Longitudinal instability of the forearm (the Essex-Lopresti injury, radioulnar dissociation) is uncommon and is often missed in the initial assessment of a patient with a radial head fracture. The present review outlines the anatomy and biomechanics of the forearm unit, as well as the current means of diagnosis and the range of treatment options avaailable for this challenging problem.
Essex-LoprestiP. Fractures of the radial head with distal radio-ulnar dislocation; report of two cases. J Bone Joint Surg Br1951; 33B: 244–7.
2.
HagertCG. The distal radioulnar joint in relation to the whole forearm. Clin Orthop Relat Res1992; 275: 56–64.
3.
SoubeyrandM, WassermannV, HirschC,. The middle radioulnar joint and triarticular forearm complex. J Hand Surg Eur2011; 36: 447–54.
4.
HotchkissRN, AnKN, SowaDT, BastaS, WeilandAJ. An anatomic and mechanical study of the interosseous membrane of the forearm: pathomechanics of proximal migration of the radius. J Hand Surg Am1989; 14(Pt 1):256–61.
5.
SkahenJRIII, PalmerAK, WernerFW, FortinoMD. The interosseous membrane of the forearm: anatomy and function. J Hand Surg Am1997; 22: 981–5.
6.
NodaK, GotoA, MuraseT,. Interosseous membrane of the forearm: an anatomical study of ligament attachment locations. J Hand Surg Am2009; 34: 415–22.
7.
MorreyBF, Sanchez-SoteloJ. The elbow and its disorders.Fourth edition. Philadelphia, PA: Saunders Elsevier, 2009.
8.
GoftonWT, GordonKD, DunningCE, JohnsonJA, KingGJ. Soft-tissue stabilizers of the distal radioulnar joint: an in vitro kinematic study. J Hand Surg Am2004; 29: 423–31.
9.
JungJM, BaekGH, KimJH, LeeYH, ChungMS. Changes in ulnar variance in relation to forearm rotation and grip. J Bone Joint Surg Br2001; 83: 1029–33.
10.
RabinowitzRS, LightTR, HaveyRM,. The role of the interosseous membrane and triangular fibrocartilage complex in forearm stability. J Hand Surg Am1994; 19: 385–93.
11.
PalmerAK, WernerFW. Biomechanics of the distal radioulnar joint. Clin Orthop Relat Res1984; 187: 26–35.
12.
HallsAA, TravillA. Transmission of pressures across the elbow joint. Anat. Rec.1964; 150: 243–7.
13.
JungbluthP, FrangenTM, MuhrG, KalickeT. A primarily overlooked and incorrectly treated Essex-Lopresti injury: what can this lead to?Arch Orthop Trauma Surg2008; 128: 89–95.
14.
DavidsonPA, MoseleyJBJr, TullosHS. Radial head fracture: a potentially complex injury. Clin Orthop Relat Res1993; 297: 224–30.
15.
TrousdaleRT, AmadioPC, CooneyWP, MorreyBF. Radio-ulnar dissociation. A review of twenty cases. J Bone Joint Surg Am1992; 74: 1486–97.
16.
EdwardsGSJr, JupiterJB. Radial head fractures with acute distal radioulnar dislocation. Essex-Lopresti revisited. Clin Orthop Relat Res1988; 234: 61–9.
17.
DuckworthAD, WatsonBS, WillEM,. Radial shortening following a fracture of the proximal radius. Acta Orthop2011; 82: 356–9.
18.
Rodriguez-MartinJ, Pretell-MazziniJ, Vidal-BujandaC. Unusual pattern of Essex-Lopresti injury with negative plain radiographs of the wrist: a case report and literature review. Hand Surg2010; 15: 41–5.
19.
Rodriguez-MartinJ, Pretell-MazziniJ. The role of ultrasound and magnetic resonance imaging in the evaluation of the forearm interosseous membrane. A review. Skeletal Radiol2011; 40: 1512–22.
20.
SoubeyrandM, LafontC, OberlinC,. The ‘muscular hernia sign’: an original ultrasonographic sign to detect lesions of the forearm's interosseous membrane. Surg Radiol Anat2006; 28: 372–8.
21.
FaillaJM, JacobsonJ, van HolsbeeckM. Ultrasound diagnosis and surgical pathology of the torn interosseous membrane in forearm fractures/dislocations. J Hand Surg Am1999; 24: 257–66.
22.
MatsuokaJ, BeppuM, NakajimaH, AokiH. Ultrasonography for the interosseous membrane of the forearm. Hand Surg2003; 8: 227–35.
23.
HausmannJT, VekszlerG, BreitenseherM,. Mason type-I radial head fractures and interosseous membrane lesions – a prospective study. J Trauma2009; 66: 457–61.
24.
FesterEW, MurrayPM, SandersTG,. The efficacy of magnetic resonance imaging and ultrasound in detecting disruptions of the forearm interosseous membrane: a cadaver study. J Hand Surg Am2002; 27: 418–24.
25.
SoubeyrandM, CiaisG, WassermannV,. The intra-operative radius joystick test to diagnose complete disruption of the interosseous membrane. J Bone Joint Surg Br2011; 93: 1389–94.
26.
GeelCW, PalmerAK. Radial head fractures and their effect on the distal radioulnar joint. A rationale for treatment. Clin Orthop Relat Res1992; 275: 79–84.
27.
JungbluthP, FrangenTM, ArensS, MuhrG, KalickeT. The undiagnosed Essex-Lopresti injury. J Bone Joint Surg Br2006; 88: 1629–33.
28.
SzaboRM, HotchkissRN, SlaterRRJr. The use of frozen-allograft radial head replacement for treatment of established symptomatic proximal translation of the radius: preliminary experience in five cases. J Hand Surg Am1997; 22: 269–78.
