Essex-Lopresti injuries (ELIs) are characterized by fracture of the radial head, disruption of the forearm interosseous membrane, and. The Essex–Lopresti lesion is an unusual injury, consisting of a radial head or neck fracture, distal radioulnar joint (DRUJ) injury and interosseous membrane. The Essex-Lopresti injury is rare. It consists of fracture of the head of the radius, rupture of the interosseous membrane and disruption of the distal radioulnar.
Essex-Lopresti fracture-dislocation is characterized by a fracture of the radial head, dislocation of the distal radioulnar joint and rupture of the antebrachial. Essex-Lopresti injury consists of a radial head fracture AND dislocation of the distal radioulnar joint (DRUJ) AND disruption of the interosseous. Aim of this study is to focus on the different lesion patterns causing forearm Five patients affected by acute Essex-Lopresti injury have been.
Essex-Lopresti injury consists of a radial head fracture AND dislocation of the distal radioulnar joint (DRUJ) AND disruption of the interosseous. The Essex–Lopresti lesion is an unusual injury, consisting of a radial head or neck fracture, distal radioulnar joint (DRUJ) injury and interosseous membrane. Aim of this study is to focus on the different lesion patterns causing forearm Five patients affected by acute Essex-Lopresti injury have been.
Acute Essex-Lopresti injury is a rare and disabling condition of longitudinal instability of the forearm. When early diagnosed, essex report better outcomes with higher functional recovery. Aim of this study is to focus on the different lesion patterns essex forearm instability, reviewing literature and the cases treated by the Authors and to propose a new terminology for their identification. Five patients affected by acute Essex-Lopresti injury have been enrolled for this study.
ELI was caused in two patients by bike fall, two cases lopresti road traffic accident and one patient by fall while walking. The search was limited to English language literature. All patients were operated in acute setting with radial head replacement and different combinations of interosseous membrane reconstruction and distal radio-ulnar joint stabilization.
The clinical studies present in literature reported similar results, highlighting as patients properly diagnosed and treated in acute setting report better results than patients operated after four weeks. The forearm can lopresti considered as a single articulating unit where the close interdependence of multiple anatomical structures allows forearm rotation, elbow and wrist motion [ 12 ].
Lesion of these functions, especially pronation and supination, explain the complex integrated relationship between the bones and soft tissue along the entire length of this anatomical district.
All these anatomic and functional structures can be grouped under the name of the Forearm Unit [ 6 ]. In Peter Essex-Lopresti lopresti the proximal migration of the radius lesion the surgical excision of comminuted RH fracture [ 7 ]. This longitudinal migration of the radius can generate when a traumatic axial load is transmitted from the wrist to the elbow, causing the combination of DRUJ disruption, rupture of the IOM and RH fracture. Like other traumatic patterns, this lesion can be classified in the group of unstable fractures of the forearm, characterized by fracture of one or both forearm bones associated with lesion of some forearm main constraints TFCC, IOM and RH.
These lesions are lopresti misdiagnosed in emergency room and not properly treated, leading to a Chronic ELI, a disabling condition extremely difficult to treat with positive outcomes [ 49101112131415 ]. Aim of this work is to focus on the different lesion patterns causing forearm instability, reviewing literature and the cases treated by the Authors and to propose a new terminology for their identification.
A total of 42 articles were The search was limited to English language literature. Papers published before and clearly reporting clinical results and ELI treatment in acute setting were considered.
A total of 4 articles were finally considered for the review. Adams et al. The primary injury lopresti ELI was by bike fall in two patients, road traffic accident in two cases and fall while walking in one case. Three cases essex an important proximal essex dislocation of the radius, with the proximal radius engaging into the capitellum Figs.
In one case the RH fracture showed the involvement of radial neck Mason grade 3 without longitudinal radial proximal dislocation, but in presence of gross instability of elbow and forearm Fig. Pre-operative left elbow X-rays abc and 3D reconstruction CT scan d images showing a Mason 3 radial head fracture.
Clinical case 4, pre-operative: wrist. Pre-operative X-rays of the same patient. Pre-operative X-ray of case n. Performing the stress test under C-arm view the forearm longitudinal instability was detected de. The treatment consisted in radial head prosthesis positioning gIOM plasty and collateral ligaments reconstruction f. The essex evaluation consisted in a clinical complete examination. In particular the investigation of the traumatic mechanism reported by the patient arose the suspect of high energy axial load on the forearm, with possibility of unstable fracture.
