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Diagnosis and Treatment of an Essex-Lopresti Injury
Key Points
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Essex-Lopresti injuries are frequently missed, therefore every proximal radius fracture requires at least a clinical and radiological examination of the elbow, forearm and wrist.
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In case of a clinical suspect Essex-Lopresti injury the recommended diagnostic tools to find or rule out an intraosseous membrane (IOM) rupture are either MRI or ultrasound (US).
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During proximal radius fracture surgery, forearm stability should always be examined by a combination of the radius push/pull test and Joystick test.
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An Essex-Lopresti injury should be preferably treated in the acute phase (< 4 weeks).
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Treatment of a chronic Essex-Lopresti injury should be assessed on a case-to-case basis.
Importance of the Problem
An ELI is a pattern injury that consist of a fracture of the proximal radius, disruption of the distal radial ulnar joint, and a rupture of the interosseous membrane (IOM) of the forearm. ELIs are rare and due to the predominant symptoms of a proximal radius fracture they are regularly missed or poorly treated. Most case series show a missed diagnosis frequency that exceeds 60%. In some cases longitudinal forearm instability due to a rupture of the interosseous membrane can be diagnosed acutely (< 4 weeks); however, it is more common that the interosseous membrane is partly ruptured causing progressing forearm instability over time.
A late treatment of an ELI is associated with a worse outcome for the patient. Patients who were treated in the acute phase showed an 80% success rate, well 80% of the patients treated for a chronic ELI demonstrated failure. Therefore it is crucial to know how to diagnose and treat ELIs in the acute phase.
Main Question
How can an Essex-Lopresti injury be diagnosed and what is the most effective management in the acute and chronic phase?
Current Opinion
ELI should be part of the differential diagnosis in every radial head fracture. Therefore, every radial head fracture requires a full radiological assessment of the elbow, forearm, and wrist. To diagnose subluxation or dislocation of the distal radioulnar joint (DRUJ) it is crucial to perform both a true posterior anterior as well as a true lateral view radiographs in neutral position. An additional radiograph of the wrist on the uninjured side enables assessment of the normal DRUJ variance. However, earlier studies found that radiographs alone are not reliable to either diagnose or rule out an ELI. Therefore, clinical examination is the most important indicator to decide if further investigation is required. A painful wrist and pain trough the forearm during clinical examination is the most important reason to perform additional radiologic examination. In the acute phase it is possible to detect an IOM injury by ultrasound (US) or magnetic resonance imaging (MRI). Furthermore, intraoperative examination can be performed to diagnose an IOM injury.
The IOM is known for having a low healing potential. Therefore, the golden standard treatment for acute or chronic ELIs has become surgical treatment. The treatment is focusing on restoring the radio-ulnar length and stabilizing the forearm. The acute treatment typically consists of either a replacement or fixation of the radial head in combination with pinning of the DRUJ. Depending on the grade of the distal instability, a TFCC repair could be considered. However, adding a TFCC repair to the procedure is more invasive and expensive compared to DRUJ pinning and should therefore be considered carefully. Chronic ELIs are treated by restoring the longitudinal stability between radius and ulna by reconstructive surgery. However, it is not clear what diagnostic tool and surgical technique is best to use to diagnose and treat an acute or chronic ELI.
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