Coronoid fracture or coronoid process fracture is fracture anterior projection of ulna in its superior part where together with the posterior projection of ulna, olecranon, it expands the articular area of the upper end of the ulna. Ulna articulates with the lower end of humerus in this articular notch.
Both coronoid and olecranon processes also provide stability to humerus by forming anterior and posterior supports by virtue of projections.
While fracture of olecranon is very common, a coronoid fracture is seen less commonly. Fractures of the coronoid process usually reflect severe trauma to the elbow.
Coronoid fracture usually occurs in association with other injuries of the elbow, namely elbow dislocation. Isolated coronoid fracture is less common.
Large coronoid fractures often are associated with persistent elbow instability even after reduction of the dislocation.
Coronoid fracture accounts for less than 1-2% of all elbow fractures. Coronoid fractures have been identified in 10-15% of elbow dislocations.
Mechanism of Coronoid Fracture
Previously, it was thought that these fractures were as a result of avulsion force acting on coronoid but now it is thought that they probably are due to direct impact of trochlea on the coronoid when a force acts.
The brachialis muscle, which was thought to put a force of avulsion, inserts much distally than the tip of the coronoid. However, it is not uncommon to find attached fibers of brachialis in a larger fragment distal to the coronoid process.
When the fragment of coronoid is large, it may cause dislocation of the elbow as the supportive buttress is no longer available [See classification]. But a small coronoid potentially severe trauma with possible acute recurrent dislocation.
Classification of Cornoid Fracture
The classification was suggested by Regan and Morrey who after a retrospective study, classified the fracture into three types.
Classification of coronoid fracture
Type I—small avulsion fracture at tip of coronoid
Type II—fragment involves 50% of the coronoid but does not extend to the base
Type III—Fracture at the base of the coronoid, likely including the insertions of the brachialis and the anterior band of the medial collateral ligament.
In spite of their type, the presence of a coronoid fracture should evoke concern for acute instability.
Imaging
AP and lateral views of the elbow are sufficient for most of the cases. In complex injuries of the elbow with concomitant coronoid fracture, CT may be required.
Treatment of Coronoid Fracture
Fracture of the coronoid process are generally not amenable to closed treatment. Therefore open reduction is almost always the treatment of choice where the fragment is stabilized using either screw or wire fixation.
Because they are generally associated with elbow instability, open reduction with internal fixation of a significant coronoid fracture often provides the necessary stability to prevent further dislocation.
Operative intervention may also be considered for those fractures that interfere with joint motion. This can occur if the fragment is intraarticular or if it unites proximally and forms a significant bone block to flexion.
After the surgery, the limb is immobilized for a period of 3 to 4 weeks. Weekly follow up should be done with xray.
After this period , gentle elbow mobilization is begun.
Complications of Coronoid Fracture
- Neurovascular injury
- Stiffness
- Heterotopic ossification
- Instability and recurrent dislocation
- Posttraumatic arthritis of the elbow
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Hello, I am writing because I have been treated for tennis elbow for over one year now. I have had a total of 3 cortizone shots in that period of time. I was laid-off over a year ago and have been a server ever since. After my last injection, the pain became unbearable as it wore off rather quickly. I had been taken tylenol, etc. to help with the pain during my injection periods as that did not fully help. As I said, my pain has been quite severe, no range of motion, no sleep and my children have been helping me dress… Ugh. I have missed much work because I was not able to serve properly and ended up back at the doctors office. By off chance, my doctor was not in that day so I had to see someone else. My arm and fingers were swollen and I was in severe pain. My original doctor prescribed me Tramadol (didn't even touch the pain). When I saw the other doctor, he asked me if they had taken any x-rays when I was diagnosed. He looked at me quite bewildered when I told him no…
He had me take some x-rays and off I went with a prescription for Oxycodone. I later ended up in the ER. Just couldn't take it anymore. I pride myself on a high pain tolerance, but this was out of hand. He agreed with the other doctor and said I needed to go back to the Orthopedic as soon as possible. I ended up with a prescription of Valium as well. Now I am in an induced coma…. atleast it feels that way. Yes, I am very careful with my prescriptions. Anyhow, I got a call Monday morning from the nurse who told me I needed to take these x-rays w/ me to the Ortho ASAP. I asked why and she told me I have had a "small avulsion fracture noted off the coronoid process of the proximal right ulna". Grrrrrr…….I have been living with this pain for over a year now and I am wondering if it is even fixable at this point? What process do you think will take place, and, will this be permanent? Any ideas as I am desperate at this point. The Ortho can't get me in until April 4th, even with a mis-diagnosis…. Please help me with some advice. It is so greatly appreciated. Thanks ahead of time from a hard-working mom who's in school full time and can't write her own essays. By the way, I am going for my nursing degree, will I be able to continue this degree with my elbow?