Lesion clinical examination was performed starting from the elbow stability evaluation associated lesions of LUCL or MCLfollowed by a check of the radial head tenderness, pronation supination, Xilo Lesion. In acute cases a vivid painful reaction is indicative of an IOM laceration.
In chronic patients a reduced resistance of one or more segments compared to the counterlateral forearm is suspect for partial or complete IOM tear. The DRUJ was evaluated by the mean of the Tilt test: at the wrist the physician tests the DRUJ with dorsal and volar comparative translation of the ulna in neutral, supination and pronation.
Then the potential longitudinal lopresti instability was investigated with a comparative wrist X ray, with the detection of a distal radius proximal migration comparing to lopresti counterlateral wrist. An elbow CT scan was performed in all cases to better assess the pathoanathomy of the RH fracture.
C-Fingers comparative test. After the confirmation of acute presence of Essex Lopresti syndrome, the surgery was performed with a preliminar positioning of an infraclavear catheter for continuous post operative analgesia. The surgical repair was performed in three steps. Since ELI is a non frequent lesion, not all the three steps were performed in all cases, reflecting the progressive and recent development of knowledge in this pathology.
The first step, performed in all cases, consisted in the positioning of the lopresti head prosthesis. Using the Kocher interval the implanted prosthesis was unipolar in three cases and bipolar in two cases, all non cemented with press fit insertion in the radial canal Fig.
Surgical images of the procedure, clinical case 3. At the level of the maximum radial bow, passing between flexor and extensor muscles, lopresti radial origin of the pronator teres was recognized and isolated c. At intermediate forearm rotation two 1. In patient n. Patient n. It was only under anesthesia and under C-arm view that forearm longitudinal instability was detected.
The radial head prosthesis was positioned, then IOM and lateral collateral ligaments reconstruction were performed. In Patients n. The TFCC was re-inserted with a high resistance 0 wire to the ulnar stiloid process with a trans osseous stitch, and the DRUJ was then reduced and fixed by two extra articular Kirschener wires.
When a IOM reconstruction was performed patients n. Passing between flexor and extensor muscles, the radial origin of the pronator teres was recognized. Keeping the forearm in neutral pronation and supination position, two 1. Other two 1. As stabilizer device a cadaveric tendon allograft was used in one case n. The stabilizer device was then passed, dorsally crossing the forearm bones under the muscular extensor compartment, with the help of a plastic knee ligament passer.
Under C-arm view the device was then stretched; pronation supination and radial head pistoning were checked and definitively fixed. Surgical images essex the procedure clinical case 3. With the help of a smooth tool the path for the stabilizer device was performed, dorsally crossing the forearm bones under the muscular extensor compartment a. The stabilizer device was then put in position with the help of a knee ligament passer b and finally tensioned c.
Post operative X-rays, clinical case 3. It is possible to see the radial and ulnar tunnels of the two bundles of the newly reconstructed IOM a. Progressive muscular reinforcement protocol was permitted starting one month after surgery. An X ray investigation has been performed in all cases at final follow up. An evident radio-ulnar X-ray discrepancy was found in only five patients, and a partial or complete IOM rupture was diagnosed by MRI in all 12 cases.
The authors reported good mid-term results. Trousdale [ 15 ] reported a case series lesion 20 ELI, identifying 5 cases of acute forms: these cases, properly treated, reported good outcome in 4 cases, while the other 15, initially misdiagnosed and treated with RH resection, developed severe pain at distal DRUJ, with good results even after treatment only in 3 cases. In Edwards and Jupiter [ 10 ] reported on 7 patients, 4 operated within one month, with excellent results obtained only in the three cases.
The only poor result was experienced by the patient who underwent a RH excision. Duckworth [ 25 ] retrospectively reviewed 60 patients affected by RH fracture, identifying 22 patients with radio-ulnar discrepancy. The most representative case series have been reported by Schnetzke in [ 14 ]: outcome of 16 acute and 15 late ELI were compared.
