Operative treatment of coronoid fracture often requires a large dissection of soft tissue, resulting in elbow stiffness and functional limitation. The authors present a minimal invasive, safe technique, useful in the case of isolated coronoid fracture associated with elbow dislocation. This technique does not require soft tissue dissection and allows an early unlimited resumption of sports activitie

Bollmann, C.

Borens, O.

Garofalo, R.

Kombot, C.

Moretti, B.

Mouhsine, E.

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IntroductionFractures of the coronoid process are often an indirectsign of luxation or subluxation of the elbow [6, 7, 9].Depending on the fragment size the indication for openreduction and internal ﬁxation of coronoid process iscontroversial. The coronoid does play an importantrole in posterior stability [3], so overall large fracturefragments should be ﬁxed to avoid unfavourable out-come [8, 11]. Heterotopic ossiﬁcation is a recognizedcomplication in complex fracture-dislocation of the el-bow. Operative treatment of the coronoid is technicallydemanding and requires additional dissection; thismight play a role in increasing the risk of HO andelbow stiﬀness [12]. We present a minimal invasivesurgical technique to ﬁx a type III (Regan-Morrey)coronoid fracture associated with a dislocation of theelbow. As the surgical trauma to the elbow remainsminimal the risk of heterotopic ossiﬁcation should notbe increased.Case report and surgical techniqueA 20-year-old man had fallen on his left elbow during abasketball match. He presented himself with a defor-mation of the left elbow. The elbow was swollen andﬁxed in 35 of ﬂexion. Neurovascular testing of the leftarm and hand were normal. Anteroposterior and lateralradiographs conﬁrmed the diagnosis of posterior elbowdislocation associated to a type III coronoid fracture(Fig. 1). X-ray ﬁlms after reduction didn’t show otherlesions.The patient was operated upon 48 h after the acci-dent through a minimally invasive anterior and posteriorapproach: under general anesthesia the patient is placedin supine position and the left arm is positioned on aradiolucent arm board. The operation was performedwithout tourniquet to allow the surgeon to feel theanterior brachial vascular bundle. Under Fluoroscopiccontrol a ﬁrst 1.6-mm K-wire is introduced anteriorlyfrom a 1-cm skin incision and Kryle protection and usedR. GarofaloC. BollmannC. KombotB. MorettiO. BorensE. MouhsineMinimal invasive surgery for coronoidfracture: technical noteReceived: 31 March 2004Accepted: 22 September 2004Published online: 28 January 2005 Springer-Verlag 2005Abstract Operative treatment ofcoronoid fracture often requires alarge dissection of soft tissue,resulting in elbow stiﬀness andfunctional limitation. The authorspresent a minimal invasive, safetechnique, useful in the case of iso-lated coronoid fracture associatedwith elbow dislocation. This tech-nique does not require soft tissuedissection and allows an earlyunlimited resumption of sportsactivities.Keywords Coronoid Æ Fracture ÆElbow Æ TraumaDOI 10.1007/s00167-004-0594-5Knee Surg Sports Traumatol Arthrosc(2005) 13: 608–611 SPORTS MEDICINER. Garofalo Æ C. Bollmann Æ C. KombotB. Moretti Æ O. Borens Æ E. Mouhsine (&)Department of Orthopaedics andTraumatology, University Hospital,OTR-BH 14 CHUV, 1011 Lausanne,SwitzerlandE-mail: Elyazid.Mouhsine@hospvd.chTel.: +41-21-3142791Fax: +41-21-3142800as a joystick to reduce the fracture, which was stabilizedby two 1.6-mm K-wires, introduced anteriorly and withthe same technique as the ﬁrst K-wire. These two K-wires are introduced across the coronoid, the olecranonand the posterior skin. This technique permits theintroduction of two cannulated 3.5 screws posteriorly asa deﬁnitive stabilisation (Fig. 2).The K-wires are then removed. At the end of surgerythe elbow stability was assessed and only a posterolat-eral rotatory instability in full extension was noted.Postoperatively the elbow is immobilized in a plastercast with the elbow ﬂexed at 30 for 10 days and thengravity-assisted active range of motion exercises arestarted. The postoperative course was uneventful.Three months after surgery the fracture was unitedand the patient returned to his sportive activity withoutpain, and normal range of motion of the elbow andforearm rotation. One year after surgery the patient stillhad unlimited sports activities; the X-ray ﬁlms showedan excellent fracture union and no signs of heterotopicossiﬁcation (Fig. 3).DiscussionFractures of the coronoid often occurred in associationwith the elbow. Regan and Morrey [11] proposed aradiographic classiﬁcation of the coronoid that have aprognostic value. They classiﬁed coronoid fractures basedon the size of the fragment. Type I fracture is described asa small shear fracture and it indicates that a minimaldislocation of the elbow must have occurred. Type IIfractures involve 50% of the coronoid and type III areshear fractures of the whole coronoid process (> 50%).As the mechanism of these fractures are mostlyshearing forces caused by posterior dislocation someauthors [9, 11] believe that they are pathognomonic forelbow instability. Type I fractures are usually too smallfor an open reduction and internal ﬁxation. This frac-ture can be managed by immobilization (maximum3 weeks) and early range of motion. Rarely do thesetype I fractures require removal of intraarticular frag-ments [8].Recently, Terada [14] suggested that even some small(‘‘ﬂeck-fractures’’) type I or