The treatment of the acute Essex-Lopresti injury

Interosseus Membrane Reconstruction Following a Forearm Injury: A Case Report

Background  Essex-Lopresti injuries are complex, frequently missed forearm/elbow injuries consisting of a fracture of the radial head with disruption of both the distal radioulnar joint (DRUJ) and the interosseous membrane (IOM). Ideal management of these injuries remains controversial, especially in relation to the IOM, due in part to underdiagnosis of IOM injury and incomplete understanding of the IOM role. Methods  A 43-year-old man sustained an open radial shaft fracture with associated radial head subluxation, coronoid base fracture, and DRUJ injury with ulnar head subluxation. He was taken for surgery, where elbow instability with near complete disruption of the IOM was observed. Persistent gross rotational instability was noted following radius fixation, so braided suture and button reconstruction of the central band of the IOM was performed. This restored rotational and longitudinal stability to the radiocapitellar joint and DRUJ. Over 1 year out from the index surgery, the patient's elbow and DRUJ have remained stable, and he is back working as a laborer. Results  While little literature exists on outcomes of acute IOM reconstruction in these injuries, recent biomechanical studies have shown the importance of the central band on rotational elbow stability. Conclusion  This case supports the importance of the central band of the IOM by demonstrating the impact of its repair on the longitudinal and rotational stability of the elbow and DRUJ. IOM repair has the potential to improve our treatment of this complicated injury by better restoring forearm stability and function of the elbow, which future studies could help further elucidate.

[Central band reconstruction in Essex-Lopresti lesions]

OBJECTIVE

Restoration of longitudinal forearm stability by reconstruction of the central band (CB) of the interosseous membrane (IOM) of the forearm.

INDICATIONS

Acute and chronic Essex-Lopresti lesions (EL) with longitudinal forearm instability.

CONTRAINDICATIONS

Absolute: acute/subacute infection. Relative: severe complex regional pain syndrome (CRPS), bony deformity/bone loss, pronounced osteoarthritis of the elbow and wrist.

SURGICAL TECHNIQUE

Ulnar approach with exposure of the ulna approximately 6 cm proximal to the ulnar styloid. Creation of a 3.5 mm drill hole from ulnar-distal to radial-proximal. A Fiberloop (Fa. Arthrex, Naples, FL, USA) is fixed to one end of the LARS (Ligament Advanced Reconstruction System, Fa. Corin Group, Cirencester, UK) in a whipstitch technique, is shuttled through the drill hole from radial to ulnar and fixed over a BicepsButton (Fa. Arthrex, Naples, FL, USA). Exposure of the radius through a modified Henry approach. A 3.5 mm drill hole is made from radial-proximal to ulnar-distal approximately 12 cm proximal to the radial styloid. The graft is shuttled from the ulnar to the radial incision directly on the palmar surface of the IOM and shortened to the required length. Another Fiberloop is used to perform a whipstitch on the free end of the LARS. The final fixation of the CB reconstruction is achieved by shuttling the Fiberloop sutures through the radial drill hole with fixation over a BicepsButton.

POSTOPERATIVE MANAGEMENT

Short-term immobilization in a long arm cast with subsequent early functional treatment.

RESULTS

Mediocre to poor clinical results are reported in the literature for the treatment of chronic EL. Future research will tell whether the advanced surgical techniques with CB reconstruction will lead to better clinical outcomes.

Radiographic Comparison of Forearm Symmetry in Healthy Individuals and its Importance in the Diagnosis of Longitudinal Radioulnar Dissociation

PURPOSE

Longitudinal radioulnar dissociation (LRD) is an injury often missed upon initial presentation. A recent study examined a radiographic screening test in cadavers that showed increased interosseous distance when the interosseous ligament (IOL) was divided. For this test to be clinically useful, it is necessary for uninjured forearms to have similar interosseous spaces. The purpose of this study was to determine the typical differences between right and left interosseous spaces of healthy individuals.

METHODS

Anterior-posterior x-rays of bilateral forearms in maximum supination of 28 surgical residents with no history of injury were obtained. These images were uploaded into a picture archiving and communication system and then digitized. The length of the radius was measured (Xr). The maximum interosseous distance (Dmax) between the radius and ulna as well as the interosseous distance at a location 0.3 Xr from the distal radioulnar joint was measured. The right and left arm distances were compared. Also, an outlier analysis was used to evaluate forearm rotational asymmetry between right and left arms.

