Orthopedics

Tips & Techniques 

Arthroscopically Assisted Surgery for Coronoid Fractures

Jong Myung Lee, MD; Young Yi, MD; Jeong Woo Kim, MD, PhD

Abstract

Coronoid fractures are not easily accessed surgically. Despite the majority of cases of coronoid fracture responding to conservative treatment, limited range of motion or instability can develop after such treatment. Therefore, unstable coronoid fractures should be treated surgically to improve clinical outcome. Several approaches and treatment methods have been used for coronoid fractures. The authors report the clinical characteristics, results, and outcomes of 10 cases of Regan-Morrey Type I, Type II, and Type III coronoid fractures treated using a novel arthroscopic technique. [Orthopedics. 2015; 38(12):742–746.]

Abstract

Coronoid fractures are not easily accessed surgically. Despite the majority of cases of coronoid fracture responding to conservative treatment, limited range of motion or instability can develop after such treatment. Therefore, unstable coronoid fractures should be treated surgically to improve clinical outcome. Several approaches and treatment methods have been used for coronoid fractures. The authors report the clinical characteristics, results, and outcomes of 10 cases of Regan-Morrey Type I, Type II, and Type III coronoid fractures treated using a novel arthroscopic technique. [Orthopedics. 2015; 38(12):742–746.]

Fractures of the coronoid process of the elbow joint are relatively infrequent and are often accompanied by other joint injuries. They are found in 2% to 10% of cases of elbow joint dislocation. Ten percent of cases of elbow joint dislocation with coronoid process fracture are associated with recurrent dislocation of the elbow joint.1–3

Coronoid fractures are known to be caused by avulsing force of the brachialis muscle with a hyperextended position of the elbow, but recently they have been reported to be caused by shearing force acting on the surface of the trochlear when there is posterior dislocation of the elbow joint.4–6

Regarding treatment for coronoid fractures, according to the Regan-Morrey classification, all Type III fractures are to be managed surgically. In the case of Type I and Type II fractures, surgery is recommended when instability of the elbow joint is caused by concomitant dislocation or subluxation of the elbow joint.7–9

However, coronoid fractures are not easily accessed surgically, and in many cases, rigid fixation of a coronoid fracture is difficult. Hence, surgery is often deferred and long-term conservative treatment, which can easily lead to functional decline of the elbow joint, including limited range of motion and joint instability, is often employed.10,11

Recent studies have described an arthroscopic method of coronoid fixation, but there was no evaluation of follow-up results.12,13 In the current study, the authors report on 10 cases of coronoid fracture treated with a novel arthroscopic technique and their clinical characteristics and surgical outcomes with a minimum of 16 months of follow-up.

Surgical Technique

Patients received either general anesthesia or a brachial plexus block. A tourniquet was applied around the upper arm with patients in the lateral decubitus position. Routine portals for arthroscopic examination were made and an evaluation for intra-articular pathology such as articular cartilage defects or rupture of the joint capsule was performed.

Multiple Kirschner wires were used in 8 cases that revealed large fragments. Reduction was achieved through Kirschner wires inserted from the posterior to the anterior aspect of the ulna. To prevent iatrogenic cartilage injury, fixation of Kirschner wires was started 5 mm distal to the guide pin that was placed on the radial head. In 1 case, only 2 Kirschner wires were used due to small characteristics of the fragment. Then, using the arthroscope, the articular surfaces were inspected for intrusions (Figure 1).

Arthroscopic technique for coronoid fracture fixation. Kirschner wire illustration (A) and intraoperative arthroscopic view (B) for coronoid fracture (Regan-Morrey Type III). Reduction of the fracture using the probe or grasper (C) under the arthroscopic view (D). The probe can act as a guide in measuring the length of the Kirschner wires and protection for the soft tissue. The use of 3 to 4 Kirschner wires will add stability to fracture fixation (E, F). Postoperative anteroposterior (G) and lateral (H) radiographs.