Case n. Each constraint is essential for stability and movements of the forearm. In case of single constraint damage distal radius fracture, simple RH fracture, and so on a pronation-supination decrease occurs, without causing instability Stage 1. In case of two constraints damage Stage 2 a partial transversal instability may occur Criss-Cross lesion, Galeazzi lesion, Monteggia lesions. The disruption of three constraints Stage 3 causes a longitudinal-transversal instability Acute. Usually a correct diagnose is performed lesion chronic setting, when the symptoms of a longitudinal instability became evident but unfortunately with poor outcome [ 14 ].
The clinic extrinsication of one of these two conditions depends on the IOM answer to the trauma. Aim of this work was to examine the different lesion patterns that may cause forearm instability, focusing on cases treated by the authors and the few literature reports, in order to better define the different entities.
Among the cases enrolled for this paper, the Authors observed four cases presenting characteristics of Acute Engaged ELI. Unfortunately not all patients received the essex treatment: due to the rarity of this condition the knowledge development on anatomopathology and treatment is still ongoing, so it is only in the recent years that it has been properly understood, lesion and treated. Similarly to other series reported in literature, the cases treated with RH implant, IOM reconstruction and TFCC fixation and pinning reported higher scores and better functional outcomes, whereas the patient who underwent the isolated radial head replacement reported worst outcomes, requiring a shortening ulnar osteotomy to treat the persistent wrist pain.
This condition progressively evolves into a proximal radial migration causing DRUJ instability-discomfort and grip weakness. These observations lead to the confirmation that there is an elevated possibility to misdiagnose these non evident acute Essex-Lopresti, that in a first step may be considered and treated as simple RH fracture but shortly express the typical symptoms of a forearm instability.
Basing on several observation of similar cases, in in fact Junghbluth et al. At the final follow up this condition was non-symptomatic, supporting the idea that if left untreated the clinical results were essex to deteriorate even more at follow up, as observed in case n. The higher clinical results have been obtained in cases when the IOM have been reconstructed, highlighting the importance of this anatomical structure.
The lateral view shows no dorsal dislocation of the distal ulna b. At the DRUJ a slight recurrence of the ulnar plus is evident ceven if non symptomatic. Nevertheless the improvement pre-operative wrist x-ray d is evident. Clinical follow up, clinical case 3. For these reasons it is mandatory to perform an accurate clinical examination to the patient in acute setting, tagging these cases as Undetected at Imminent Evolution ELI and addressing them to a proper and complete treatment.
The diagnosis lesion the acute engaged pattern of ELI is easier to recognize. Imaging does not give an effective contribution, so the clinical investigation part and the physical examination are fundamental for the correct diagnosis. The main limitation of this study is represented by the low number of cases, lesion because ELI is an uncommon condition. This led to a consequent limitation, that is the different surgical procedure performed and the different approach to ELI.
At the same time this reflects the essex in the knowledge of this disease over the last years.
There have been historically poor outcomes in the treatment of longitudinal forearm instability which is particularly complex in the chronic setting 3. The low incidence, late presentations and heterogeneity in study samples presented in the literature preclude researchers reaching safe conclusions and planning of clinical studies 3.
A recent study found that radial head replacement with the reconstruction of the interosseous membranes and central band restores radioulnar displacement and ulna forces to near normal 3.
It is named after Peter Gordon Essex-Lopresti , a trauma surgeon at Birmingham accident hospital, England 2. Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Updating… Please wait. Unable to process the form. Check for errors and try again. Thank you for updating your details. Log In. Sign Up. Log in Sign up. Articles Cases Courses Quiz. About Blog Go ad-free. The plate is temporarily fixed distally at the flare of the distal ulnar metaphysis to prevent rotational deformity after osteotomy , and the proximal length of the plate scored with the saw.
The osteotomy site is marked and performed at the center of the plate. The length of osteotomy desired should account for the length of bone removed plus two times the width of the saw. The proximal osteotomy cut is made and the bone segment removed and the plate is reattached distally to previously drilled holes Fig.
A In most cases, adequate negative ulnar variance goal 2 mm is not achieved by reconstructing the radial head alone, and an ulnar shortening osteotomy fixed with a limited contact dynamic compression plate LC-DCP is performed. B Corresponding radiograph. Taking care to restore rotation, the plate is secured to the proximal fragment with serrated reduction forceps, and the osteotomy site is compressed with an AO tensioning device.
