Thank you, Julie. Actually, when I was a resident, we thought all those small coronoid fragments were pieces of the radial head, and we ignored them. I never actually fixed a coronoid fracture when I was in training. I think these are actually hard fractures to fix. When you have a traumatic elbow, all the swelling, I never get to these within the same day, but two or three days, all the swelling really goes medially. So if you do an immediate approach to a traumatic elbow, it can be a deep hole. It can be very difficult to assess. I used to fix most of these fractures, even the tip fractures, pull them down with suture. And now, actually, I fix very few of the type one or type one and a half, so to speak, fractures. But the larger fractures are still a challenge, and I sort of enjoy fixing them. But just from this picture here, you can get an idea of a few things. One, the MCL is often intact on these, unless there's been a terrible triad component of the fracture. And then when you approach these operatively, you get your exposure, which we'll show a little bit later. But you can feel the sharp edge of the fracture itself, and that guides you, based on your preoperative CT scan, to stay away from the area of the MCL. You can put your knife blade starting distally and come proximally to expose the fracture. So you can feel that once you get in. It's a nice little guide. Classification, my partner, Bernie Morey, classified these into types one, two, and three. Very easy to remember. This was in the year before CT scans. And inconveniently, the fractures don't go across like cutting right across from a lateral view. I wish they did. It would be a lot easier to fix. Well, we revisited this a few years ago and found that, actually, most of these do still correlate to the one through three classification. But we found that a lot of these break, actually, medially and laterally, particularly with the terrible triad. And so we sort of came up with a four-part classification system that we did a high intra-observer reliability. Well, here's a type four L, again. Significant dislocation. You can see the comminution of the radial head. And you can see the oblique nature of the coronoid fracture. This is one, if you looked at just the CT cut on the left, you might say, wow, we really need to fix that. But if you look on the right, you can see that the very medial buttress of the coronoid is still intact. So if you, in this case, probably replace the radial head, you have your lateral runner, so to speak, and you have your medial runner still intact, and the patient should do OK. So I think it's helpful to think of medial and lateral runners, fixing the radial head to get stability or replacing it, and looking very significantly at that very medial aspect of the coronoid. So type one fractures, these are the ones that I used to fix all the time. They were fun. I used to use an ACL guide and thought that was kind of fun because I couldn't do knee surgery anymore and passing sutures around and pulling it down. But I think we found through biomechanical studies that this is not really providing a buttress effect because it's not a plate. And it's really not a Bankart lesion of the elbow. It really isn't. The forces are this way, and it'll tend to slide over that. And here you can see the technique that I don't do anymore. But you see the fun little ACL guide there. Makes it easy. Put two holes in there, pull the sutures down, and tie them over the ulna. I do this from time to time. This is using screw fixation. And I have a little rule for myself is that if I think I can only put one screw into the fragment, guess what? I'm not fixing that fragment. I think it needs to be significant that you say, I can put two 2-7 size screws, for example, into that fragment. Then I'm going to fix it through a posterior approach. And you can see using an ACL guide initially, and then a heavy clamp to hold that down in that position, and then you fire your screws into that under floral control. So in the terrible triad diffraction, when do you need to fix the coronoid? This is a good example. This is a 64-year-old lady with a big arm. And I think you need to be very cautious of elderly ladies with big arms or males with big arms. There's a lot of weight hanging off of that elbow, whether it's fat or whether it's muscle. And if you're fixing the coronoid, or think you're going to fix the coronoid, you really need to fix it well, because a lot of these dislocate. And also your ligamentous repair at the end needs to be good also. So here we can see her comminuted radial head. And it's important to see here, like that other case I showed, that if you look carefully, you can see that the vast majority of her coronoid is intact. So this is one that even though you're going to get the x-ray, you're going to get the CAT scan, the two-dimensional