patterns, Outcomes, and Complications of Terrible Triad Injury in Elderly Patients

Suture button systems for coronoid fracture fixation: a biomechanical time-zero pilot study

PurposeThis study aims to describe a fixation technique for coronoid fractures using suture buttons, and to biomechanically evaluate this technique in comparison to screw fixation as a time-zero pilot study.MethodsAn O’Driscoll type 2 anteromedial coronoid facet (AMCF) fracture was simulated in 20 fresh-frozen human elbows. The specimens were randomized into two groups and fracture fixation was performed with either a suture button system or a 3.5 mm cannulated screw. Ultimate load-to-failure (N) was then tested for each specimen.ResultsThe mean load-to-failure was 322.6 ± 75.9 N for suture button fixation and 314.2 ± 85.9 N for screw fixation. The differences were not statistically significant (p = 0.432). Additional fracturing of the coronoid fragment was observed in two specimens with screw fixation.ConclusionPromising biomechanical evaluations show that this fixation technique using suture buttons in the treatment of coronoid fractures provides equal construct stability as screw fixation. Further studies are required to fully validate this procedure.

Surgical Treatment of Coronoid Fracture With Elbow Varus Posteromedial Rotatory Instability: An Instructional Review.

Varus posteromedial rotatory instability (VPMRI) of the elbow is one of the complex elbow instability. The primary sites of injury encompass fractures of the anteromedial coronoid process and injuries to the lateral collateral ligament of the elbow. Some patients may present with involvement of the medial collateral ligament of the elbow. Owing to its distinctive injury mechanism and imaging characteristics, this condition is infrequent in clinical practice and susceptible to misdiagnosis and missed diagnosis. Literature reviews indicate that conservative management of VPMRI is associated with numerous complications, such as persistent pain, traumatic arthritis, and chronic elbow instability. Consequently, surgical intervention has emerged as the recommended treatment modality. Nonetheless, the lack of systematic research on VPMRI in clinical practice has been inconclusive regarding the optimal internal fixation techniques and surgical approaches. Therefore, investigating the treatment modalities, surgical techniques, and internal fixation strategies for VPMRI associated with coronoid fractures holds substantial importance for informing clinical management. In this review, we systematically synthesize the existing literature on coronoid fractures with VPMRI for offering a valuable reference for future clinical treatment.

A Case Series of Terrible Triad Elbow Injuries Treated with Lasso Suture Fixation for Coronoid, Tripod Fixation for Radial Head, and LCL Repair.

Terrible triad includes posterior dislocation of the elbow, radial head fracture, and coronoid fracture. It renders the elbow joint unstable, creating a need for surgical intervention. The purpose of our study was to analyze the outcomes in such patients who underwent surgery in this tertiary care center. Ten cases were identified in this monocentric single surgeon retrospective study. The cases had radial head tripod fixation with Headless screws, coronoid fixation with transosseous suture tape, and lateral collateral ligament (LCL) repair with suture anchors/ethibond. The assessment was done using the Oxford elbow score and range of motion. Eight of the ten cases had Mason type 3 radial head fracture pattern, and the remaining had type 2. Six cases had Regan Morey type 1 coronoid fracture, rest had type 2. The mean follow-up period was 38 months (range 4-64 months). The Oxford elbow scores for Pain: A mean of 98.6 (standard deviation [SD] 3.1), Function: A mean of 97.8 (SD 3.6), and Psychosocial domain: A mean of 96 (SD 5.8). The flexion-extension range of motion arc mean is 130° (SD 6.1). The mean Pronation is 69° (SD 2.23). The mean supination is 79° (SD 2.23). Heterotopic ossification was noticed in one patient. A radial head fracture with three or more fragments should not always indicate a radial head prosthesis or excision. Fixation can also achieve good results. LCL repair, coronoid fixation, and the anterior capsule add to joint stability.

Role of 3D CT with Humeral Subtraction in Assessing Anteromedial Facet Coronoid Fractures

Role of 3D CT with Humeral Subtraction in Assessing Anteromedial Facet Coronoid Fractures

The Challenge of Trans-Ulnar Basal Coronoid Fracture-Dislocations: A Surgical Strategy Based on the Pattern of Coronoid Fracture.

