Coronoid Process Fracture - Case Presentation

CASE PRESENTATION

INTRODUCTION & BACKGROUND:

The coronoid is the most important portion of ulno-humeral articulation

Reasons:

1.  Provides anterior buttress

2.  Anterior capsule and brachialis attach to coronoid

3.  Anterior band of the MCL attaches to it

    - Distally and medially on sublime tubercle

Instability rises and prognosis deteriorates according to the amount of coronoid process that is fractured.

ANATOMY:

 

                

CLASSIFICATION:

Coronoid process fractures have been classified into three types:

·         type 1: avulsion of the tip of the coronoid process

·         type 2: fragment involving <50% of the coronoid process

·         type 3: fragment involving >50% of the coronoid process

The prognostic relevance of this classification is contentious, but there is some correlation with the pattern of associated injuries: smaller fractures are more likely to be associated with the “terrible triad” pattern of injury, whereas larger fragments tend to occur with anterior and posterior fracture-dislocations of the olecranon 

PATIENT INFORMATION:

Ø  Patient - ‘X’

Ø  Age - 39 years/ Male

Ø  Date of Admission: 08/09/2016

Ø  Date of Surgery: 13/09/2016

CHIEF COMPLAINT:

    Patient has restricted elbow movements and inability to use Left elbow since 1week.

HISTORY OF PRESENT ILLNESS:

    Patient has restricted elbow movements and inability to use Left elbow since 1week. Patient gave history of slip and fall, while tried to catch the bus. Since then patient complaints of pain, swelling, range of movements restricted.

            After the injury patient went to the nearby hospital. In the hospital patient has been taken to the emergency department. There was a mild abrasion over the elbow, no any severe bleeding or deep wound is noticed over other parts of the body. Patient treated conservatively, patient had no relief.

            Patient came to our hospital for further management. X-ray taken and it showed Coronoid process fracture with displacement. Above elbow (AE) slab has been given.

v  Previous Injury: No

v  Developmental History: No any developmental histories

v  Drug History: No known drug allergies. Not on any chronic medication.

v  Past Medical History: No DM; No HTN; No Asthma; No thyroid disease.

v  Past Surgical History: No & No any blood transfusion.

ON EXAMINATION:

Patient is conscious, oriented.

Vital Signs:

·         BP – 130/80 mmHg

·         PR – 80/min

·         SPO2 – 98%

LOCAL EXAMINATION:

·         Pain and Swelling over the Left Elbow is present.

·         Tenderness and Crepitus over the Left Elbow is present.

·         Range of Motion of Left Elbow is restricted.

·         Any attempted movements painful.

·         Active finger movements present.

·         Radial pulse present.

X-RAY FINDING:

                        Fracture Coronoid Process of Ulna with displacement Left Side.

PREPARATION:

         Supine Position for Anterior Access:

The patient is supine position. The arm is abducted, supported on a padded table for upper extremity surgery. The elbow is extended and the forearm supinated.

SKIN INCISION:

           A curved incision over the anterior aspect of the elbow is performed 5 cm above the flexion the flexion crease on lateral side of biceps.

Curvi-linear incision over the front of the elbow. It ends on the medial border of the brachio-radialis.

SURGICAL DISSECTION:

        Identify and protect the Posterior Interosseous branch (PIN) of the medial nerve at the lateral margin of the brachial muscle, carefully follow it to the supinator muscle. Split the fascia and ligate the recurrent radial artery.

                 

                                                            Intraoperative image: Ligating the radial artery.

  Further deep dissection exposes the bicipital tuberosity of the radius. Reflect the supinator carefully protecting the PIN, to display the tuberosity.

 

PROCEDURE:

      The coronoid fragment dissected reduced and fixed by 2 K-wires under c-arm guidance.

    The fragment was stabilized by 4 mm partially threaded cannulated screws. Position of screw checked c-arm and found satisfactory.

Then the radial pulse was found to be normal. Thorough wound wash given. Wound closed in layers.AE (Above Elbow) slab was given.

POST OPERATIVE X-RAY:

CLASSIFICATION:

  According to the classification. The fracture is classified as:

Ø  According to REGAN & MORREY classification: which is based on height of the coronoid fragment. TYPE III – Fracture greater than 50% of coronoid process height.

Ø  According to O’ Driscoll classification: TYPE III - BASAL; SUBTYPE 1- CORONOID BODY & BASE.

CONCLUSION:

Ø  Early surgery, good anatomical reduction and internal fixation helps to recover the full range of movements.

Ø  Stability is RESTORED.

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