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The Essex-Lopresti Injury.

The human forearm can sustain significant loads while rotating through a 180[degrees] arc allowing humans to position the hand in space. (1,2) In order for the forearm to rotate, the radius and ulna must articulate through the proximal (PRUJ) and distal radioulnar joints (DRUJ). The entire construct is held in place by the interosseous membrane (IOM) of the forearm. (2,3) An injury of the IOM, in conjunction with a radial head fracture, shortening of the radius, and dislocation of the distal radioulnar joint is known as an Essex-Lopresti injury. (1)

The injury is caused by a violent longitudinal compression force transmitted from the wrist to the elbow. (4) Because it is rare, it is often missed. (5) Attention is often focused on the radial head fracture; the associated tear of the IOM and the injury to the DRUJ may be overlooked, delaying diagnosis and treatment. Delayed management can lead to proximal migration of the radius, persistent dislocation of the DRUJ, and ultimately chronic instability. (5) Since the proximal migration of the radius occurs slowly, it may not be identified on the initial radiographs. Ultimately, patients will develop restriction of movement and ulnocarpal wrist pain. (1,4-6)

Historical Perspective

Peter Essex-Lopresti, trained at the Royal Free Hospital and then joined the Royal Army Medical corps in 1943 during WWII. (7) He volunteered for the 225th Field Ambulance division, a parachute division. He parachuted into France a few hours prior to the D-Day invasion. (7) After the war, in 1946, he published an article entitled "The Hazards of Parachuting" that chronicled the parachute related injuries he encountered during his time with the airborne division and detailed injuries that occurred during the three phases of the jump. (8) In 1947, he was appointed as a consultant to the Birmingham Accident Hospital. It is here where he described his classification of calcaneus fractures, as well as where he published "Fractures of the Radial Head with Distal Radioulnar Dislocation," which described two cases of the injury that now bears his name. (4,7) Unfortunately, soon after his paper was published, he died of a suspected myocardial infarction at the early age of 35. (7)

Anatomy

In order to fully understand the anatomy of the IOM, one must consider the anatomy of the forearm as a whole. The forearm is composed of the radius, the ulna, the PRUJ, the DRUJ, the triangular fibrocartilage complex, and the IOM, with each structure contributing to forearm stability. (3)

The IOM is made up of a proximal, a middle, and a distal portion. The proximal portion of the IOM has two components, the proximal oblique cord and the dorsal oblique accessory cord. (2,3) The proximal oblique cord originates from the anterolateral aspect of the coronoid and inserts just distally to the radial tuberosity. The dorsal oblique accessory cord originates in the proximal ulna at the junction of the proximal one-third and distal two-thirds and inserts on the interosseous crest of the radius. (2)

The middle portion of the IOM is composed of the central band and an accessory band. The central band is the widest and thickest ligament. (2,3) It originates on the interosseous crest of the radius and inserts on the interosseous border of the ulna. The accessory band can vary in the number of fibers and is usually evident distal to the central band. Skahen et al. (9,10) performed a cadaveric study and found that the central band is oriented 21[degrees] in a distal and ulnar direction.

The distal portion of the IOM underlies the pronator quadratus muscle and is made of membranous tissue and a ligamentous structure, the distal oblique bundle (DOB). (2,11) It originates from the distal one-sixth of the ulnar shaft and inserts along the inferior edge of the sigmoid notch, extending both volar and dorsal and blending into the fibers of the volar and dorsal DRUJ ligaments of the triangular fibrocartilage complex (TFCC). Of note, the DOB is not found in all cadaver specimens. (2,11)

Biomechanics of the IOM

The interosseous membrane serves several biomechanical functions for the stability of the forearm. First, it functions in the transmission of load from the wrist to the elbow. (1) In an ulnar neutral wrist, approximately 80% of the axial load is transmitted through the radiocarpal joint. (12) As this force is transmitted proximally, the IOM transfers some of this load from the radius to the ulna so that at the elbow 60% of the load is received by the radiocapitellar joint and 40% by the ulnohumeral joint. (12) Cadaveric studies have shown that with the radial head excised, the central band becomes responsible for the majority of the longitudinal stiffness of the IOM and can handle approximately 1,000 N of force. (13,14) In addition, the position of the forearm in space determines where the majority of the load is seen. In pronation, the strain is mainly found proximal, while in supination, the strain is increased distally. (15)

Skahen et al. (9,10) demonstrated the secondary role in maintaining dynamic radioulnar stability when changes in radial length occur such as in radial head fractures using a cadaver model. They compared the percentage of strain withstood by the central band with an intact radial head to the strain experienced after radial head excision. They showed that the strain in the central band is significantly increased after excision as the forearm proceeds from a position of supination to pronation.