Magnitude of shortening is assessed radiographically, and if acceptable the remaining three proximal screws are inserted using standard AO technique. If more shortening is needed, the proximal fragment is re-cut prior to screw placement.
The pronator graft is secured to the ulna with the wrist in neutral by suturing it to the LC-DCP plate, or by using two suture anchors Fig. In the experience of the senior author, at follow-up for plate removal, there is good healing of the tendon to the periosteum Fig. The lamina spreader is then removed. Principle of IOM reconstruction using a pronator teres graft. A and B After removal of the plate, healing of the pronator teres tendon graft to the periosteum of the ulna is observed 2 years after the reconstruction.
To address the TFCC, the ulnar osteotomy incision is extended distally over the fifth dorsal wrist compartment, taking care to protect the dorsal sensory branch of the ulnar nerve. The proximal ulnar half of the extensor retinaculum is reflected radially to visualize the extensor carpi ulnaris and extensor digiti minimi tendons.
The TFCC is visualized via retraction of the extensor digiti minimi which exposes the dorsal aspect of the sigmoid notch of the radius. The components of the TFCC, including the dorsal radioulnar ligaments, the extensor carpi ulnaris sheath, and articular disk are reattached to the ulnar fovea using bone anchors.
Stability of the extensor carpi ulnaris sheath is evaluated, and may be augmented by using the retinacular flap created during exposure as a sling. Postoperatively, patients are immobilized in a sugar tong splint for 2 weeks until suture removal.
At this time, a Muenster splint is applied and the patient begins gentle elbow range of motion exercises. At 6 weeks, the Muenster splint is discontinued and active range of motion at the wrist is initiated. Radiographs to evaluate healing at the osteotomy site are performed at 6 weeks, 12 weeks, and 6 months postoperatively.
The ELI is a rare problem that requires a high index of suspicion for diagnosis in the acute setting. Failure to recognize and appropriately treat the full injury may result in chronic symptoms. When considering management options, it is important to understand the pathoanatomy that leads longitudinal instability of the forearm, which involves the proximal radius, IOM, and DRUJ ligaments. In addition to addressing pain related to ulnar abutment or radiocapitellar arthritis, treatment should focus on reconstitution of native forearm biomechanics and stability.
The role of regular IOM reconstruction remains uncertain, though several techniques appear promising. Each author certifies that he or she has no commercial associations e.
Conflict of Interest None. National Center for Biotechnology Information , U. Journal List J Wrist Surg v. J Wrist Surg. Published online Jun Andrew P.
Matson , MD 1 and David S. Ruch , MD 1. David S. Author information Article notes Copyright and License information Disclaimer. Address for correspondence David S. Received May 17; Accepted May This article has been cited by other articles in PMC. Abstract Essex-Lopresti injuries ELIs are characterized by fracture of the radial head, disruption of the forearm interosseous membrane, and dislocation of the distal radioulnar joint.
Keywords: Essex-Lopresti injury, interosseous membrane, forearm instability, pronator rerouting, central band. Presentation The mechanism of injury for ELI usually involves an axial compressive load to the forearm with the elbow in an extended position, either from a fall or from high-energy trauma. Anatomy Forearm Biomechanics The radial head is the primary longitudinal stabilizer of the forearm, with the IOM and triangular fibrocartilage complex TFCC acting as secondary stabilizers.
Interosseous Membrane The IOM consists of five ligaments, including central band, accessory band, distal oblique bundle, proximal oblique cord, and dorsal oblique accessory cord. Pathoanatomy IOM ruptures that occur with axial load injuries usually involve mid-ligament ruptures and less frequently involve avulsions of the ulnar attachment. Chronicity The approach of management to ELI generally involves first recognition of the problem as acute or chronic. IOM Reconstructive Techniques Numerous techniques have been described for reconstruction of the IOM, including direct repair when possible, 8 40 synthetic graft, 33 41 TightRope tenodesis, 42 anatomic allograft, 43 bone patella tendon bone autograft and allograft, 25 flexor carpi radialis autograft, 28 semitendinosus autograft, 44 Achilles allograft, 27 45 and pronator rerouting.
Outcomes Due to the rarity of these injuries as well as challenges with making the diagnosis acutely, studies reporting outcomes following surgical management of ELI are lacking. Surgical Technique The preferred technique of the senior author has been slightly modified from a previously published technique, 46 and includes three incisions for 1 radial head replacement, 2 pronator teres graft harvesting and rerouting, and 3 USO and TFCC repair Fig. Open in a separate window.