RESULTS

The outlier analysis revealed two sets of forearm x-rays were rotationally different compared to the rest of the group due to asymmetric arm positioning; these data were excluded from the analysis. The average difference in Dmax was 1.7 mm (standard deviation [SD] 1.5) between right and left arms, and this was found at a position of 0.28 Xr on average. The difference in interosseous distance measured at a fixed location 0.3 Xr was 1.6 mm (SD 1.5). No significant difference was found between the paired right and left arms for Dmax or at 0.3 Xr.

CONCLUSIONS

There does not appear to be any significant difference between the maximum interosseous distance of right and left arms in healthy individuals. Therefore, analyzing bilateral forearm x-rays may be a simple LRD screening test.

CLINICAL RELEVANCE

Understanding the degree of normal variation in the forearm bone spacing might inform evaluation of abnormal forearm bone alignment resulting from LRD.

Anatomic and Biomechanical Study of the Forearm Interosseous Membrane, Distal Oblique Bundle, and Triangular Fibrocartilage Complex: Role in Galeazzi Fracture Dislocation

Purpose

The purpose of this study was to measure distal radioulnar joint (DRUJ) dislocation and radioulnar displacement associated with sequential sectioning of the different bands of the interosseous membrane and triangular fibrocartilage complex in the simulation of a Galeazzi fracture dislocation.

Methods

Twelve fresh-frozen cadaver forearms were dissected. We examined the anatomy and function of the forearm interosseous membrane. Each forearm was then mounted onto a biomechanical wrist and forearm device. In the control group, radial osteotomy was performed and the degree of DRUJ displacement with progressive loads was measured. In addition to radial osteotomy, in group 1, the central band (CB) was sectioned; in group 2, the CB, distal membranous portion of the interosseous membrane, and distal oblique bundle were sectioned; and in group 3, the CB, distal membranous portion of the interosseous membrane, distal oblique bundle, and triangular fibrocartilage complex were sectioned.

Results

The radioulnar displacement (mm) at 25 N, 50 N, and 75 N was recorded. In group 1, applying progressive loads resulted in an average DRUJ displacement of 4.3, 5.9, and 7.9 mm, respectively. In group 2, the displacement was 5.2, 5.7, and 6.9 mm, respectively. In group 3, the displacement was 6.2, 8.1, and 9.9 mm, respectively. Our study showed a correlation between increase in the load applied to the same injury and the degree of displacement (P = .001). In group 3, the degree of DRUJ displacement was statistically increased compared to the other groups (P = .04).

Conclusions

Migration of the radius under loads implies disruption of both the CB and triangular fibrocartilage complex. The distal oblique bundle by itself does not seem to have a relevant role in radioulnar displacement at the DRUJ.

Clinical relevance

This study provides insights into the interosseous membrane and stability of the DRUJ, which can contribute to a better understanding of Galeazzi fracture-dislocations.

Elbow Dislocation With Associated Essex-Lopresti Injury: A Case Treated Conservatively

A 23-year-old woman suffered a posterior elbow dislocation, distal radius intraarticular fracture, distal radioulnar joint subluxation, and coronoid process fracture, suggesting an Essex-Lopresti injury variant. Closed reduction for the elbow dislocation was performed, and the limb was immobilized at a 90-degree angle with the forearm in a neutral position with a long posterior splint. Three months later complete fracture healing was noted radiologically. One year post-injury full range of motion regarding flexion, pronation, and supination was achieved with only 10 degrees of extension deficit remaining, suggesting a case of Essex-Lopresti injury managed conservatively with excellent results.

Simultaneous Reconstruction of the Distal Radioulnar Joint Ligaments and Interosseous Membrane Combined with Ulna Shortening Osteotomy for Chronic Essex-Lopresti Injury

The Essex-Lopresti pattern of injury comprises radial head fracture, distal radioulnar joint (DRUJ) dislocation and disruption of the interosseus membrane (IOM). Diagnosis is often delayed, and reconstruction remains a management dilemma, with several proposed techniques addressing the radial head via either replacement or fixation; reconstruction of the DRUJ ligaments via anatomic or non-anatomic methods; and IOM reconstruction with synthetic grafts, allograft or autograft. We present a 26-year-old man with a chronic Essex-Lopresti injury who underwent revision ulnar shortening osteotomy (USO), IOM reconstruction using a brachioradialis graft and an Adams–Berger ligament reconstruction of the DRUJ ligaments following a three-year course of increasing pain and instability following radial head dislocation. This case demonstrates the feasibility of a single-stage reconstruction of a chronic Essex-Lopresti injury using a brachioradialis and a palmaris longus autograft.

