Persistent Elbow Pain In A Softball Pitcher - Page #4
 

Working Diagnosis:
Ulnar Coronoid Stress Fracture

Treatment:
Relative rest, ice, physical therapy, bone stimulator 3x/week x 6 weeks

Outcome:
At the 1 week follow up, patient was without complaints with improved pain and function. She began supervised pitching motions approximately 2 months after diagnosis. Return to full activity without pain was possible 4 months following diagnosis. The athlete tolerated progressive RTP and is currently participating with a compression sleeve.

Author's Comments:
The coronoid process plays an important role in elbow stability. Coronoid fractures are rare in isolation and occur in only 10-15% of elbow dislocations. They usually occur in conjunction with traumatic posterolateral elbow dislocations and radial head fractures, termed the "terrible triad". Stress fractures of the coronoid are exceedingly rare in the literature. The Regan and Morrey classification for coronoid fractures involves the size of the coronoid fragment and elbow joint stability. Based on the MRI interpretation, approximately 50% of the coronoid process had increased signal intensity. Assuming the presence of a corresponding fracture and less than 50% involvement, our patient would meet criteria for a Type II nondisplaced coronoid fracture without instability. Treatment for this classification is usually conservative. Our patient responded to relative rest, ice, physical therapy, and a bone stimulator. Her pain and function improved gradually and she ultimately tolerated progressive return to play with a compression sleeve. If instability was present on exam, she may have been a surgical candidate. This case illustrates the importance of prompt recognition and management of relatively rare fractures which can respond to conservative treatments.

Editor's Comments:
Quoted statistics are that although coronoid fx constitutes only 1-2% of elbow fx, it occurs in 10-15% of dislocations. The authors have brought us an interesting case of a non-displaced fracture which was successfully managed with conservative treatment. The key finding was pain over the affected area with flexion, which prompted the MRI in the face of a normal radiograph. References present a good source of review.

References:
1. Morrey BF. The elbow and its disorders. 3rd ed. Philadelphia, PA: W.B. Saunders Company; 2000
2. Wells B, Ablove RH. Coronoid fractures of the elbow. Clin Med Res. 2008;6(1):40-44
3. Selesnick FH, Dolitsky B, Haskell SS. Fracture of the coronoid process requiring ORIF. A case report. J Bone Joint Surg Am 1984;66:1304-1306

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