@Jennifer Rodriguez,
There are two things that I can get from your writing
1] You were treated for Tennis elbow
2] There is a small avulsion fracture in your coronoid on the same side.
First, a small old [probably] coronoid fracture would not cause that much pain.
And at the same time, tennis elbow responds very well to steroid injections. You would have intermittent periods of few dayswhere you should be symptom free.
Please see your specialist. Things would become clearer then.
13 weeks ago I fell onto an outstretched arm onto my hand backwards whilst ice skating. The pain was excrutiating down my forearm and I thought at first I had broken my wrist. The pain then went into my elbow and it kept me awake all night.
I had xrays the next day and went to see my Orthopedic surgeon
The xrays were normal, he noted that I could pronate and supernate my arm and sent me home with the advice of R.I.C.E and physio.
After two weeks and complying with everything I was told my elbow was not getting better so I went back for another consult, I was sent for another xray which was still negative and told to continue with physio and use transact patches for pain, I had already gone through several bottles of NSAIDS, he said if it didn't get better he would give me a cortisone injection into the joint.
After spending the past four weeks looking at articles on the internet to try and find out what I had done, I thought that I needed an MRI, so I went back again to the Orthopedic surgeon who was now unsure what was going on as well so he then suggested an MRI much to my relief and this is the report.
"The primary pathology appears to be a fracture of the coronoid process of the olecranon with extension into the joint space with significant joint effusion.There is oedema at the level of the insertion of the brachialis tendon into the coranoid process and extensive bone bruising" No tricep injury or other pathology was noted.
The orthopedist phoned me to tell me the result and added that "I wasn't imagining it". He then said to go and see him in two/three weeks and I may have another xray and to just rest my elbow and that was it.
So thats what I did, I had another "negative" xray and since then I have been having physiotherapy. She thinks I had a neuropathy of the radial nerve as I am having difficulty flexing the tricep muscles if my arm is supernated and out to the side. The bone is really very painful and I cannot take any weight on my arm at all, I now have most of my rom but my shoulder is now giving me trouble ( previous acromioplasty ) as I am using that instead of my elbow for movement. I would really appreciate any feedback you may be able to give me as its my dominant arm and it also makes a sort of juddering grinding sound when I rotate it. I am not keen to go back to the Orthopod either as I feel he thinks I am wasting his time.
@Sue Funcke,
The reply is delayed by one month. So first thing I need to ask is how are you now?
Hi,
Thank you for replying.
My elbow is still causing problems, I can fully extend it but it does not flex fully, so its awkward drinking as i have to support the cup with both hands and lean forward slightly. I still cannot tighten the tricep muscle in the back of my arm, and it will not support any weight, I tried to pull a plug out of a wall socket the other day and the pain in the joint was quite bad, and I couldn't do that either. I went to my GP who put me onto an anti inflammatory Arcoxia 120mg, I have been on it for 2 weeks and it seems to have lessened the pain and it's not as stiff as it was, but I am still waking up at night with half my hand completely numb, ring and small finger and if my arm is above my head the entire arm is dead, but that could be from my shoulder. I also get a burning pain in and around the elbow joint. Any sudden movement to the arm also elicits a lot of pain that goes down my arm. My GP has asked me to come back in 2 weeks.
Thanks again for responding to my post, I really appreciate it. Sue
@ Sue Funcke
Unfortunately no tips or advice, but I have the exact same symptoms – weakness / inability to flex triceps muscles when arm is extended and out to the side. I injured it a year ago and just had a second X-ray which revealed the coronoid process fracture. It sounds like it's not the type of thing that heals on it's own for some reason, so doc told me I can either have surgery on it or just continue to deal with it.
Hi Brian
Sorry to hear about your coronoid#. I had posted a follow up on here especially as they said the response had been delayed, but it seems to have disappeared!
I have since had a nerve conduction test, which was normal and a CT which showed a healed coronoid # at the tip.
I went back to my orthopedic surgeon today as I am still having the same problems and now have developed this horrid crepitus in the joint, it also seems to get stiff if its left in the same position, especially at night and anything that seems to "open" the joint for example if i even lift the duvet cover up whilst in bed it hurts.
So I got given the choice of a cortisone injection into the joint or just leave it and see if it gets better, he was not keen to do an arthroscopy to see what was going on, I was very reluctant to have cortisone as I have had quite a few into various muscles etc over the past few years and they are not pleasant and into the joint sounded awful.
Anyway I asked him what he would do and he said seeing it was now so long and it wasn't improving have the injection, so I did. It wasn't too bad, so I guess its now wait and see. Oh there was an effusion still in the joint, so there is some inflammatory reaction going on, so lets hope the cortisone sorts it out.
Thank you for replying, nice to know someone reads the posts 🙂
Oh dear, seems the post I thought had gone has now reappeared but it says its awaiting moderation. So I suppose its not been read yet.