Level of Evidence: Level V (Therapeutic)

Essex-Lopresti Lesions and Longitudinal Radioulnar Instability: A Narrative Review

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An Essex-Lopresti injury (ELI) is classically described as a radial head fracture with a concomitant interosseous ligament complex (IOC) injury. However, multiple injury patterns may be present, and an interosseous membrane (IOM) injury should be evaluated for in any axial load injury through the forearm. ELI may result in longitudinal radioulnar instability (LRUI).

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Diagnosis of an IOC injury can be difficult. Evaluation begins with standard wrist and elbow radiographs and is supplemented with radiographs and intraoperative maneuvers to assess for proximal radial migration. Magnetic resonance imaging and ultrasonography may be useful in the acute setting, although indications and the clinical importance of the findings remain unclear.

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Surgical management of an acute ELI is focused on restoration of radial length and temporary distal radioulnar joint (DRUJ) stabilization. Radial head excision in the acute setting should be approached with caution because proximal migration may not be present acutely but may develop over time. The indication for acute IOM repair and reconstruction remains unclear.

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Surgical management of a chronic ELI is focused on restoration of radial length, wrist leveling, and treatment of degenerative changes (either at the radiocapitellar joint or the DRUJ). Reconstruction of the central band can restore forearm load transfer and produce favorable functional outcomes, but its indications continue to be debated.

Elbow Dislocation with Irretrievable Rotating-Rope Injury of the Forearm: Case Report and Literature Review

Background

Simultaneous dislocation of the elbow, radioulnar joint and proximal radius fracture with rotary noose injury to the medial ulna tubercle is extremely rare. An emergency surgery was performed to reduce it. The radial head with the backbone was reset after two hammers were fixed, then the radial capitulum safety was fixed with a locking plate. After the ulnar instability was examined, two Kirschner wires were drilled percutaneously to fix the elbow flexion at 100° under closed reduction, and two Kirschner wires were drilled percutaneously to fix the ulnar joint. Good follow‐up results were achieved. To the best of our knowledge, this is the first report on this particular type of injury and on this approach to treating this type of injury.

Case presentation

We report the case of a 36‐year‐old male, who extended and landed on his left hand to protect his child in right arm before felling, resulting in severe pain and deformity of his left elbow and wrist and loss of movement in these joints. X‐ray examination found proximal distal radioulnar joints, a proximal radial fracture and a dislocation bowstring in the ulna nodule. For a timely diagnosis in an emergency open reduction situation, accurate judgment of this injury is highly important. After 12 months of postoperative follow‐up, the patient was symptom‐free, and radiographs showed fracture healing.

Conclusion

We performed emergency reduction and internal fixation of the elbow and successfully saved elbow function, no stability decrease and movement restriction. This case also provides a new reference for the treatment of this type of elbow fracture dislocation.

An Unusual Terrible Triad Variant Associated with an Essex-Lopresti Injury

Essex-Lopresti injuries and terrible triad injuries of the elbow are rare injuries that typically result from high-energy trauma such as falling from a height or a motor vehicle collision. However, the combination of an Essex-Lopresti injury and terrible triad injury is unique and poses a significant challenge for treatment as these injuries are independently associated with poor functional outcomes if they are not acutely diagnosed. We describe a case of a 19-year-old who presented with an unusual variant of a terrible triad injury associated with an Essex-Lopresti injury. The patient had a distal radioulnar joint (DRUJ) and elbow dislocation, a radial head and coronoid process fracture, and a distal radius fracture. Almost a reverse Essex-Lopresti, this injury was successfully managed with open reduction and repair of the distal radius, radial head, and damaged ligaments in the elbow, along with an internal joint stabilizer (IJS).

Results of radial head prostheses implanted during Essex-Lopresti syndrome in multicentric study

AIMS

The aim was to evaluate the results of radial head prostheses (RHP) in Essex-Lopresti injury (ELI) and to compare results after RHP between acute and chronic ELI.