29.
KarlstadR, MorreyBF, CooneyWP. Failure of fresh-frozen radial head allografts in the treatment of Essex-Lopresti injury. A report of four cases. J Bone Joint Surg Am2005; 87: 1828–33.
30.
SellmanDC, SeitzWHJr, PostakPD, GreenwaldAS. Reconstructive strategies for radioulnar dissociation: a biomechanical study. J Orthop Trauma1995; 9: 516–22.
31.
BirkedalJP, DealDN, RuchDS. Loss of flexion after radial head replacement. J Shoulder Elbow Surg2004; 13: 208–13.
32.
Van GlabbeekF, Van RietRP, BaumfeldJA,. Detrimental effects of overstuffing or understuffing with a radial head replacement in the medial collateral-ligament deficient elbow. J Bone Joint Surg Am2004; 86-A: 2629–35.
33.
Van RietRP, Van GlabbeekF, VerborgtO, GielenJ. Capitellar erosion caused by a metal radial head prosthesis. A case report. J Bone Joint Surg Am2004; 86-A: 1061–4.
34.
DoornbergJN, LinzelDS, ZurakowskiD, RingD. Reference points for radial head prosthesis size. J Hand Surg Am2006; 31: 53–7.
35.
FrankSG, GrewalR, JohnsonJ,. Determination of correct implant size in radial head arthroplasty to avoid overlengthening. J Bone Joint Surg Am2009; 91: 1738–46.
36.
ShoreBJ, MozzonJB, MacDermidJC, FaberKJ, KingGJ. Chronic posttraumatic elbow disorders treated with metallic radial head arthroplasty. J Bone Joint Surg Am2008; 90: 271–80.
37.
HeijinkA, MorreyBF, van RietRP, O'DriscollSW, CooneyWPIII. Delayed treatment of elbow pain and dysfunction following Essex-Lopresti injury with metallic radial head replacement: a case series. J Shoulder Elbow Surg2010; 19: 929–36.
38.
TomainoM. The emerging role for Uni-Elbow arthroplasty. Am J Orthop2008; 37(Suppl 1): 26–8.
39.
DuckworthAD, ClementND, AitkenSA, RingD, McQueenMM. Essex-Lopresti lesion associated with an impacted radial neck fracture: interest of ulnar shortening in the secondary management of sequelae. J Shoulder Elbow Surg2011; 20: e19–24.
40.
PfaeffleHJ, StabileKJ, LiZM, TomainoMM. Reconstruction of the interosseous ligament unloads metallic radial head arthroplasty and the distal ulna in cadavers. J Hand Surg Am2006; 31: 269–78.
41.
AdamsJE, CulpRW, OstermanAL. Interosseous membrane reconstruction for the Essex-Lopresti injury. J Hand Surg Am2010; 35: 129–36.
42.
StevensonJD, RadeshL, PickardS, AdrianS, HaySM. Falsely reassuring magnetic resonance imaging appearance of the forearm interosseous membrane following Essex-Lopresti injury: does it ever completely heal?Shoulder Elbow2010; 2: 287–90.
43.
GongHS, ChungMS, OhJH,. Failure of the interosseous membrane to heal with immobilization, pinning of the distal radioulnar joint, and bipolar radial head replacement in a case of Essex-Lopresti injury: case report. J Hand Surg Am2010; 35: 976–80.
44.
SkahenJRIII, PalmerAK, WernerFW, FortinoMD. Reconstruction of the interosseous membrane of the forearm in cadavers. J Hand Surg Am1997; 22: 986–94.
45.
TomainoMM, PfaeffleJ, StabileK, LiZM. Reconstruction of the interosseous ligament of the forearm reduces load on the radial head in cadavers. J Hand Surg Br2003; 28: 267–70.
46.
PfaeffleHJ, StabileKJ, LiZM, TomainoMM. Reconstruction of the interosseous ligament restores normal forearm compressive load transfer in cadavers. J Hand Surg Am2005; 30: 319–25.
47.
TejwaniSG, MarkolfKL, BenhaimP. Reconstruction of the interosseous membrane of the forearm with a graft substitute: a cadaveric study. J Hand Surg Am2005; 30: 326–34.
48.
TejwaniSG, MarkolfKL, BenhaimP. Graft reconstruction of the interosseous membrane in conjunction with metallic radial head replacement: a cadaveric study. J Hand Surg Am2005; 30: 335–42.
49.
SoubeyrandM, OberlinC, DumontierC,. Ligamentoplasty of the forearm interosseous membrane using the semitendinosus tendon: anatomical study and surgical procedure. Surg Radiol Anat2006; 28: 300–7.
50.
ChlorosGD, WieslerER, StabileKJ,. Reconstruction of essexlopresti injury of the forearm: technical note. J Hand Surg Am2008; 33: 124–30.
51.
AdamsJE, OstermanMN, OstermanAL. Interosseous membrane reconstruction for forearm longitudinal instability. Tech Hand Up Extrem Surg2010; 14: 222–5.
52.
KamCC, JonesCM, FennemaJL,. Suture-button construct for interosseous ligament reconstruction in longitudinal radioulnar dissociations: a biomechanical study. J Hand Surg Am2010; 35: 1626–32.
53.
DrakeML, FarberGL, WhiteKL, ParksBG, SegalmanKA. Restoration of longitudinal forearm stability using a suture button construct. J Hand Surg Am2010; 35: 1981–5.
54.
PetersonCAII, MakiS, WoodMB. Clinical results of the one-bone forearm. J Hand Surg Am1995; 20: 609–18.
55.
MarcotteAL, OstermanAL. Longitudinal radioulnar dissociation: identification and treatment of acute and chronic injuries. Hand Clin2007; 23: 195–208.