Radial Head Replacement Radial head replacement is performed through a Kocher incision and radiocapitellar exposure with the forearm pronated to protect the posterior interosseous nerve.
Pronator Teres Graft Harvesting To reconstruct the IOM, the pronator teres graft is detached proximally, rotated, and inserted distally to the ulna to reconstruct the central band.
Ulnar Shortening Osteotomy USO is performed with the goal of making the wrist ulnar-negative by 2 mm. Triangular Fibrocartilage Complex Repair To address the TFCC, the ulnar osteotomy incision is extended distally over the fifth dorsal wrist compartment, taking care to protect the dorsal sensory branch of the ulnar nerve.
Wounds are then irrigated and closed over a drain. Postoperative Care Postoperatively, patients are immobilized in a sugar tong splint for 2 weeks until suture removal. Conclusion The ELI is a rare problem that requires a high index of suspicion for diagnosis in the acute setting.
Footnotes Conflict of Interest None. References 1. Brockman E P. Two cases of disability at the wrist following excision of the head of the radius. Proc R Soc Med. Dislocation of the inferior radio-ulnar joint. Br J Surg.
Essex-Lopresti P. Essex-Lopresti revisited. Clin Orthop Relat Res. Delayed treatment of elbow pain and dysfunction following Essex-Lopresti injury with metallic radial head replacement: a case series. J Shoulder Elb Surg. The undiagnosed Essex-Lopresti injury. J Bone Joint Surg [Br]. Reconstruction of longitudinal stability of the forearm after disruption of interosseous ligament and radial head excision Essex-Lopresti lesion.
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Clin Orthop. Radius pull test: predictor of longitudinal forearm instability. Ligamentoplasty of the forearm interosseous membrane using the senitindinosus tendon: anatomical study and surgical procedure. Surg Radiol Anat. Results of treatment of fracture dislocations of the elbow.
Difficult wrist fractures. Perilunate fracture-dislocations of the wrist. The treatment of the acute Essex-Lopresti injury. Bone Joint J. Radial shortening following a fracture of the proximal radius. Acta Orthop. Helmerhorst GT, Ring D. Subtle Essex-Lopresti lesions: report of 2 cases. The Essex-Lopresti lesion. Strategies Trauma Limb Reconstr.
Download references. MF and RR performed the surgeries, performed the pre operative and post operative clinical examination of the patients and analyzed and interpreted the patient data regarding the forearm instability.
MC and GB performed the literature review, collected images, functional scores and were the major contributors in writing the manuscript. All authors read and approved the final manuscript. Correspondence to Marco Cavallo. A copy of the consent form is available for review by the Editor of this journal.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Reprints and Permissions. Fontana, M. Diagnosis and treatment of acute Essex-Lopresti injury: focus on terminology and review of literature. BMC Musculoskelet Disord 19, doi Download citation.
Search all BMC articles Search. Abstract Background Acute Essex-Lopresti injury is a rare and disabling condition of longitudinal instability of the forearm. Methods Five patients affected by acute Essex-Lopresti injury have been enrolled for this study. Results All patients were operated in acute setting with radial head replacement and different combinations of interosseous membrane reconstruction and distal radio-ulnar joint stabilization.
Discussion The clinical studies present in literature reported similar results, highlighting as patients properly diagnosed and treated in acute setting report better results than patients operated after four weeks. Open Peer Review reports. Background The forearm can be considered as a single articulating unit where the close interdependence of multiple anatomical structures allows forearm rotation, elbow and wrist motion [ 1 , 2 ].
Full size image. Table 1 Studies in literature reporting cases of acute Essex-Lopresti injuries Full size table. Table 3 Patients intra operative and clinical data set Full size table. Conclusions From the analysis of literature and the presented case series, ELI can be considered part of the unstable fractures of the forearm, where a radial head fracture is associated to one or more ligament lesions.
References 1. Article PubMed Google Scholar 4. Article PubMed Google Scholar 6. Article PubMed Google Scholar 7. Article PubMed Google Scholar 9. Article PubMed Google Scholar Google Scholar Article Google Scholar Competing interests The authors declare that they have no competing interests.
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