PATIENTS AND METHODS

Thirty-one patients treated with RHP for ELI were selected from a multicenter retrospective series of 310 RHP, with follow-up greater than two years. Two groups were acute ELI group (n=19, average diagnosis = 5+/-9 days) and chronic ELI group (n=12, average diagnosis 8.4+/-7.1 months). RHP was associated in some cases with K-wires: during acute ELI to stabilize the distal radio-ulnar joint (n=4) or during chronic ELI with ulnar osteotomy or palliative surgery (n=4). Clinical and radiologic evaluation was performed including analysis of the complications and revisions rates, pain level, range of motion, and MEPS (Mayo Elbow Performance Score) and DASH score (Disabilities of the Arm, Shoulder and Hand).

RESULTS

At last follow-up (71+/-38 months), survival of RHP in the acute ELI group was 84% (16/19) and 92% (11/12) in the chronic ELI group without statistically significant difference. Flexion (acute=131degrees+/-13.4 vs chronic=22+/-12.8, p=0.041) and supination (ELI=71+/-16.8 vs chronic=58+/-17.4; p=0.045) were better in acute ELI group. The DASH score was also better in the acute group (15+/-9.1 versus 24+/-15.2, p=0.048). There was more advanced stage of humero-radial osteoarthritis in the chronic ELI group (0.7+/-0.5 versus 1.4+/-0.6, p=0.041).

CONCLUSION

RHP in acute ELIs provide better clinical results, although RHPs are part of the therapeutic arsenal to treat chronic ELI.

The Serially-Operated Essex-Lopresti Injury: Long-Term Outcomes in a Retrospective Cohort

Objective  The main aim of this article is to report 10-year outcomes after Essex-Lopresti injury (ELI). Study Design  Retrospective case series. Two level I trauma centers and one associated community hospital from 2003 to 2016. Patients  Sixteen patients who sustained an ELI and were treated at one of our three regional hospitals. Intervention  Initially, 4 patients (25%) were treated nonoperatively by immobilization and 12 patients (75%) were treated operatively. Proximal surgery included radial head open reduction and internal fixation (ORIF), radial head arthroplasty, radial head excision and forearm ORIF, and wound debridement. Ten patients (63%) were acutely identified with longitudinal forearm instability. Of these, four patients had the distal radioulnar joint pinned. In the other six patients, the forearm was immobilized. Overall, 16 patients underwent a total of 32 revision surgeries. Main Outcome Measure  Performance of Patient-Reported Outcomes Measurement Information System Upper Extremity (PROMIS UE) Physical score, Numeric Rating Scale (NRS) score for pain-severity, and NRS score for satisfaction of overall outcome. Results  Follow-up for outcome evaluation was available for 10 patients, at a median of 10 (interquartile range [IQR]: 8.0-12) years after date of injury. The median PROMIS UE Physical score was 36 (IQR: 33-38). Median NRS score for pain-severity on average was 5 (IQR: 0-6). The median NRS score for satisfaction of overall outcome was 7 (IQR: 5-8). Conclusion  Patients who sustain an ELI generally have substantial deficits of upper extremity function as measured by PROMIS UE. Early radial head arthroplasty may be beneficial, but further study in a larger cohort is needed. Outcomes of nonoperative treatment and operative treatment were similar and suggest that current surgical treatments are incomplete.

Immunofluorescence analysis of sensory nerve endings in the interosseous membrane of the forearm

The human interosseous membrane (IOM) is a fundamental stabilizer during forearm rotation. To investigate the dynamic aspects of forearm stability, we analyzed sensory nerve endings in the IOM. The distal oblique bundle (DOB), the distal accessory band (DAB), the central band (CB), the proximal accessory band (PAB), the dorsal oblique accessory cord (DOAC) and the proximal oblique cord (POC) were dissected from 11 human cadaver forearms. Sensory nerve endings were analyzed at two levels per specimen as total cell amount/mm² after immunofluorescence staining with low-affinity neurotrophin receptor p75, protein gene product 9.5, S-100 protein and 4',6-diamidino-2-phenylindole on an Apotome microscope, according to Freeman and Wyke's classification. Sensory nerve endings were significantly more commonly found to be equally distributed throughout the structures, rather than being epifascicular, interstitial, or close to the insertion into bone (P ≤ 0.001, respectively). Free nerve endings were the predominant mechanoreceptor in all six structures, with highest density in the DOB, followed by the POC (P ≤ 0.0001, respectively). The DOB had the highest density of Pacini corpuscles. The DOAC and CB had the lowest amounts of sensory innervation. The high density of sensory corpuscles in the DOB, PAB and POC indicate that proprioceptive control of the compressive and directional muscular forces acting on the distal and proximal radioulnar joints is monitored by the DOB, PAB and POC, respectively, due to their closed proximity to both joints, whereas the central parts of the IOM act as structures of passive restraint.