CAT scan's going to show, may look like a significant coronoid fracture, but I would advocate that you can ignore this coronoid fracture and just excise it, and focus on fixing or replacing your lateral runner of the radial head, which we did here. It was unstable elbow dislocation. And so I always, and I'd recommend to all of us to, it only takes, adds maybe five minutes to the case, but every coronoid fracture, unless it's a simple radial head fracture, I will do a just quick floral EUA. One, you know what, ligaments are torn. Sometimes you think the MCL, like I said earlier, is intact, and you find out that, ooh, it's not intact at all. And a quick floral exam lets you know what you're dealing with before you make a skin incision. And in this case, we found out that she was very unstable at 60 degrees of flexion, and we did a poster incision to release the ulnar nerve. I resected the coronoid fracture, and then repaired back that lateral ligament, because I knew this is very important in this lady because she's unstable, and replaced the radial head. Now this happened. So she came back at two weeks, and you can see she's subluxed, and I remember the fellow said, I already spoke to her about going back to the OR. Well, you can look at this, and there's a few things you know. We know that the medial runner is intact. Remember that the significant part of the coronoid is intact. So we actually have an intact medial runner. We replaced the radial head, and maybe put a little bit larger one in, but it's certainly intact. So this is a case where the bony construct, so to speak, is intact. And this you can treat with just watching and waiting. And so we didn't take it back to the OR, but just started on overhead exercises, and she reduced. So this is very important to know that the runners are intact. If your medial buttress you did not fix, and you see that X-ray, then you need to go back to the OR and repair that coronoid fracture. This has already been discussed in non-operative and operative patients, but David Ring and Mike McKee, the so-called drop sign of the elbow. So something to recognize. You'll see it after simple dislocations of the elbow. Doesn't mean you need to rush back to the OR, but you can watch this at least for a couple of weeks. It should self-reduce over a two to three week period. So the intramedial fractures are the ones that kind of give us all a bit of a headache. You can see here, one, you can see the trochlea driving through the coronoid. This has been called post-termedial rotatory instability. And it's a good way to think about it. This is rotating into varus. You have the coronoid fracture, of course. This usually will pop the lateral colligament off. And biomechanical studies by Graham King's group have shown that it's very important to fix that lateral avulsion of the lateral complex because that will unload whatever you do to fix the coronoid fracture. And if you don't, it'll tend to push through your repair. And it's always a bit of a fragile repair on that medial side. And the posterior MCL, we don't care about. It's not the important part. And as I said, often the main part of the MCL is still intact. So what to fix. You can go from a posterior approach or more of a direct medial approach. I do more of a posterior medial approach because I don't have to worry about the medial anterobrachyteneus nerve so much. Going to the floor of the ulnar nerve and your choice to fix with a plate or screw fixation. And again, the lateral side, you'll pick this up from your EUA before you start it and floor it, as I said. You'll know how incompetent that lateral side is. And occasionally, it's not incompetent. So it's very important, I think, to do that EUA beforehand. So the operative approach that I tend to do is through the floor of the FCU. But just for completeness sake, you can do an over-the-top approach like Bob Hodgkiss described, coming through the flexor pronator group, get your exposure to the coronoid. And you think, well, that's pretty good. But if you try to lengthen that to get plate fixation in the coronoid, it's very difficult. So if you're just gonna do a screw fixation, I think over-the-top is fine. Then you have this floor of the ulnar nerve. And the issue here is, as you get more distal, if you actually have a shaft fracture of the ulna, you're gonna come into significant branches of the ulnar nerve, about a couple centimeters down here, and you can't cut those. So if you really need extensile exposure, if you elevate everything, and I mean everything off of the ulna, elevating the ulnar nerve up, your exposure of the tip of the coronoid is not so great. But then you can put a plate all the way down the ulna. So those are the three approaches. I think if you're just doing screw, you can do a simple over-the-top. Majority of these will be through the floor of the ulnar