The rarity and complexity of trans-ulnar basal coronoid fracture-dislocations pose significant challenges in treatment. This study aimed to categorize these fractures based on coronoid fracture patterns and propose tailored surgical approaches for each type. Additionally, we evaluated the functional and radiological outcomes among the patients managed using our treatment algorithm. A total of 19 patients who underwent open reduction and internal fixation for trans-ulnar basal coronoid fracture-dislocations between March 2018 and October 2022 were enrolled in this study. These patients were classified based on the coronoid fracture patterns associated with olecranon fractures: type 1 involved anteromedial facet (AMF) fractures, type 2 encompassed coronoid base and body fractures, and type 3 involved a combination of types 1 and 2. We made a midline longitudinal dorsal incision to facilitate the provisional fixation of the olecranon fragment to the distal metaphysis using a locking plate. Subsequently, we employed the over-the-top (type 1) and Taylor-Scham (type 3) approaches for direct coronoid process fixation with buttress plating. Type 2 fractures were approached via medial fascial exposure from the posterior ulnar cortex or through the olecranon fractures, and subsequently fixed with miniplates and screws. Bony union and joint articulation were assessed via plain radiographs, and functional outcomes were evaluated using range of motion and the Mayo Elbow Performance Score. Among the 19 patients, 3 had type 1 fractures, 14 had type 2 fractures, and 2 had type 3 fractures. All fractures exhibited solid osseous union without subluxation or dislocation. The average flexion and extension arc was 119.47° ± 20.88°, with a mean flexion of 127.37° ± 13.37° and an average flexion contracture of 7.89° ± 10.04°. The average Mayo Elbow Performance Score was 82.63 ± 12.51 points. Qualitatively, patient outcomes were excellent in 5 patients, good in 9, and fair in 5. Most of our patients presented with easily approachable coronoid base and body fractures. However, in AMF fractures of the coronoid process, a direct medial approach is required for buttress plating. We believe our study helps provide useful guidelines for making appropriate decisions in trans-ulnar basal coronoid fracture-dislocations.

Prognostic value of the CURL classification system for proximal ulna fracture dislocations of the elbow.

Prognostic value of the CURL classification system for proximal ulna fracture dislocations of the elbow.

Internal brace augmentation in elbow varus posteromedial rotatory instability (VPMRI) allows early rehabilitation and prevents stiffness.

Varus posteromedial rotatory instability (VPMRI) involves anteromedial coronoid fracture (AMCF), lateral ulnar collateral ligament (LUCL), and medial collateral ligament (MCL) injury. There is no general consensus regarding the surgical treatment, but most surgeons recommend internal fixation of the coronoid along with primary ligament repair. This methodology involves postoperative immobilization to allow ligament healing, occasionally associated with stiffness. Augmentation of one/or both collateral ligaments using a non-absorbable suture tape as an internal brace in VPMRI cases was the subject of the presented study. This method allows brace-free initiation of full elbow range of motion while protecting bony and soft tissue healing. 17 patients (13 males and four females) with VPMRI were treated in the center from 2017 to 2021 with internal brace augmentation of collateral ligament along with ORIF (Open reduction & internal fixation)/ reconstruction of the coronoid fragment. All patients were actively mobilized early after surgery. Patients who completed a minimum follow up of 24 months were included in the study. Clinical examination findings at follow-up assessment included ROM (range of motion) recording and instability testing, including special instability tests such as moving valgus stress test, lateral pivot shift test, Posterolateral rotatory drawer test, and gravity-assisted varus stress test. Disabilities of arm, shoulder and hand (DASH) score, Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), Visual Analogue Score (VAS), and SEV (Simple Elbow values) were assessed and noted at follow-up. At 43 months of mean follow-up, none of the patients had significant postoperative contracture, and none had any clinically apparent signs of instability or suffered subluxation or re-dislocation. Postoperative radiographs showed complete fracture/graft healing with no signs of subluxation in all patients. The mean range of motion of the patients was 6.20 (1.00-11.30) to 139.10 (136.20-142.00), with a mean Oxford elbow score (OES) of 42.0 (39.9-44.7). The mean DASH (Disability of Arm, Shoulder & Hand) score was 11.4 (6.7-16.1), the mean MEPS (Mayo Elbow Performance Score) was 91.2 (86.3-96.0), the mean Visual Analogue Score (VAS) score was 0.6 (0.1-1.2), and the mean Simple Elbow value (SEV) was 85.4% (81.1-89.8%). Internal brace augmentation with a non-absorbable suture tape in the setting of VPMRI is a safe and helpful adjunct to coronoid repair/reconstruction and primary ligament repair and allows early mobilization and recovery of elbow stability and range of motion.