The IOM also contributes to longitudinal and transverse forearm stability. (14,16-18) The radial head is the primary restraint to proximal migration of the radius. (14,18) The IOM and TFCC serve as important secondary stabilizers.14,18 The IOM also provides transverse stability to the forearm through the central band. The force vectors pull the radius and ulna toward each other preventing splaying of the two bones as the forearm rotates secondary to the orientation of the IOM fibers. (16,17)

Using cadavers, Rabinowitz et al. (18) demonstrated that the IOM was the main secondary restraint to migration of the radius. With the head excised and the TFCC transected, there was minimal proximal radius migration. But when the central band of the IOM was transected, there was a significant increase in the amount of proximal migration of the radius. (18)

Finally, the IOM contributes to DRUJ stability. (2,11,19) Noda et al. (2) performed cadaveric dissections of the distal oblique bundle and found that it is present in approximately 40% of forearms. Maritomo et al. (11) report that the DOB functions as an isometric collateral ligament within the TFCC. Kitamura et al. (19) found that cadavers with a DOB had greater DRUJ stability when stressed. They also found that for dorsal DRUJ dislocations to occur in these specimens, both the DRUJ and DOB had to be disrupted. (19)

Clinical Presentation

These injuries occur secondary to a violent, high-energy load to the forearm with the elbow in an extended position. (1,4,20) If a sufficient force is exerted on the forearm, the head of the radius fractures or dislocates, the IOM ruptures, and the DRUJ dislocates. The radius then migrates proximally, leaving the patient with complex forearm instability. On presentation, these patients will complain of elbow and wrist pain, and some will have pain throughout the forearm. (1,4,20)

On physical exam, it is important to assess for signs of an open fracture, which would turn the injury into an emergent operative case. A thorough elbow exam should be performed, paying attention to bony prominences, range of motion, and any blocks to motion. If there is a concern for block to motion, the elbow can be aspirated and injected with lidocaine to better obtain a more complete examination. Elbow joint varus and valgus stability in both full extension and 30[degrees] of flexion should be assessed, although this may be difficult on initial evaluation due to pain. The wrist must be examined, particularly the DRUJ for any signs of instability or tenderness. Finally, the forearm should be inspected for ecchymosis and palpated to assess for tenderness over the IOM.

It is important to recognize that the position of the outstretched arm at the time of injury will determine the injury pattern. McGinley et al. (15) performed a cadaveric study looking at the effect of arm position on the forearm injury pattern. With the forearm in a position of supination, the radiocapitellar joint has the least amount of contact and the maximum amount of tension within the IOM, leading to a transfer of force from the radius to the ulna and resulting in a both bone forearm fracture. In neutral rotation, there is moderate contact between the radiocapitellar joint and an isolated radial head fracture occurs. Finally, in pronation, the radiocapitellar joint has the most contact. All the force is transmitted through the radius leading to a comminuted radial head, migration of the radius, and tearing of the IOM. (15)

With radial migration, patients can develop ulnocarpal impaction at the wrist. The distal ulna can migrate dorsally within the sigmoid notch, impacting the carpus, limiting supination and wrist extension, and leading to wrist pain. In addition, proximally, the radius abuts the capitellum leading to elbow pain and decreased range of motion. (1,5,20)

Diagnosis and Imaging

The diagnosis of acute Essex-Lopresti injuries are commonly missed, with one report indicating that only 20% are recognized on initial presentation. (21) This means that often patients present late with chronic injuries. In acute injuries, there is likely complete rupture of the IOM membrane allowing for obvious proximal migration of the radius on presentation. In chronic injuries, the IOM or part of the membrane may remain intact and over time due to radial head instability, it may fail, leading to radius migration, forearm instability, and pain. (1,22,23)

Radiographs of the elbow, wrist, and forearm should be the first imaging modalities obtained. (1) If there is a question of DRUJ injury, contralateral wrist films should be obtained to assess for ulnar variance and DRUJ positioning. The optimal position to obtain an image of the DRUJ is with the shoulder abducted to 90[degrees], the elbow flexed to 90[degrees], and the forearm in neutral rotation. (1) A CT scan of the elbow should be obtained to assess the degree of radial head comminution and aid in surgical planning.