Figure 1:

Arthroscopic technique for coronoid fracture fixation. Kirschner wire illustration (A) and intraoperative arthroscopic view (B) for coronoid fracture (Regan-Morrey Type III). Reduction of the fracture using the probe or grasper (C) under the arthroscopic view (D). The probe can act as a guide in measuring the length of the Kirschner wires and protection for the soft tissue. The use of 3 to 4 Kirschner wires will add stability to fracture fixation (E, F). Postoperative anteroposterior (G) and lateral (H) radiographs.

In 2 cases, Ethibond (Ethicon, Somerville, New Jersey) was used as a fixation suture because of the small fragment suturing the surrounding an-of the fracture. Reduction was terior capsule of the coronoid. performed arthroscopically by A 2.7-mm drill bit was used to create 2 holes on the ulna toward the coronoid process. These holes passed through the fracture site and the Ethibond to make an interosseous suture on the ulna (Figure 2).

Arthroscopic technique for coronoid fractures using Ethibond (Ethicon, Somerville, New Jersey). Coronoid fracture (Regan-Morrey Type I) that could not be fixed using multiple Kirschner wires (A, B). Using the arthroscope, the soft tissue was sutured around the fracture fragment. Using a 2.7-mm drill bit, 2 holes were created on the coronoid process that passed through the fracture site (C, D). The Ethibond was inserted through the drill hole to make an interosseous suture on the ulna (E, F). Postoperative anteroposterior (G) and lateral (H) radiographs.

Figure 2:

Arthroscopic technique for coronoid fractures using Ethibond (Ethicon, Somerville, New Jersey). Coronoid fracture (Regan-Morrey Type I) that could not be fixed using multiple Kirschner wires (A, B). Using the arthroscope, the soft tissue was sutured around the fracture fragment. Using a 2.7-mm drill bit, 2 holes were created on the coronoid process that passed through the fracture site (C, D). The Ethibond was inserted through the drill hole to make an interosseous suture on the ulna (E, F). Postoperative anteroposterior (G) and lateral (H) radiographs.

In cases with concomitant elbow injuries, initial reduction and fixation of the coronoid process were followed by repair of the lateral ulnar collateral ligament or medial collateral ligament. In radial head fractures, fixation was performed with an Acutrak screw (Acumed, Hillsboro, Oregon).

Early active joint mobilization was performed to prevent muscle weakness and elbow joint ankylosis and to improve dynamic joint stability. Radiographs were obtained at all follow-up visits. The Kirschner wires were removed 12 to 14 weeks after surgery, once evidence of callus formation was apparent on radiographs.

Discussion

The most important finding of this study was that coronoid fractures can be successfully treated arthroscopically, with less exposure to radiation and fewer complications. A few studies have reported satisfactory clinical outcomes with arthroscopic reduction and fixation of intra-articular fractures.12,14,15 However, these studies have limitations associated with complication rates and length of follow-up.

Goals of treatment for coronoid fractures include obtaining anatomical reduction and stability of the elbow joint, but these are arguable in cases of Type I and Type II fractures.16–18 Type I fractures (relatively small transverse fractures) may be treated best by suture fixation because the fragment often is too small for reliable screw fixation and because restoration of the anterior capsular attachment and anterior bony buttress are far more important than articular incongruity in this area. Type II fractures (anteromedial facet fractures) may be addressed best with buttress plating of the anteromedial surface of the coronoid. Regan and Morrey18 had patients with Type I and Type II fractures without elbow dislocation or concomitant fractures and patients with Type II fractures with concomitant fractures around the joint that caused instability of the elbow joint after internal fixation perform active joint exercises less than 3 weeks after fixation.18

In cases of Type III fractures (fractures involving nearly the entire coronoid down to its base), early open reduction with rigid internal fixation is required. They may be treated best with plate and screw fixation supplemented by sutures and medial plates.18 External fixation is used to treat unstable elbow joints due to severe comminution or large fracture fragments.

Doornberg and Ring16 noted that patients with Type I and Type II fractures tend to have a poorer prognosis, regardless of accompanying ligament injuries, when compared with patients with Type III fractures. Cage et al1 insisted that coronoid fractures with a small fragment that is attached to the anterior joint capsule can induce clinical symptoms and that once it is anatomically reduced, stability of the elbow joint can be obtained. Okazaki et al19 noted that in Type I and Type II fractures with severely damaged major ligaments, manual reduction and conservative treatment involving splinting are inadequate—these fractures require surgery. Eppright and Wilkins4 noted that fracture segments with attached ligaments disrupt elbow flexion and warrant surgery. Selesnick et al20 noted that in cases of displaced fracture segments with attached ligaments, open reduction and internal fixation should be performed, even if the radial collateral ligament is intact.