Fracture of the Anteromedial Facet of the Coronoid is More Common Than Previously Thought in Combined Fractures of the Coronoid and Radial Head.

The terrible triad injury involves an ulnohumeral dislocation, radial head fracture, and coronoid process fracture. According to traditional teaching, these injuries are strongly associated with anterolateral coronoid tip fractures and can be addressed via a lateral approach to the elbow. However, recent small clinical series suggest that some terrible triad injuries have larger coronoid fractures involving the anteromedial facet. It is important to understand how often these larger coronoid fractures occur because anteromedial facet fractures may need a different approach and different implants for fixation. An improved understanding of coronoid fracture morphology in terrible triad injuries may help surgeons construct a surgical plan. To better define coronoid fracture morphology in combined coronoid and radial head fractures, we therefore asked: What is the distribution of anterolateral facet versus anteromedial facet coronoid fragments in combined coronoid and radial head fractures without an ulnar shaft fracture? This retrospective, multicenter descriptive study evaluated preoperative CT scans from adult patients (18 years or older) diagnosed with combined coronoid and radial head fractures. Between February 2014 and March 2023, we identified 10,016 adult patients with elbow or forearm injuries who underwent CT scans. Among these patients, we considered those diagnosed with combined coronoid and radial head fractures without an ulnar shaft fracture based on elbow CT scans performed within 4 weeks of the injury as potentially eligible. During that time, elbow CT scans were generally ordered to assess complex fractures, confirm diagnoses when radiographs were inconclusive, evaluate joint involvement, or plan for surgical interventions. Based on that, 2% (175 of 10,016) were eligible; a further 0.001% (8 of 10,016) were excluded because of preexisting elbow pathology, prior surgery, or low-quality CT images (including slice thickness greater than 2 mm, motion artifacts, and incomplete visualization of the osseous structure of the elbow and all its articulations), leaving 2% (167 of 10,016) for analysis. The mean age was 50 ± 15 years, and more than half of the patients were female (54% [90 of 167]). Coronoid fractures in patients with combined coronoid and radial head fractures were classified using the O'Driscoll classification into three types: Type 1 (anterolateral tip fractures), Type 2 (anteromedial facet fractures), and Type 3 (base fractures). Each type was further subcategorized based on specific fracture characteristics. Two of three trained researchers independently classified the coronoid fracture type of each patient using radiographs, two-dimensional (2D) CT scans, three-dimensional (3D) CT scans, and intraoperative findings, with interrater reliability assessed by the Cohen kappa, yielding a substantial agreement value of 0.658. Disagreements were resolved through discussions with a fellowship-trained orthopaedic trauma surgeon. Sixty-five percent (109 of 167) of patients had a Type 1 anterolateral coronoid tip fracture, 30% (50 of 167) had a Type 2 anteromedial facet fracture, and 5% (8 of 167) had a Type 3 basal fracture. Surgeons should recognize that anteromedial facet involvement in coronoid fractures is more prevalent in combined coronoid and radial head fractures than previously appreciated. Future research should investigate whether these anteromedial fractures are more likely to need an additional medial approach to improve patient outcomes. This study suggests that anteromedial facet involvement is more common than traditionally recognized in terrible triad injuries, and surgeons should be prepared to address a larger fragment when treating these injuries.

Transolecranon fracture dislocation and transolecranon basal coronoid fracture dislocation; results of standardized treatment in a retrospective cohort

Transolecranon fracture dislocation and transolecranon basal coronoid fracture dislocation; results of standardized treatment in a retrospective cohort

Treatment of the terrible triad of the elbow by olecranon osteotomy: a retrospective cohort study.