Recent cadaveric studies have shown ultrasound to be an effective imaging modality to assess injury to the IOM. (24,25) Jaakola et al. (24) showed in a cadaveric study that a tear in the IOM could be recognized with 96% accuracy. As with other ultrasound-based imaging, the results are user dependent. In addition, MRI has more recently been recognized as an effective tool to confirm the diagnosis. McGinley et al. (25) found that MRI had a 100% positive predictive value, with the interosseous membrane best viewed on axial T2-weight images. Future in vivo studies would aid in further delineating the effectiveness of these advanced imaging modalities.

Evolution of Treatment

Although this injury is named after Peter Essex-Lopresti, the first documented case of an Essex-Lopresti injury was reported by Curr and Coe in The British Journal of Surgery in 1946. (26) They described a patient who sustained a mining accident and presented with a radially deviated hand and swelling and limited motion at the elbow, forearm, and wrist. They concluded that the IOM must have been damaged given their findings and were able to reduce the proximal dislocation of the radius using traction. They immobilized the arm for 6 weeks and at 1-year follow-up the patient had good elbow and wrist motion but only 5[degrees] of pronation and supination. (26)

Then in 1951 Essex-Lopresti reported two cases of radioulnar dissociation. His first case was of a 46-year-old man who was pushing a loaded truck with his arms extended when the truck stopped suddenly. (4) The patient underwent a radial head excision and subsequently developed radius migration. An attempt at closed reduction failed. The patient ended up with radial deviation of his hand and a poor result. The second case of radio-ulnar instability Essex-Lopresti saw was a man who fell from a ladder onto an outstretched hand. After the poor outcome he observed with radial head excision alone, he decided to change his management for his second case, repairing the radial head and immobilizing the patient in supination. The patient ended up with good motion at the elbow and an arc of rotation of 45[degrees]. (4)

After treating these injuries, Essex-Lopresti noted two important points. First, although this injury is uncommon, you must examine the DRUJ whenever a radial head fracture is present because if the injury is missed it can lead to more severe complications requiring further surgery. Second, excision of the radial head should be avoided at all costs in these patients. (4)

The next report of the Essex-Lopresti injury did not occur until 1957 where, despite the previous warning about radial head excision, McDouggall excised the radial head in a farmer thrown from a motorcycle leading to further displacement of the radius and advanced arthritic changes at the wrist. (27)

It was not until almost 20 years later that Levin reported the use of a silicone implant for use in Essex-Lopresti injuries, with fair outcomes at 1-year follow-up. (28)

Edwards and Jupiter (29) described the first classification of Essex-Lopresti injuries when they reviewed their series of seven cases. They defined type I injuries as radial head fractures with large displaced fragments, type II as those with severe comminution of the radial head, and type III injuries as old chronic injuries with irreducible migration. (29)

Current Acute Management Recommendations

Every effort should be made to save the native radial head. (1,30) If an open reduction and internal fixation cannot be achieved, then a prosthetic replacement should be considered. The radial head should never be excised. (1,30) The injured DRUJ should be pinned to allow for IOM healing. It is important to place the wires through four cortices to allow retrieval from both the ulnar and radial side in case of pin breakage. It is controversial whether reconstruction of the IOM should be performed in the acute setting. In general, radial head fractures should be treated with open reduction and internal fixation (ORIF) if there are less than four fracture fragments. (1,3)

Radial head fractures should be treated with open reduction and internal fixation (ORIF) if there are three or less fracture fragments. (31) In cases with more than three pieces, radial head replacement should be performed. Ring et al., (31) reviewed 56 patients with radial head fractures treated with ORIF and an average follow-up of 48 months. They found worse outcomes and higher complication rates in fractures in those with more than three fragments. They recommended replacement in cases with greater than three pieces. (31) Currently, the recommended radial head implant is a bipolar or monopolar titanium radial head prostheses. (1)