Surgery for coronoid fractures and repair of the joint capsule can be performed via different approaches, but it can also result in damaged nerves and veins.18,21,22 Because rigid fixation of the coronoid process can be difficult, surgery is often overlooked or sometimes patients have long-term fixations, which often lead to decreased elbow joint range of motion and instability.10,11

The current study included 10 patients who had arthroscopically assisted surgery between May 2008 and January 2011. The mean follow-up was 16.9 months. All Type I and Type II fractures were treated surgically because of the presence of elbow instability. Although the Type III fractures were also treated arthroscopically, not all Type III fractures should be. Treatment of the coronoid fractures was based on an algorithm from Zeiders and Patel23 that was modified (Figure 3).

Treatment algorithm for achievement of a stable elbow joint for patients with a coronoid fracture after elbow dislocation or subluxation. Abbreviations: A/S, arthroscopic; LCL, lateral collateral ligament; LUCL, lateral ulnar collateral ligament; MCL, medial collateral ligament.

Figure 3:

Treatment algorithm for achievement of a stable elbow joint for patients with a coronoid fracture after elbow dislocation or subluxation. Abbreviations: A/S, arthroscopic; LCL, lateral collateral ligament; LUCL, lateral ulnar collateral ligament; MCL, medial collateral ligament.

No patient dropped out of this study. However, 1 patient had delayed union, which was detected on a follow-up computed tomography scan, but there was no need for futher treatment. Significant findings of elbow joint arthritis were not present on the final radiographs (Table 1).

Characteristics of the 10 Patients With Coronoid Process Fractures

Table 1:

Characteristics of the 10 Patients With Coronoid Process Fractures

All patients had anteroposterior and lateral radiographs of the elbow joint obtained at each follow-up visit. Follow-up occurred at 3 months, 6 months, and 16 to 18 months after surgery. All patients had Mayo Elbow Performance Score (MEPS) and range of motion assessed at each follow-up visit.

At the 12-week follow-up, mean flexion contracture was 8°±6.3°, extension contracture was 138°±6.7°, pronation was 79°±8.3°, and supination was 73°±10.8°. All patients exhibited range of motion at 12 weeks. At 64 weeks, almost all patients exhibited normal range of motion in the operated on extremity compared with the contralateral extremity (P>.05) (Table 2). The mean MEPS was excellent, being 92.5 in all surgically treated elbows at the 12-week follow-up. The MEPS gradually improved from 95 at 24 weeks to 98.5 at the final follow-up at 64 weeks. This was satisfactorily good compared with the contralateral elbow (P>.05) (Table 3).

Range of Motion for the Patients

Table 2:

Range of Motion for the Patients

Mayo Elbow Performance Scores for the Patients

Table 3:

Mayo Elbow Performance Scores for the Patients

An arthroscopic approach offers surgeons an easier and safer way to inspect the articular surface using just small incisions compared with incisions in arthrotomy. Therefore, arthroscopically assisted percutaneous fixation can lower the risk of complications and increase the possibility of direct and precise reduction compared with open reduction surgery. Several studies have reported satisfactory clinical outcomes with arthroscopic reduction and fixation of intra-articular fractures.11,12,14 However, these studies have had in-sufficient numbers of subjects.

Similar to previous studies,12,13 the results of this study are limited by the small number of cases due to the rarity of this fracture. Additionally, patients were not compared with those who underwent open reduction and internal fixation. Furthermore, the statistical analysis of outcome was not able to reflect the size of the fragment and the presence of comorbidities of the patients. Finally, only radiographs of the last follow-up were available in this study.

Despite these limitations, arthroscopic surgery can be an alternative approach for coronoid fractures. Fracture reduction can be achieved through arthroscopy, if it is performed properly. Patient exposure to radiation is avoided by using this arthroscopic technique. The minimal incisions in the elbow and damage to soft tissue around the fracture site allow patients to engage in early rehabilitation and to return to pre-injury status.