The Emergent Evaluation and Treatment of Elbow and Forearm Injuries

This article provides an updated review of the emergent evalution and treatment of elbow and forearm injuries in the emergency department. Clinically necessary imaging is discussed. Common and uncommon injuries of the elbow and forearm are reviewed with an emphasis on early recognition, efficient management, and avoidance of complications. The astute emergency physician will rely on a focused history and precise examination, applied anatomic knowledge, and strong radiographic interpretative skills to avoid missed injuries and complications.

Diagnosis and treatment of acute Essex-Lopresti injury: focus on terminology and review of literature

Background

Acute Essex-Lopresti injury is a rare and disabling condition of longitudinal instability of the forearm. When early diagnosed, patients report better outcomes with higher functional recovery. Aim of this study 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.

Methods

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 by road traffic accident and one patient by fall while walking. A literature search was performed using Ovid Medline, Ovid Embase, Scopus and Cochrane Library and the Medical Subject Headings vocabulary. The search was limited to English language literature. 42 articles were evaluated, and finally four papers were considered for the review.

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. Patients were followed for a mean of 15 months: a consistent improvement of clinical results were observed, reporting a mean MEPS of 92 and a mean MMWS of 90.8. One case complained persistent wrist pain associated to DRUJ discrepancy of 3 mm and underwent ulnar shortening osteotomy nine months after surgery, with good results.

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. In this study, the definitions of “Acute Engaged” and “Undetected at Imminent Evolution” Essex-Lopresti injury are proposed, in order to underline the necessity to carefully investigate the anatomical and radiological features in order to perform an early and proper surgical treatment.

Conclusions

Following the observations, the definitions of “Acute Engaged” and “Undetected at Imminent Evolution” injuries are proposed to distinguish between evident cases and more insidious settings, with necessity of carefully investigate the anatomical and radiological features in order to address patients to an early and proper surgical treatment.

A Novel Algorithmic Approach to Chronic Forearm Longitudinal Instability

Essex-Lopresti Lesions are rare injuries that are often missed in the acute setting. Delayed intervention may lead to chronic wrist and elbow pain and overall poor outcomes. The literature currently supports treatments that involve shortening of the ulna to reduce the relative degree of ulnar impaction, followed by attempted reduction of the distal radioulnar joint. Although such techniques may help to temporarily reduce wrist pain secondary to ulnar impaction, they do not address the proximal migration of the radius and ipsilateral radial head dislocation at the elbow. Subsequent procedures are often needed to replace or resect the radial head. We present a novel approach to chronic Essex-Lopresti lesions resulting in anatomic restoration of forearm length with return of elbow and wrist flexion/extension as well as improved forearm pronation/supination.

Late Reconstruction of the Interosseous Membrane with Bone-Patellar Tendon-Bone Graft for Chronic Essex-Lopresti Injuries: Outcomes with a Mean Follow-up of Over 10 Years

BACKGROUND

The purpose of this study was to report our long-term outcomes following reconstruction of the forearm interosseous membrane (IOM) with bone-patellar tendon-bone (BPTB) graft for treatment of chronic Essex-Lopresti injuries.

METHODS

We identified 33 patients who underwent IOM reconstruction with BPTB graft for chronic Essex-Lopresti injuries over a 20-year treatment interval. Twenty male and 13 female patients, with a mean age of 42.1 years (range, 19 to 73 years) and a minimum follow-up interval of 5 years, were included. Preinjury clinical examination and radiographic measurements were obtained from records for comparison with prospectively collected data. Additional functional outcome data collected postoperatively included QuickDASH (an abbreviated version of the Disabilities of the Arm, Shoulder and Hand [DASH]), modified Mayo wrist (MMW), and Broberg-Morrey elbow function scores.