Intraoperative tests should be performed to assess IOM stability. The radius pull test is performed by applying approximately 20 pounds of traction to the proximal radius using a tenaculum. Three millimeters or more of radial migration is indicative of IOM disruption. (32) Another test that can be performed is the radius joystick test once the radial head is removed. (33) A clamp is placed on the radial neck, and the forearm is maximally pronated with the shoulder internally rotated and abducted. The surgeon holds the forearm in place while an assistant pulls laterally on the tenaculum. If there is greater than 5 mm of translation, and the radius can sublux from under the capitellum, this suggests the IOM is disrupted. (33)

After replacement of the radial head, the DRUJ should be assessed. If it is determined to be unstable, an ulnar incision proximal to the wrist joint should be made, and the DRUJ should be pinned in neutral with two 2.0 mm buried Kirschner wires, each placed through four cortices to allow for retrieval in case of breakage. The wires should be removed after 6 to 8 weeks. (1,20)

Outcomes of Acute Management

There is a paucity of data in the literature regarding the outcomes in acute management of these patients. Grassman et al. (30) looked at 295 patients with radial head fractures. Thirty-nine patients had ipsilateral wrist pain and received MRIs. Of the 39 patients undergoing MRI, 12 were found to have IOM tears. They all underwent surgery within 3 to 12 days after injury. At a mean follow-up of 59 months, these investigators concluded that early treatment led to good outcomes and avoided the complications of a missed diagnosis and difficulties of late treatment. (30)

However, Gong et al. (34) reported a failure of the IOM to heal in a patient treated with a radial head replacement and pinning of the DRUJ. They believed that this could possibly be due to herniation of forearm musculature preventing healing. This case report calls into question the need for possible acute interosseous membrane reconstruction.

There are only a few reports in the literature of acute treatment with IOM reconstruction. Brin et al. (35) described a case report of acutely repairing the IOM with a TightRope[R] (Arthrex, Inc., Naples, Florida, USA). On postoperative follow-up ultrasound, they found a continuous IOM with a scar. They reported a good functional outcome in their patient. Matthias et al. (36) also described a case of acute repair using a radial head replacement, DRUJ pinning, and TightRope[R] reconstruction. At 1-year follow-up, the patient was slightly ulnar positive. However, there are no series comparing acute reconstruction versus no reconstruction to date, and acute reconstruction remains a highly controversial topic.

Reconstructive Options

Multiple reconstructive options have been reported in the literature. Bone-patellar tendon-bone allograft and autograft have been described. (3,20,22,37-39) Jones et al. (38) showed that bone-patellar tendon-bone graft alone reduced radioulnar translation by 50% in cadaver specimens and, when combined with a radial head replacement, returned stability to that of the intact specimen.

Flexor carpi radialis (FCR) autograft has also been described. Skahen et al. (10) showed that FCR autograft improved but did not normalize longitudinal force transfer in the forearm. In addition, the use of palmaris longus autograft has been described. (39)

Tejwani et al. (39) created a cadaver model comparing the native IOM, palmaris, FCR, and bone patellar tendon bone allograft as reconstructive options for the IOM. They found that no graft reconstruction limited proximal radial displacement as effectively as the native IOM. Of the three graft tissues tested, bone-patellar tendon-bone allograft had the greatest cross-sectional area, allowed the least proximal radial displacement, and displayed the least permanent elongation after cyclical loading.

Most recently TightRope[R] (Arthrex, Inc., Naples, Florida, USA) tenodesis has been described. (35,36,40,41) Drake et al. (40) showed that this construct could restore longitudinal stability equivalent to that provided by the interosseous membrane.

Chronic Essex-Lopresti Management

The majority of Essex-Lopresti injuries present in a chronic setting with subsequent pain and deformity. (5,22,37,39) Surgical treatment strategies for chronic injuries revolve around recreating the anatomy at the elbow, wrist, and forearm. At the elbow, the radiocapitellar articulation needs to be reestablished with a metallic prosthesis. At the wrist, the goal is to achieve a level joint and address lesions of the TFCC. However, a radial head prosthesis alone will not be powerful enough to shift the radius and level the wrist joint. Therefore, an ulnar shortening osteotomy must be performed to reestablish correct ulnar variance. Finally, the IOM should be reconstructed. (5,22,37,39)

Heijink et al. (6) demonstrated, in a series of eight patients with chronic Essex-Lopresti injuries, that replacement of the radial head is not a reliable treatment method with five of the eight implants failing at a mean of 3 years postoperatively due to loosening or radiocapitellar arthrosis. Jungbluth et al. (23) also followed a series of patients with chronic Essex-Lopresti injuries treated with radial head replacement alone and found a mean postoperative DASH score of 55 and postoperative grip strength of 68% of the contralateral side. Both of these studies show that radial head replacement alone is an ineffective treatment.