nerve. And if you have a really bad one, you can elevate everything up. And here you can see the exposure for the tip fracture. And again, as I said, starting your exposure distally, I think most of us do that now, is coming proximally as opposed to going straight down onto the coronoid fragment. It's easier to start elevating, fill that sharp edge where the fracture starts, but also the sharp edge of the ulna that's naturally there. And if you put your blade on that sharp edge and go proximally, it'll bring you just in the upper 1 3rd, so to speak, of the MCL, and you'll be safe, and you won't take down the MCL. There's a biomechanical study, again, showing that, as we all probably know, that plate and screw fixation is better than just screw fixation for coronoid fractures. And this is what it'll look like. This is sort of a live picture, but you can see what's going on here. This is a swollen elbow. You can look at this ulnar nerve. You can see it's going into that. And I'm trying, I don't retract hard all the time on the ulnar nerve, but I've had people come up to me and say, you know, I did that approach you mentioned, and the ulnar nerve was out, significant ulnar nerve issues, and it's true. So you, it's a swollen, if you do this in the cadaver, like you come to some of the courses, you think, wow, this is a pretty straightforward, sweet, sweet approach, but in a swollen elbow, you'll be dancing with the ulnar nerve a bit more, and it can make it a bit harder, and I always use a headlight and loops to fix these fractures. There's a patient, actually, I actually had a radial head fracture, too, we fixed at the same time. So here you can see in the OR, I've not taken down the flexor pronator group. You can see here, this is a left elbow. The ulnar nerve is here. You can see I'm dancing with the ulnar nerve, retracting it, not trying for the picture, but not always having that retractor, and not putting a fixed retractor in there, just a handheld retractor to get that exposure. If you can see a paddle part, because a very thin part of the coronoid, often you can't put a screw in, because it's only about five millimeters thick, so there are different pre-contoured plates. There's like three or four in the market now, and they all work equally bad, or equally good, I would say. So what do you do when you have a common in a coronoid fracture? And I've learned this the hard way. I'm just not that good at fixing coronoids that are in three pieces. So here's an electrician that fell at work, drove himself in, so he's self-employed, hard-working guy, so he's probably gonna do okay, if you get some good reduction. But this is an ominous picture. If you see an X-ray like this, that shows a gap on the lateral side. There's only two things it can be, gross instability of the elbow, gross simple dislocation, so to speak, or there's a coronoid fracture there somewhere, and you have to look for it. And you can see the fragments, so you know, because it's closed down over the medial side, there's a coronoid fracture. This is also a clue. He came in reduced. We put him in the scanner, and we dislocated him. So so far, we're not really helping this guy, but we can tell that he's probably pretty loose. So when I saw this, I said, wow, he's pretty loose. So coronoid in three pieces, one, two, and three. And so I'm like, okay, I know how to fix coronoid fractures. I've done this a few times, so we'll try and approach it from the medial side. But I did remember that barely, barely 2 1⁄3 of a sublime tubercle is intact. And there's been a lot of biomechanical studies, but for me, if I see 2 1⁄3 of the sublime tubercle is intact, I take a deep breath. If I get ligamentous stability, maybe perhaps using an X-fix, perhaps using heavy suture, I'll probably do okay, even if I can't get a good repair of that coronoid. But if you don't get good ligamentous stability, you might be in trouble. So 2 1⁄3 is the minimum amount for coronoid fracture. Again, like I said, every case, that's not simple. I do a five-minute or less EUA. You can see his MCL's torn. You can see his lateral collar ligament's torn. We sort of already knew that. And he dislocates at 45 degrees. So this is sort of game on. He's grossly unstable, has a three-part coronoid fracture. So I dove right in and got to work. I usually do the coronoid fracture first. I don't know if it makes a big difference. And I'm like, okay, I found two pieces. Where's the third? And then I kind of fooled around. The MCL was shredded. And I kind of piled them up like stones. Kind of looked at the plate I had, looked at that and said, I can't fix that. So I excised them. And the MCL was shredded. I didn't even bother trying to put sutures in. Here's my ulnar nerve again. The flexor pronator group was grossly intact. So I didn't do anything. I just went over the medial side, spent about, I don't