This study aims to evaluate the surgical techniques and outcomes of treating elbow dislocations with coronoid and radial head fractures, commonly referred to as the terrible triad of the elbow (TTE), through a single olecranon osteotomy. A retrospective analysis was performed on 73 patients diagnosed with TTE between January 2015 and April 2022. The cohort included 44 men and 29 women, with an average age of 40.0±15.1 years (range, 18-68 years). Among these patients, Mason Type I, II, and III fractures were identified in 11, 42, and 20 cases, respectively, while Morrey Type I, II, and III fractures were observed in 45, 23, and five cases, respectively. All patients underwent treatment via a single olecranon osteotomy. The average interval between injury and surgery was 5.6±1.6 days (range, 3-8 days). Elbow function was assessed using the Mayo Elbow Performance Score (MEPS), pain was measured via the Visual Analogue Scale (VAS), and quality of life was evaluated using the SF-36 questionnaire. Patients were followed for 15 to 60 months (mean, 37.1±13.3 months). All coronoid and radial head fractures achieved complete healing, with an average recovery time of 4.3±1.1 months (range, 3-6 months). By the final follow-up, all patients had regained normal elbow function. The mean elbow flexion was 124.4°±9.2°, extension was 9.6°±6.5°, and the total range of flexion-extension was 114.8°±11.7°. Forearm pronation averaged 77.3°±4.8°, supination 79.2°±6.5°, and total forearm rotation 156.5°±8.4°. The mean MEPS was 89.3±6.4, with 36 patients achieving excellent scores and 37 obtaining good scores. Preoperative VAS scores averaged 8.78±1.11, which significantly dropped to 0.97±0.83 at the final follow-up (p=0.000). The SF-36 preoperative PCS and MCS scores were 45.77±3.59 and 60.67±3.91, respectively, with postoperative improvements to 93.85±2.65 (p=0.000) and 95.79±3.11 (p=0.000). This retrospective analysis indicates that a single olecranon osteotomy could be a viable treatment option for TTE. However, additional research involving a control group is essential to substantiate the efficacy of this technique.

Surgical Treatment and Outcomes of Trans-Ulnar Basal Coronoid Fracture-Dislocations

Surgical Treatment and Outcomes of Trans-Ulnar Basal Coronoid Fracture-Dislocations

Functional and subjective outcomes after surgical management of complex elbow dislocations: a retrospective study.

Dislocations of the elbow are the second most frequent upper-body injury after shoulder dislocations, comprising 11-28% of all elbow injuries. Complex elbow dislocations pose challenging management due to the involvement of critical stabilizing structures. This study aimed to investigate functional and subjective outcomes (MEPS, DASH, Oxford score) in 44 patients with complex elbow dislocations who underwent surgery between 2018 and 2020, with subgroup analysis focusing on gender and age differences. A retrospective analysis was conducted on patients treated at C.T.O. Hospital, Turin, for complex elbow dislocations between January 2018 and December 2020. Surgical approaches included radial head synthesis, coronoid fixation, ligamentous repair, and ulnar nerve management. Postoperatively, patients followed a standardized or individualized program. Data analysis involved t-tests to assess score differences between subgroups. Among the 44 analyzed patients, the mean age was 48years, and the mean follow-up time was 29months. Various types of complex dislocations were identified, with radial head and coronoid fractures classified accordingly. Surgical approaches included multiple methods of reduction and synthesis. While most patients adhered to postoperative programs, subsequent reoperations were conducted in 11% of cases. Scores did not significantly differ between genders, although a trend toward better DASH scores in males was observed. Younger patients showed better, though not statistically significant, outcomes in mobility and functional measures. This study underscores the importance of pre-operative assessment for positive surgical outcomes in complex elbow dislocations. Additionally, findings suggest that younger age may correlate with slightly better functional outcomes. Despite limitations such as retrospective design and sample size, the study enhances our understanding of complex dislocation outcomes and provides valuable insights for future interventions.

Medial elbow approaches for coronoid fractures: risk to the ulnar nerve

Medial elbow approaches for coronoid fractures: risk to the ulnar nerve

Novel Tripartite Classificationfor Fractures ofCoronoid Process of Mandible: A Retrospective Tertiary Center Study.

Coronoid process of mandible is seldom fractured during maxillofacial trauma. Majority of the cases of coronoid fracture are treated conservatively, but some lead to complications which are often overlooked. At present, the literature on coronoid fractures is inadequate for meta-analysis. Also, there exists no standardized classification in the literature. Hence, the purpose of this study was to analyze the incidence and establish a novel 'tripartite' classification. In this study carried out at level 1 trauma center, all patients with coronoid fracture with or without associated maxillofacial fractures were included. Relevant data were noted from Hospital records and CT scans (computer tomographic scans). These cases were classified according to 'tripartite' classification and treated. Data feed was given to IBM® SPSS® statistics (version 21) for analysis. Among 33 coronoid fracture patients, majority (57.57% cases) were from age group of 21-40years with 82.85% cases attributed to road traffic accidents. 11.43% cases were bilateral, and the rest unilateral cases revealed right-side predilection. Novel tripartite classification allows us to easily categorize and visualize the coronoid fractures. Horizontal types 1 to 3 and vertical types 4 to 6 are in increasing order of incidence, which makes it easy for communication, treatment approach and record maintenance.

