What are the surgical approaches to coronoid process fractures of the mandible?

From the Guidelines

Surgical approaches to coronoid process fractures of the mandible typically involve a medial, anterior, or lateral approach, with the choice of approach depending on the fracture type, size, and associated injuries, as well as the need to address potential tendon injuries, as suggested by the clinical context of acute trauma and elbow dislocation 1. The surgical approach to coronoid process fractures is crucial in restoring elbow stability and preventing long-term morbidity.

• The medial approach is preferred for anteromedial coronoid fractures, providing excellent visualization of the anteromedial facet.
• The anterior approach is useful for larger coronoid fragments, involving an incision along the flexor-pronator mass.
• The lateral approach is typically used when addressing associated radial head or lateral collateral ligament injuries. Fixation methods include screws (2.0-2.7mm), suture anchors, or plate fixation for larger fragments, with the goal of reestablishing the anterior buttress effect of the coronoid to prevent posterior subluxation of the ulnohumeral joint during flexion and extension movements, as implied by the association of coronoid process fractures with prior elbow dislocation and soft tissue injury 1. Postoperatively, early protected motion is initiated within 1-2 weeks to prevent stiffness, with gradual progression to full activities over 3 months, aiming to improve quality of life and reduce morbidity.
• Proper anatomic reduction is crucial as malunion can lead to arthrosis and persistent instability, highlighting the importance of careful surgical planning and execution.
• The presence of a joint effusion, as identified on conventional radiography, can imply an occult elbow fracture, and coronoid process fractures should prompt the referring provider to assess for associated tendon injuries, as noted in the context of acute elbow and forearm pain 1.

From the Research

Surgical Approaches to Coronoid Process Fractures

The coronoid process fractures can be approached through various surgical methods, including:

• Anterior approach: This approach is used to address coronoid process fractures, especially in cases of complex elbow instability 2, 3.
• Anteromedial approach: This approach is used to treat anteromedial coronoid facet fractures and associated injuries 4.
• Medial and lateral approaches: These approaches have been popularized in recent literature, but there is no universally accepted approach 2.
• Open reduction and internal fixation: This method is used to treat coronoid process fractures, especially in cases of type II and III fractures 3, 4, 5.

Fixation Techniques

Various fixation techniques are used to stabilize coronoid process fractures, including:

• Suture lasso
• Suture anchors
• Lag screws
• Plating
• Antero-posterior screw fixation combined with buttress plating 2
• Mini-plate fixation 4
• Antero-posterior lag-screw fixation 5

Considerations

When treating coronoid process fractures, it is essential to consider the following factors:

• Associated injuries, such as elbow dislocation and radial head fracture 2, 3, 5
• Comminution of the detached fragment 5
• Postoperative complications, such as limited mouth opening and pain 6
• Rehabilitation and postoperative care, including the timing of plaster application and rehabilitation 4