In a series of seven patients with chronic Essex-Lopresti injuries, Venouziou et al. (42) reported good results following radial head replacement and ulnar shortening osteotomy. At 33 months postoperatively, pain score improved from 8.4 to 3.3, range of motion improved significantly, wrist and elbow functional scores were good, and positive ulnar variance improved from +8.0 to 3.5 mm. However, it is unclear, given the high forces seen at the radiocapitellar joint without reconstruction of the IOM, if this will lead to progressive radiocapitellar arthritis later.

Marcotte and Osterman (5) reported on a series of 16 patients with chronic Essex-Lopresti injuries. These investigators performed ulnar shortening osteotomy and bone patellar tendon bone autograft reconstruction of the IOM and found that at 78 months postoperatively, 15 out of 16 patients had improved pain and average grip strength improved from 59% to 86%. However, 25% of patients developed persistent pain at the autograft donor site. This associated morbidity of the autograft prompted these investigators to change their surgical technique from the use of allograft to autograft bone-patellar tendon-bone. (5)

Most recently Gaspar et al. (43) reviewed 10 patients treated with ulnar shortening and Mini TightRope[R] (Arthrex, Inc., Naples, Florida, USA) interosseous membrane reconstruction. The surgeries were performed on average more than 2 years after injury. At 3-year follow-up, patients had improved ROM, DASH scores, and ulnar variance. Complications included one revision ulnar shortening osteotomy and one removal of a TightRope[R] for lost supination. (43)

When reconstruction fails, the surgeon is faced with an even more difficult situation than the chronic Essex-Lopresti injury. One salvage option is the "one-bone forearm" procedure, or radioulnar synostosis. (44-48) This is indicated for persistent longitudinal radioulnar instability despite attempted reconstruction. Lee et al. (47) reported good outcomes of one case at 8-year follow-up. However, reports in the literature are mixed with some studies reporting poor outcomes with high complication rates. (44-48) The radioulnar synostosis procedure should be considered only as a salvage procedure.

The Authors' Preferred Treatment

All patients with radial head fractures should have their forearm and wrist evaluated for interosseous ligament and DRUJ injuries. If no instability is present, then treat them for an isolated radial head fracture. If instability is evident, and it is less than 4 weeks old, perform either a radial head ORIF or arthroplasty plus DRUJ stabilization and consider acute reconstruction. If the injury is more than 4 weeks old and they have pain and instability, perform an USO, reconstruct the IOM with a bone-patellar tendon-bone allograft or TightRope[R] and treat the radial head with a prosthesis. If these treatments fail, consider a salvage procedure like a radioulnar synostosis as a last resort.

Conclusion

The greatest challenge with the Essex-Lopresti injury is the diagnosis. The physician must have a high index of suspicion whenever a patient presents with a radial head fracture. Once a diagnosis is established, the surgical treatment focuses on addressing the radial head fracture and the DRUJ disruption in order to restore forearm length and stability. Chronic or untreated injuries continue to challenge treating physicians and often require reconstructive or salvage procedures to minimize pain and restore function.

Disclosure Statement

None of the authors have a financial or proprietary interest in the subject matter or materials discussed, including, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony.

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Michael S. Guss, MD, and Michael E. Rettig, MD

Michael S. Guss, MD, Department of Orthopaedic Surgery, Newton-Wellesley Hospital, Tufts University School of Medicine, Boston, Massachusetts, USA. Michael E. Rettig, MD, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, 301 East 17th Street, New York, New York, 10003, USA.

Correspondence: Michael S. Guss, MD, Department of Orthopaedic Surgery, Newton-Wellesley Hospital, Hand Surgery, PC, 2000 Washington Street, Blue Building Suite 201, Newton, Massachusetts 02446, USA; michaelgussmd@gmail.com.

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Author:Guss, Michael S.; Rettig, Michael E.
Publication:Bulletin of the NYU Hospital for Joint Diseases
Article Type:Disease/Disorder overview
Date:Jan 1, 2019
Words:5315
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