This video demonstrates a novel approach for coronoid fracture fixation. The authors have no relevant disclosures to make. The authors have not received any commercial support. A coronoid process serves as an important constraint that provides ulnar-fumaral joint stability. Multiple studies have demonstrated that the coronoid functions as a stabilizer against axial, varus, posterior medial, and posterior lateral forces. The coronoid process of the proximal ulna articulates with the trochlea of the humerus proximally and with the radial head on its lateral side. It forms the greater sigmoid notch in conjunction with the olepnod. As the proximal ulna increases in coronal plane diameter, progressing distally, it widens to form the coronoid and the sublime tumorcle, onto which the anterior band of the medial collateral ligament inserts. Traditionally, isolated coronoid fractures were managed non-operatively. However, it has become apparent that coronoid fractures that appear to be isolated may be more sinister, potentially involving injury to the collateral ligament, which could result in posterior medial rotatory instability. Fracture of the anterior medial facet can result in recurrent subluxation, which we consider an indication for operative intervention. We've also observed that often the posterior bundle of the MCL is injured as well and should be repaired at the time of fixation. Multiple surgical approaches have been described for coronoid repair. We have been using a less invasive surgical approach that is a variation of the approach described by Taylor and Sham. The approach described by Taylor and Sham involves an incision along the subcutaneous border of the ulna, followed by subperiosteal dissection medially. An elevation of the ulnar and deep heads of the flexor digitorum superficialis and pronator teres. The muscular origin of the flexor digitorum profundus is then elevated with dissection carried anteriorly until the anterior margins of the coronoid and the sublime tumour call are delineated. The Hotchkiss approach involves a posterior medial skin incision, identification and dissection of the ulnar nerve distally, visualization of the medial antebrachial cutaneous nerve and the splitting of the flexor carpi ulnaris. Morey and O'Driscoll described a posterior elbow incision which allows for subsequent lateral exposure through a single incision, followed by exposure of the ulnar nerve, elevation of the brachialis and pronator and then leaving a cuff of the FCU for closure. The presently described approach differs from all the previous reports except for that of Taylor and Sham. Our approach differs from theirs in the extent of dissection. We use a more limited skin incision followed by a more limited elevation of the flexor pronator mass. Preoperatively, we recommend good quality orthogonal radiographs. If the patient has significant distal humerus or proximal ulnar fractures, then stress radiograph views are helpful. In the case of an isolated coronoid fracture, we always obtain a computed tomography scan in the plane of the elbow. This is helpful to assess which facet of the coronoid is fractured. In the case of an anterior medial facet fracture, the collateral ligaments are commonly injured. While it can be difficult due to the lack of adequate anesthesia to obtain stress radiograph views, if possible, under local anesthesia, we will obtain varus and valgus stress views. Commonly in the setting of an isolated coronoid fracture, there is also an injury to the LCL. Regardless of whether stress radiographs are obtained preoperatively, dynamic stress fluoroscopy should absolutely be obtained in the operating room under anesthesia. The surgeon must ensure that no lateral approach is required. Here, we present a case in which radiographs demonstrate an anterior medial facet fracture of the coronoid process, which was confirmed with CT. There was no fracture of the radial head or neck. The elbow demonstrated posterior medial instability and the inability to maintain reduction even up to 90 degrees. The patient is positioned supine with her left arm secured in a McConnell shoulder positioner with the shoulder and elbow flexed at 90 degrees. The skin incision extends 2 centimeters proximal to the olecranon tip and 4 centimeters distally on the subcutaneous border of the ulna. The ulnar nerve is identified, unroofed, and left in situ. We do not transpose the ulnar nerve. In other series, transposition has led to postoperative neuropathies. And now, similar to us, Dr. Rang and group, as they noted in their recent coronoid paper, no longer transpose. The ruptured posterior MCL and the medial border of the trochlea and anterior medial facet can be seen, along with the obvious instability. The small piece of articular surface was identified, carefully anatomically reduced and temporarily fixed with a Kirschner wire. The coronoid plate is then fitted against the fragment and fixed with the center screw. The plate is then rotated into position in order to compress the fragment onto its anatomic position. Drill holes were made at the anatomic site of the insertion of the posterior MCL and PDS sutures were used to repair the MCL. The flexor pronator mass was anatomically reattached to the subcutaneous border of the ulna. There is a temporary Kirschner wire that is left in position in order to provide additional support. Post-operatively, we splint patients for one week to facilitate wound healing. We immediately initiate hand exercises and all patients are provided HO prophylaxis. At one week, we remove the splint and initiate active assisted elbow motion. Because the MCL is repaired and commonly the LCL may also need to be repaired, we observe various valgus stress precautions such as avoiding shoulder abduction for six weeks. Elbow flexion and extension is permitted in supination and active forearm rotation is done with the elbow at 90 degrees. At six weeks, we lift various valgus stress precautions and start resistive exercises. At three months, we permit full activity without restrictions. The indications for this approach are a fracture of the anterior medial facet, any instability, associated terrible triad injuries, and montasia fractures with a large associated coronoid fragment. The contraindications for this approach are a small isolated coronoid fracture without instability or a transverse tip fracture of the coronoid associated with a terrible triad that can be addressed from a lateral exposure. There are many potential complications of fracture surgery about the elbow and these remain germane for this approach as well. They include heterotopic ossification, ulnar nerve injury, failure of fixation, nonunion, persistent posterior medial rotatory instability, wound complications, and arthrofibrosis. Our outcomes with this approach are not yet published. In the literature, likewise, there are no published series of outcomes other than anecdotal reports. Dorn and Ring and JBJS reported 11% of their patients with anterior medial facet fractures had ulnar nerve palsies after transpositions. As mentioned earlier, at the time, they routinely transposed the nerve. However, they no longer do so. We do not transpose the nerve. Our technique has been used on three consecutive patients with isolated anterior medial facet fractures with associated posterior medial instability. Postoperatively, we have observed 100% bony union, no neuropathies, wound complications, hardware failures, revisions, or heterotopic ossification. All patients obtain their full preoperative range of elbow motion and all patients return to work in full activities. In conclusion, our technique offers a novel approach to the coronoid that should be considered when patients present with a coronoid fracture and posterior medial instability.

coronoid fractures

operative intervention

surgical approaches

limited dissection

anatomical reduction