RESULTS

IOM reconstruction was performed at a mean interval (and standard deviation) of 44.9 ± 60.0 months (range, 6.4 to 208 months) from the time of the initial injury. At a mean follow-up of 10.9 ± 4.4 years (range, 5.5 to 24.2 years), significant improvements were observed in mean elbow flexion-extension arc (+13° [95% confidence interval (CI), 4° to 22°]; p = 0.005), wrist flexion-extension arc (+19° [95% CI, 4° to 34°]; p = 0.016), forearm pronation-supination (+23° [95% CI, 8° to 39°]; p = 0.004), and grip strength (+25% of that of the contralateral side [95% CI, 18% to 32% of contralateral side]; p < 0.001). Improvements in ulnar variance were sustained over the long term from +3.9 mm (95% CI, 3.2 to 4.6 mm) preoperatively to -1.6 mm (95% CI, -2.3 to -0.9 mm) immediately postoperatively and -1.1 mm (95% CI, -1.8 to -0.4 mm) at the time of the final follow-up (p < 0.001). The mean QuickDASH, MMW, and Broberg-Morrey scores were 29.8 (range, 5 to 61), 82.7 (range, 60 to 100), and 91.6 (range, 64 to 100), respectively.

CONCLUSIONS

IOM reconstruction with a BPTB graft is an effective treatment option for chronic Essex-Lopresti injuries, with satisfactory clinical and functional outcomes over the long term.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

An uncommon variant of the Essex-Lopresti injury

The Essex-Lopresti injury is an extremely rare condition combining radial head or neck fracture, distal radio-ulnar joint dislocation and rupture of the interosseous membrane. However, there are rare or unusual varieties or associated injuries. We report a case of a 46-year-old woman with a posterior dislocation of the radio-humeral joint, a radial shaft fracture, and a distal radio-ulnar joint dislocation. She underwent open reduction and internal fixation of the radial shaft fracture followed by an immobilization by a long elbow splint in supination for 6 weeks. At 18 months of follow-up, she was asymptomatic and she had a full range of elbow and wrist motion and had resumed thoroughly her previous job. The Essex-Lopresti injury results from a complex injury to the forearm axis with resultant longitudinal instability, which can be challenging to treat. There are some variations that can lead to a missed diagnosis resulting in persistent pain and instability of the wrist. The best outcomes are reached with early diagnosis and prompt management.

The challenge of Monteggia-like lesions of the elbow

Aims

The aim of this retrospective multicentre study was to evaluate mid-term results of the operative treatment of Monteggia-like lesions and to determine the prognostic factors that influence the clinical and radiological outcome.

Patients and Methods

A total of 46 patients (27 women and 19 men), with a mean age of 57.7 years (18 to 84) who had sustained a Monteggia-like lesion were followed up clinically and radiologically after surgical treatment. The Mayo Modified Wrist Score (MMWS), Mayo Elbow Performance Score (MEPS), Broberg and Morrey Score, and Disabilities of the Arm, Shoulder and Hand (DASH) score were used for evaluation at a mean of 65 months (27 to 111) postoperatively. All ulnar fractures were stabilized using a proximally contoured or precontoured locking compression plate. Mason type I fractures of the radial head were treated conservatively, type II fractures were treated with reconstruction, and type III fractures with arthroplasty. All Morrey type II and III fractures of the coronoid process was stabilized using lag screws.

Results

Good results were found for the MMWS, with a mean of 88.4 (40 to 100). There were 29 excellent results (63%), nine good (20%), seven satisfactory (15%), and one poor (2%). Excellent results were obtained for the MEPS, with a mean of 90.7 (70 to 100): 31 excellent results (68%), 13 good (28%), and two fair (4%). Good results were also found for the functional rating index of Broberg and Morrey, with a mean score of 86.6 (57 to 100). There were 16 excellent results (35%), 22 good (48%), six fair (13%), and two poor (4%). The mean DASH score was 15.1 (0 to 55.8). Two patients had delayed wound healing; four patients had nonunion requiring bone grafting. One patient had asymptomatic loosening of the radial head prosthesis.

Conclusion

Monteggia-like lesions are rare. With correct identification, classification, and understanding using CT scans followed by appropriate surgical treatment that addresses all components of the injury, good to excellent mid-term results can be achieved. Cite this article: Bone Joint J 2018;100-B:212–18.