know, 45 minutes and said, I give up. On the lateral side, you can see I have a whole flap, which is beautiful, of the whole lateral collarigment complex. Here's the radial head. So this needs to go back over here. And I think I'm just showing it going back. But I put that back significantly. But here's my concern. I don't have the best buttress effect medially. I have two thirds. It's pretty close, but I don't trust that because this is a repair I'm gonna do. A repair is not as strong as a native tissue. If this subluxes, if this repair goes into varus and he subluxes again, it's game over. There's really no good construct. You'll start getting arthritic at the trochlea coronoid interface. So in this case, I went ahead and put an X-Fix on. And with the X-Fix, a simple static X-Fix, I don't think there's any role anymore for a hinged X-Fix. I stopped probably about 10 years ago spending the usual hour and a half putting a hinged fixer on. And a couple reasons. One, it takes an hour and a half. And two, I'm usually, the area I'm trying to repair back the ligaments to is where I'm having to put some drill holes through for the fixer to try to line up the equilateral center. But here I just simply put in the same thing I use for distal radius fracture, X-Fix, two pins, a simple bar. I think all of us can do this within 20 minutes or a half hour. I hold it reduced. Resin tightens everything down. We flow check it to make sure it's reduced. Often I'm wrong. We unloosen it, tighten it down, and we're fine. So I did find the third piece of the coronoid. There it is. It's up in the bushes there. But I'm pretty confident this is not gonna sublux. It's in an X-Fix. And I take it off at four weeks in the OR, which I did. You can see we nicely broke off the pin. But he was at four weeks. And when I saw him back after that, I put him on exercises. I gave him a splint, you know. He had pretty good motion right after I took the X-Fix off. He smiled when I saw him back. And I said, I'm glad you're doing your exercises. Your motion's great. It's, you know, 10, 10 to 145. He says, I didn't do any exercise. I just went back to work. So if you have a motivated patient, you don't need to necessarily send him off to exercises. Just to finish up, the basal fractures tend to be a little bit more complex. Here was a college professor that realized, of course, the best way to get snow off your roof is to use a snowblower. It's the most efficient way until you fall. And you can see his coronoid fracture here. And these can be fun because you can approach the coronoid fracture by pulling. He's already done his own osteotomy for you. You can fix that with buried screws and then put your plate on and then fix the radial head, which we did, and he did reasonably well after that. He did his exercises. The problem cases are patients that have been fixed. This patient's two months out, has minimal motion. And you can see a couple issues here. The coronoid fracture was ignored and the radial head was excised. So you took out, your two runners, medial and lateral, don't exist. So of course this is sort of going to happen. It's a complex coronoid fracture, but even at two months you can get somewhat of a reduction. You repair your runners, so to speak, and his motion's not great, but he's sort of happy. We looked at our outcomes of 100 fractures. It was interesting that the best treatment were those we didn't treat, so again, my algorithm of not going after the types of one and one and a half were better motion than RAF. Now the ones that we did fix, obviously were more complex, but it's hard to really tease out the effect of just fixing the coronoid since the more complex ones have a radial head fracture. But again, this is a paper from David Ring, 18 patients, showing that you really do need to fix those large anterior medial fractures. If you don't, they'll go into a virus and become arthritic, as we mentioned earlier. And if you look at the very large fragments, you can see over in type C, those are the ones, the anterior medial fragments that Graham King and Ken Faber's lab showed that if you don't fix those, you will not restore stability, even if you fix that lateral cladoligament complex. You do absolutely need to go after those large anterior medial fragments. So again, I think the 3D imaging is important for surgical planning. Don't go after the small tib fractures anymore. Probably most type two fractures should be fixed. And again, you can get after these through the radial head approach if you're excising it or replacing it. And really consider an X-Fix. In the case that I showed, it's really easy to put on. It can keep you out of trouble and guarantee stability out of the box. Thank you very much. Thank you.

fixing coronoid fractures

coronoid fragments

traumatic elbow

classification of coronoid fractures

ligamentous stability