Essex-Lopresti injuries: an update

To Reconstruct or Not: A Case of Acute Reconstruction of the Forearm Interosseous Membrane with CMC Mini Tight Rope

Introduction

Essex Lopresti fractures are rare injuries of the forearm. Extent of damage to the interosseous membrane (IOM) in this setting is variable and can lead to disabling sequelae when not recognized and managed appropriately. While chronic reconstruction for longitudinal radioulnar dissociation is well studied, acute reconstruction of the membrane is infrequently documented and surgical techniques vary. There are only five documented cases of acute IOM reconstruction for Essex Lopresti injuries (ELIs). This is the first described case using a mini suture-button construct in conjunction with a radial head replacement and distal radioulnar joint (DRUJ) pinning, while also providing long-term radiographic and functional follow-up of 2 years.

Case Report

We present a case of a 40-year-old male who sustained an Essex Lopresti fracture that was acutely recognized and surgically managed with a radial head replacement, DRUJ pinning, and acute reconstruction of the IOM with a Mini TightRope suture button construct. We also provide a post-operative rehabilitation protocol with early range of motion and pin removal. At our final 2-year postoperative follow-up, the patient demonstrated excellent functional outcomes.

Conclusion

This case illustrates that a CMC Mini TightRope can be used for acute reconstruction of the IOM in the setting of ELIs which allows for early range of motion and DRUJ pin removal due to the maintenance of longitudinal radioulnar reduction.

UNSTABLE LESIONS OF THE FOREARM: TERMINOLOGY, EVALUATIVE SCORE AND SYNOPTIC TABLE

The term "unstable lesions of the forearm" (ULF) was born to more easily describe how a partial or complete instability of the forearm unit might occur due to a traumatic loss of the transverse or longitudinal connection between the radius and ulna. For such an alteration to occur, at least two of the three main osteoligamentous locks (proximal, middle and distal) must be interrupted, often in association with a radial and/or ulnar fracture. Examining the historical patterns (Monteggia, Galeazzi, Essex-Lopresti and criss-cross lesions) and variants described in the literature, out of a total of 586 recorded interventions for forearm trauma, two elbow teams and one wrist team selected 75 cases of ULF. The aim was to describe the instability depending on its clinical and radiographic features, together with the anatomopathological evolution of the lesions based on the time of diagnosis and treatment. The clinical results, evaluated using a new score (FIPS) the Forearm Italian Performance, revealed a correlation between earlier diagnosis and treatment and a better score. The authors suggest a synoptic table that describes 1) the type of instability (proximal transverse, distal transverse, longitudinal and transverse, proximal and distal transverse), 2) classic patterns and variants with characteristic lesions and evolution over time (acute, chronic dynamic, chronic static) and 3) the three forearm constraints and segmental involvement of radius and/or ulna using an alphanumeric classification. Finally, some generic surgical suggestions are proposed.

Radiographic Evaluation of Elbow Fractures

Fractures and dislocations of the elbow are a common cause of emergency department visits each year. Radiography remains the bedrock of an initial injury assessment, and recognition of distinctive injury patterns based on fracture location, morphology, and severity, guides optimal clinical decision-making. This article reviews basic elbow anatomy, frequently seen fractures and injury patterns, and highlights how these findings influence surgical planning and patient management.

Role of the interosseous membrane in post-traumatic forearm instability: instructional review

PURPOSE

In the last two decades, a strong interest on the interosseous membrane (IOM) has developed.

METHODS

The authors present a review of the new concepts regarding the understanding of forearm physiology and pathology, with current trends in the surgical management of these rare and debilitating injuries.

RESULTS

Anatomical and biomechanical studies have clarified the anatomy of forearm constrains and their role in forearm longitudinal and transverse stability. The radial pull test, a new intraoperative test, has been developed that might increase the detection on IOM injuries. The forearm is now considered a "functional unit" and, consequently, a new classification has been proposed. Uncommon variants and rare patterns of forearm fracture dislocations have been reported in the literature and could not be classified to those commonly referred to using eponyms (Monteggia, Galeazzi, Essex-Lopresti). The new Artiaco et al. classification includes all injury patterns, thus avoids confusion in the nomenclature, and helps surgeon with detection of lesions and guiding surgical treatment.

CONCLUSION

Based on the new classification and after current literature review, authors propose a management flowchart for treatment of forearm instability injuries.

The "floating ulna" injury in adults: a case report, literature review and proposed injury classification

BACKGROUND

Ipsilateral Galeazzi fracture with elbow dislocation, namely the "floating ulna" injury, is a rare injury pattern. A few reports have described this type of injury and its treatment.

CASE PRESENTATION

A 33-year-old female at 38+ weeks gestational age presented with Galeazzi fracture and posterolateral elbow dislocation of the left upper extremity. The patient was treated with closed reduction of the elbow, open reduction, and internal fixation of the radial shaft fracture with a dynamic compression plate and K-wire stabilization of the unstable distal radioulnar joint. At the 12-month follow-up, the patient had no pain or signs of instability. Range of motion was 0-135° at the elbow, 70° extension and 80° flexion at the wrist, and 80° supination and 80° pronation at the forearm.

CONCLUSION

The "floating ulna" injury is a rare and special injury pattern with ipsilateral Galeazzi fracture and elbow dislocation. This type of injury was likely caused by significant amount of deforming force and the unique position of upper limb when the patient fell from a height of 1-2 m in high-energy trauma.

Acute Distal Radioulnar Joint Instability: Evaluation and Treatment

This article reviews the anatomy and mechanics of pronation and supination (axial rotation) of the forearm through the distal radioulnar joint (DRUJ), and the proximal radioulnar joint (PRUJ). Injuries to the bones and/or ligaments of the forearm, wrist, or elbow can result in instability, pain, and limited rotation. Acute dislocations of the DRUJ commonly occur along with a fracture to the distal radius, radial metadiaphysis, or radial head. These injuries are all caused by high-energy trauma. Outcomes are predicated on anatomic reduction and restoration of stability to the DRUJ and PRUJ with or without ligamentous repair or reconstruction.

Radial head fractures

Radial head fractures are a common fracture involving the elbow joint. Patients typically present after a fall onto an outstretched hand with elbow pain and swelling. Without adequate treatment, this can lead to long-term complications, including loss of elbow motion and pain. Radial head fractures may also be associated with other injuries including elbow dislocation, neighbouring bony fractures and associated ligamentous rupture. It is therefore imperative that hospital clinicians understand the diagnosis and treatment of this condition. The plain radiograph is the optimum method to diagnose a radial head fracture. These fractures can be managed using a variety of techniques, from non-surgical conservative methods for the undisplaced fracture through to surgical fixation, radial head replacement and excision for the more complex, displaced fracture.