Outcome of Early and Late Diagnosed Essex-Lopresti Injury

BACKGROUND

The aim of this study was to investigate the outcomes in a large series of Essex-Lopresti injuries (ELIs) and to compare patients with early and late diagnoses.

METHODS

Thirty-one patients with an ELI (average age and standard deviation [SD], 46 ± 10 years) who were followed for a minimum of 2 years were included in the study. Patients were grouped according to whether the ELI had been diagnosed early (on the day of the injury) or late (>4 weeks after the radial head injury). Acute treatment of early-diagnosed ELI included temporary stabilization of the distal radioulnar joint (DRUJ) by Kirschner wires with the forearm in supination for 6 weeks. Clinical outcomes were assessed on the basis of the range of motion, Mayo Elbow Performance Score (MEPS), Mayo Wrist Score (MWS), visual analog scale (VAS) score for wrist and elbow pain, and Disabilities of the Arm, Shoulder and Hand (DASH) score.

RESULTS

The ELI was diagnosed on the day of the injury in 16 patients (52%; the early group) and late (at a mean of 7 ± 7 months; range, 1 to 24 months) in 15 (48%; the late group). After a mean duration of follow-up of 5.3 ± 3.0 years (range, 2.0 to 13.1 years), patients with an early diagnosed ELI had significantly better clinical outcomes, compared with those with a late diagnosis, with regard to the MEPS (91.3 ± 8.7 versus 74.7 ± 15.3, p = 0.003), MWS (81.3 ± 16.5 versus 66.3 ± 17.6, p = 0.019), DASH score (12.5 ± 8.7 versus 45.3 ± 23.5, p = 0.001), VAS elbow pain score (0.7 ± 1.1 versus 3.3 ± 2.1, p = 0.001), and VAS wrist pain score (0.9 ± 1.2 versus 3.9 ± 1.7, p < 0.001). The ranges of motion of the elbow and wrist did not differ significantly between the early and late groups (p > 0.05). A significantly lower percentage of patients had complications or subsequent surgical procedures in the early than in the late group (38% [6 of 16] versus 93% [14 of 15], p < 0.001).

CONCLUSIONS

Early diagnosis of an ELI with temporary stabilization of the DRUJ leads to satisfactory clinical mid-term results, whereas late diagnosis of an ELI is associated with a deteriorated outcome.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Suture button reconstruction of the central band of the interosseous membrane in Essex-Lopresti lesions: a comparative biomechanical investigation

Surgical reconstruction of the interosseous membrane may restore longitudinal forearm stability in Essex-Lopresti lesions. This study aimed to compare the longitudinal stability of the intact forearm with a single-bundle and a double-bundle reconstruction of the central band of the interosseous membrane using digital image correlation with a three-dimensional camera system. Single and cyclic axial loading of eight fresh-frozen forearm specimens was carried out in the intact state, after creation of an Essex-Lopresti lesion, after a single-bundle and after a double-bundle reconstruction of the central band using a TightRope^® (Arthrex GmbH, Munich, Germany) construct. Instability significantly increased after creation of an Essex-Lopresti lesion. The stability of intact specimens was similar to both reconstruction techniques. The results of this study suggest that TightRope^® reconstruction of the central band restores longitudinal forearm stability. However, the single-bundle technique may be less reliable than double-bundle reconstruction.

LEVEL OF EVIDENCE

Basic Science Study.

Functional outcome after Mason II-III radial head and neck fractures: study protocol for a systematic review in accordance with the PRISMA statement

INTRODUCTION

Fractures of the radial head and neck are the most common fractures of the elbow, and account for approximately one-third of all elbow fractures. Depending on the fracture type the treatment is either conservative or surgical. There is no absolute consensus regarding optimal treatment for different fracture types. The aim of this protocol is to present the method that will be used to collect, describe and analyse the current evidence regarding the treatment of Mason II-III radial head and neck fractures.

METHOD AND ANALYSIS

We will conduct a systematic review in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocol (PRISMA-P) guidelines statement. We will search a number of databases with a predefined search strategy to collect both randomised and non-randomised studies. The articles will be summarised with descriptive statistics. If applicable a meta-analysis will be conducted.

ETHICS AND DISSEMINATION

Ethical approval is not required since this is a protocol for a systematic review and no primary data will be collected. The authors will publish findings from this review in a peer-reviewed scientific journal.

TRIAL REGISTRATION NUMBER

CRD42016037627.