Conclusion

Adequate reduction of coronoid fractures using percutaneous Kirschner wires or Ethibond can be achieved by performing arthroscopic surgery. The approach results in good clinical and radiologic union and excellent functional outcome in the majority of cases. Thus, this technique provides an alternative for surgeons treating coronoid fractures.

References

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  16. Doornberg JN, Ring D. Coronoid fracture patterns. J Hand Surg Am. 2006; 31(1):45–52. doi:10.1016/j.jhsa.2005.08.014 [CrossRef]
  17. O'Driscoll SW, Jupiter JB, Cohen MS, Ring D, McKee MD. Difficult elbow fracture: pearls and pitfalls. Instr Course Lect. 2003; 52:113–134.
  18. Regan W, Morrey B. Fracture of the coronoid process of the ulna. J Bone Joint Surg Am. 1989; 71(9):1348–1354.
  19. Okazaki M, Takayama S, Seki A, Ikegami H, Nakamura T. Posterolateral rotatory instability of the elbow with insufficient coronoid process of the ulna: a report of 3 patients. J Hand Surg Am. 2007; 32(2):236–239. doi:10.1016/j.jhsa.2006.11.001 [CrossRef]
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Characteristics of the 10 Patients With Coronoid Process Fractures

Patient No./Age, y/SexClassification (Regan-Morrey)Material (No.)Combined InjuryTime to Union, wkDuration of Follow-up, moSports ActivitiesComplications


Dislocation/SubluxationFractureLigamentInstabilityHOOA
1/31/MIIK-wire (2)YesNoMCL (operated)1418YesNoNoNo
2/52/MIIK-wire (3)YesNoNo1318NoNoNoNo
3/25/FIIK-wire (4)YesNoNo1318YesNoNoNo
4/55/MIIK-wire (4)YesRadial headLCL (operated)1216YesNoNoNo
5/61/FIIIK-wire (3)YesNoLCL (operated)1318YesNoNoNo
6/46/MIIEthibondYesRadial headLUCL, LCL (operated)12 (only clinical union)17YesNoNoNo
7/21/MIIK-wire (3)YesNoNo1416YesNoNoNo
8/68/MIEthibondYesNoLCL (operated)1216YesNoNoNo
9/72/MIIK-wire (3)NoNoLCL (operated)1216NoNoNoNo
10/68/MIIIK-wire (3)YesNoNo1416NoNoNoNo

Range of Motion for the Patients

MotionFollow-up, wkRange of Motion, Mean±SDPa

Injured ElbowContralateral Elbow
Extension contracture12138°±6.75°145°±4.38°.01
24142°±5.88°.24
64144°±4.91°.41
Flexion contracture128°±6.32°−1°±2.11°.01
245°±4.71°.03
641°±2.73°.28
Pronation1279°±8.23°83°±4.83°.00
2481°±5.74°.03
6482°±5.16°.52
Supination1273°±10.85°87°±4.22°.01
2480°±6.72°.02
6486°±5.79°.39

Mayo Elbow Performance Scores for the Patients

Follow-up, wkMayo Elbow Performance Score, Mean±SDPa
Injured ElbowContralateral Elbow
1292.5±6.7799.5±1.58.02
2495±4.24.06
6498.5±1.82.57
Authors

The authors are from the Department of Orthopedic Surgery, Presbyterian Medical Center (JML), Jeon-Ju; Seoul Paik Hospital of Inje University (YY), Seoul; and Wonkwang University Hospital (JWK), Iksan, Korea.

The authors have no relevant financial relationships to disclose.

This study was supported by the Wonkwang University Foundation 2014.

Correspondence should be addressed to: Jeong Woo Kim, MD, PhD, Department of Orthopedic Surgery, Wonkwang University Hospital, 895 Muwang-ro, Iksan, Jeon-Buk 570-780, Korea ( serina@wonkwang.ac.kr).

Received: July 03, 2014
Accepted: October 22, 2014

10.3928/01477447-20151119-04

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