II coronoid fractures shouldbe repaired in order to achieve suﬃcient elbow stability:they think that with this method even partial lesions onthe anterior capsule can be healed by replacing thesesmall fragments, thus improving elbow stability.In type II lesions the most important criteria isinstability; if the elbow is unstable after reduction in 50–60 of ﬂexion [10] the associated coronoid fractureshould be ﬁxed; the stability can also be assessed ﬂuo-roscopically [13].The importance of the radial head as secondary sta-bilizer of the elbow joint has been shown by severalauthors[5, 7] and the association of coronoid fracturewith radial head fracture and elbow dislocation is rec-ognized as terrible triad injury [6]. Josefsson [7] at ﬁrsthad pointed out the importance of coronoid fracturesassociated with elbow-instability: he noted that redislo-cation of the elbow occurred in patients who underwentexcision of radial head and had an associated coronoidfracture. In particular, type II fractures produce elbowinstability near to full extension [11]; so, this kind oflesion when associated with an ipsilateral radial headfracture and elbow dislocation should be operatedon [10].The type III coronoid fractures should be treatedsurgically [8, 10]. This fracture is often part of a moreFig. 1 a Anteroposterior and b lateral view of the fracture-dislocationFig. 2 Technique of anterior insertion of the 1.6-mm K-wires usedas joystick for reduction, device for stabilisation and for screwsguidance609complex elbow injury, such as posterolateral rotatoryinstability. So, the operative treatment is directed to-ward maintaining the congruity of the joint and conse-quently reduction of the coronoid; this allows a safepostoperative mobilisation of the elbow.Closkey [3] showed in human cadaveric model anincreased posterior elbow translation with type III cor-onoid fracture from 60 to 105 of ﬂexion. When asso-ciated with radial head resection this lesion rendered theelbow grossly unstable [11].Stiﬀness after fracture-dislocation of the elbow is arecognised problem [1, 4, 11].Ka¨licke [8] found in 39 patients with fracture anddislocation of the elbow seven had developed hetero-topic ossiﬁcation and needed reoperation (arthrolysis).All these seven patients presented coronoid fractureassociated to either olecranon or radial head fracture.Thirty patients of this series had prophylaxis with in-dometacin and nine patients had a postoperative radia-tion therapy. The reported frequency of heterotopicossiﬁcation is between 5% and 50% in case of complexfracture-dislocations of the elbow [2]. The additionaldissection needed to repair the coronoid might play arole in increasing the risk of heterotopic ossiﬁcation andelbow stiﬀness [12]. For this reason, we think that aminimal invasive approach to reduce this fracture mightbe better. Our method is easy and safe as there are nonoble structures likely to be injured in this approach. Onthe other hand, it can be useful when the coronoidfracture is the only injury to be surgically repaired incase of an elbow trauma.Fig. 3 a Anteroposterior and blateral view of the fracturereduction and ﬁxationReferences1. Breitfuss H, Muhr G, Neumann K,Neumann C, Rehn J (1991) Arthrolysisof post-traumatic stiﬀ elbow. Whichfactors inﬂuence the end result. Unfall-chirurg 94(1):33–392. Broberg MA, Morrey BF (1987) Resultsof treatment of fracture-dislocations ofthe elbow. Clin Orthop 216:109–1193. Closkey RF, Goode JR, KirschenbaumD, Cody RP (2000) The role of thecoronoid process in elbow stability. Abiomechanical analysis of axial loading.J Bone Joint Surg Am 82(A):1749–17534. Cobb TK, Morrey BF (1995) Use ofdistraction arthroplasty in unstablefracture dislocations of the elbow. ClinOrthop 312:201–2105. Deutch SR, Jensen SL, Tyrdal S, OlsenBS, Sneppen O (2003) Elbow joint sta-bility following experimental osteoliga-mentous injury and reconstruction. JShoulder Elbow Surg 12(5):466–4716. Mezera K, Hotchkiss R (1996) Frac-tures and dislocations of the elbow. In:Rockwood CAGD, Buchholz RW,Heckman JD (eds) Rockwood andGreen’s fractures in adults, 5th edn.Lippincott-Raven, Philadelphia, pp921–9517. Josefsson PO, Gentz CF, Johnell O,Wendeberg B (1989) Dislocations of theelbow and intraarticular fractures. ClinOrthop 246:126–1308. Kalicke T, Westhoﬀ J, Wingenfeld C,Muhr G, Arens S (2003) Fracture dis-location of the elbow involving thecoronoid process. Unfallchirurg106(4):300–3059. Linscheid RL, Wheeler DK (1965) El-bow dislocations. JAMA 194(11):1171–117661010. Morrey B, O’Driscoll SW (2002) Frac-tures of the coronoid and complex instability of the elbow. In: Morrey B (ed)Master techniques in orthopaedic sur-gery—the elbow, 2nd edn. LippincottWilliams and Wilkins, Philadelphia, pp127–13811. Regan W, Morrey B (1989) Fractures ofthe coronoid process of the ulna. J BoneJoint Surg Am 71(9):1348–135412. Ring D, Jupiter JB (2002) SurgicalExposure of Coronoid Fractures. TechShoulder Elbow Surg 3(1):48–5613. Spencer EE, JC K (2003) A simpletechnique for coronoid ﬁxation. TechShoulder Elbow Surg 4(1):1–314. Terada N, Yamada H, Seki T, Urabe T,Takayama S (2000) The importance ofreducing small fractures of the coronoidprocess in the treatment of unstableelbow dislocation. J Shoulder ElbowSurg 9(4):344–346611

Minimal invasive surgery for coronoid fracture: technical note

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Minimal invasive surgery for coronoid fracture: technical note

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