Forearm Instability: Anatomy, Biomechanics, and Treatment Options

The forearm unit consists of the radius and ulna, a complex and interrelated set of joints (distal radioulnar joint, proximal radioulnar joint) and the soft tissue stabilizers between the 3 bones. Distally, this is represented by the triangular fibrocartilage complex at the wrist, proximally by the annular ligament at the elbow, and in the forearm by the interosseous membrane. Disruptions in any of these structures may lead to forearm instability, with consequences at each of the remaining structures.

Interosseous membrane reconstruction with a suture-button construct for treatment of chronic forearm instability

BACKGROUND

The purpose of this study was to report outcomes of interosseous membrane (IOM) reconstruction with a suture-button construct for treatment of chronic longitudinal forearm instability.

METHODS

We performed a retrospective review with prospective follow-up of patients who underwent ulnar shortening osteotomy and IOM reconstruction with the Mini TightRope device from 2011 through 2014. Bivariate statistical analysis was used for comparison of preoperative and postoperative Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores, range of motion, grip strength, and ulnar variance. Complications and patient satisfaction were also recorded.

RESULTS

Ten patients (mean age, 45.3 years) satisfied inclusion criteria: 8 treated for post-traumatic sequelae of Essex-Lopresti-type injuries, 1 for forearm instability secondary to previous elbow surgery, and 1 for instability secondary to trauma and multiple elbow surgeries. Surgeries were performed an average of 28.6 months from initial injury. At mean follow-up of 34.6 months after surgery, significant improvement was observed in elbow flexion-extension arc (+23° vs. preoperatively; P = .007), wrist flexion-extension arc (+22°; P = .016), QuickDASH score (-48; P = .000), and ulnar variance (-3.3 mm; P = .006). Three patients required additional surgery: 1 revision ulnar shortening osteotomy for persistent impingement, 1 revision ulnar osteotomy and Mini TightRope removal for lost forearm supination, and 1 fixation of a radial shaft fracture after a fall.

CONCLUSION

IOM reconstruction using a suture-button construct is an effective treatment option for chronic forearm instability.

Interosseous Membrane of the Forearm

BACKGROUND

Injuries of the interosseous membrane (IOM) of the forearm are frequently unrecognized, difficult to treat, and can result in a devastating sequelae for the wrist and elbow.

PURPOSE

The purpose of this review article is to evaluate the dignosis, biomechanics, clinical results, and propose a treatment approach to this rare complex entity.

METHODS

The biomechanical and clinical literature is reviewed. A treatment approach is described based on the known biomechanics and clinical experience of the senior author (T. W. W.).

RESULTS

Multiple different reconstructive methods have been proposed for the treatment of both acute and chronic IOM injuries. The results of the published series are reviewed. IOM injuries can have reasonable outcomes particularly if diagnosed and treated early.

CONCLUSION

There are multiple methods for treating patients with IOM injuries. Physicians should be highly suspicious about this injury when a patient presents with a highly displaced radial head fracture associated with wrist pain. Treatment with reconstruction of the cerebral band of the IOM with radial head replacement (do not overstuff) and temporary uploading the construct with K-wires from the ulna to the radius will give the most predictable results.

Management of the Essex-Lopresti Injury

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. This injury pattern results in axial and longitudinal instability of the forearm. Initial radiographs may fail to reveal the full extent of the injury, and therefore diagnosis in the acute setting requires a high index of suspicion. Early recognition and treatment are preferred as failure to fully treat the problem may result in chronic wrist pain from ulnar abutment or chronic elbow pain from radiocapitellar arthrosis. In this article the presentation, relevant anatomy, and management options for ELIs are overviewed, and a summary of outcomes reported in the literature is provided. Additionally, the preferred surgical technique of the senior author is presented, which involves reconstruction of the interosseous membrane with a local pronator rerouting autograft.

Management of complications of forearm fractures

Forearm fractures may be complicated by the disruption of the distal radioulnar, proximal radioulnar, or radiocapitellar joints. The key principles in treating this unique subset of fractures include early recognition and management of the injury and restoration and maintenance of the anatomic alignment. This articles addresses radial diaphyseal fractures with distal radioulnar joint disruption, proximal ulnar fractures with radiocapitellar disruption, and disruption of the forearm longitudinal axis and how to properly recognize and manage these forearm fracture-dislocations.