Three-dimensional quantitative study and functional outcome analysis of coronoid fracture in different elbow injury patterns

Three-dimensional quantitative study and functional outcome analysis of coronoid fracture in different elbow injury patterns

Coronoid height index: a reliable and reproducible technique for quantifying coronoid bone loss in elbow instability

Coronoid height index: a reliable and reproducible technique for quantifying coronoid bone loss in elbow instability

Highly extensile approach for comminuted ulna coronoid process fractures with mini-plate fixation: a case series of 31 patients

BackgroundFor the treatment of coronoid process fractures, medial, lateral, anterior, anteromedial, and posterior approaches have been increasingly reported; however, there is no general consensus on the method of fixation of coronal fractures. Here, we present a highly-extensile minimally invasive approach to treat coronoid process fractures using a mini-plate that can achieve anatomic reduction, stable fixation, and anterior capsular repair. Further, the study aimed to determine the complication rate of the anterior minimally invasive approach and to evaluate functional and clinical patient-reported outcomes during follow-up.MethodsThirty-one patients diagnosed with coronoid fractures accompanied with a “terrible triad” or posteromedial rotational instability between April 2012 and October 2018 were included in the analysis. Anatomical reduction and mini-plate fixation of coronoid fractures were performed using an anterior minimally invasive approach. Patient-reported outcomes were evaluated using the Mayo Elbow Performance Index (MEPI) score, range of motion (ROM), and the visual analog score (VAS). The time of fracture healing and complications were recorded.ResultsThe mean follow-up time was 26.7 months (range, 14–60 months). The average time to radiological union was 3.6 ± 1.3 months. During the follow-up period, the average elbow extension was 6.8 ± 2.9° while the average flexion was 129.6 ± 4.6°. According to Morrey’s criteria, 26 (81%) elbows achieved a normal desired ROM. At the last follow-up, the mean MEPI score was 98 ± 3.3 points. There were no instances of elbow instability, elbow joint stiffness, subluxation or dislocation, infection, blood vessel complications, or nerve palsy. Overall, 10 elbows (31%) experienced heterotopic ossification.ConclusionAn anterior minimally invasive approach allows satisfactory fixation of coronoid fractures while reducing incision complications due to over-dissection of soft tissue injuries. In addition, this incision does not compromise the soft tissue stability of the elbow joint and allows the patient a more rapid return to rehabilitation exercises.

Management of Limited Mouth Opening After Open Reduction and Fixation of Mandibular Coronoid Fractures.

Mandibular coronoid process fractures are relatively rare and generally treated conservatively. This paper reports a case of limited mouth opening and pain after open reduction and fixation of the mandibular coronoid fracture. After the loose titanium screws, plates, and absorbed coronoid fracture fragments were removed, the patient's mouth opening was restored immediately. The authors believe that open reduction and fixation for coronoid process fractures can cause postoperative limited mouth opening and pain. Conservative treatment of coronoid process fractures is more beneficial for patients.

Coronoid fractures and complex elbow instability: current concepts.

Fractures of the coronoid process typically occur as part of more complex injury patterns, such as terrible triads, trans-olecranon fracture-dislocations, posteromedial rotatory injuries or Monteggia-like lesions. Each pattern is associated with a specific type of coronoid fracture with regard to shape and size and specific soft-tissue lesions. O' Driscoll classification incorporates those associations identifying three major types of fractures: tip, anteromedial facet, and basal fractures. The objective of this study is to review the most common types of complex elbow instability, identify the indications for coronoid fixation and guide the appropriate management. Tip fractures as those seen in terrible triads can conditionally left untreated provided that elbow stability has been restored after radial head fixation and ligaments repair. Anteromedial facet fractures benefit from a buttress plate, while large basilar fractures can be effectively secured with posteroanterior screws. Coronoid reconstruction with a graft should be considered in post-traumatic cases of chronic coronoid deficiency.