Strategies in Trauma and Limb Reconstruction

Register      Login

VOLUME 7 , ISSUE 3 ( November, 2012 ) > List of Articles


The Essex-Lopresti lesion

K. Wegmann, J. Dargel, K. J. Burkhart, G. P. Brüggemann, L. P. Müller

Keywords : Essex-Lopresti lesion, Longitudinal forearm instability, Radial head fracture, Distal radio-ulnar joint, Interosseous membrane, Radial head prosthesis

Citation Information : Wegmann K, Dargel J, Burkhart KJ, Brüggemann GP, Müller LP. The Essex-Lopresti lesion. 2012; 7 (3):131-139.

DOI: 10.1007/s11751-012-0149-0

License: CC BY-NC-SA 4.0

Published Online: 30-11-2012

Copyright Statement:  Copyright © 2012; Jaypee Brothers Medical Publishers (P) Ltd.


The Essex-Lopresti lesion represents a severe injury of the forearm unit. In the 1940s, it\'s pathology and consequences have already been mentioned by several authors. Over the course of time, the pathophysiology of the lesion was displayed in more detail. Therefore, an intensive analysis of the involved anatomic structures was done. The interosseous membrane was shown to play a major role in stabilising the forearm unit, in the situation of a fractured radial head, which is the primary stabiliser of the longitudinal forearm stability. Moreover, biomechanical analyses showed a relevant attribution of the distal radio-ulnar joint to the forearm stability. If, in the case of a full-blown Essex-Lopresti lesion, the radial head, the interosseous membrane and the distal radio-ulnar joint are injured, proximalisation of the radius will take place and will come along with secondary symptoms at the elbow joint and the wrist. According to actual studies, the lesion seems to occur more often than realised up to now. Thus, to avoid missing the complex injury, subtle clinical diagnosis combined with adequate imaging has to be undertaken. If the lesion is confirmed, several operative treatment options are available, yet not proofed to be sufficient.

PDF Share
  1. Adams BD, Berger RA (2002) An anatomic reconstruction of the distal radioulnar ligaments for posttraumatic distal radioulnar joint instability. J Hand Surg Am 27(2):243-251
  2. Adams BD, Divelbiss BJ (2001) Reconstruction of the posttraumatic unstable distal radioulnar joint. Orthop Clin North Am 32(2):353-363 x
  3. Adams JE, Steinmann SP, Osterman AL (2010) Management of injuries to the interosseous membrane. Hand Clin 26(4):543-548. doi:10.1016/j.hcl.2010.05.003
  4. Almquist EE (1992) Evolution of the distal radioulnar joint. Clin Orthop Relat Res 275:5-13
  5. Anderson ML, Larson AN, Moran SL, Cooney WP, Amrami KK, Berger RA (2008) Clinical comparison of arthroscopic versus open repair of triangular fibrocartilage complex tears. J Hand Surg Am 33(5):675-682. doi:10.1016/j.jhsa.2008.01.020
  6. Birkbeck DP, Failla JM, Hoshaw SJ, Fyhrie DP, Schaffler M (1997) The interosseous membrane affects load distribution in the forearm. J Hand Surg Am 22(6):975-980. doi:10.1016/S0363-5023(97)80035-4
  7. Burkhart KJ, Mattyasovszky SG, Runkel M, Schwarz C, Kuchle R, Hessmann MH, Rommens PM, Lars MP (2010) Mid- to longterm results after bipolar radial head arthroplasty. J Shoulder Elbow Surg 19(7):965-972. doi:10.1016/j.jse.2010.05.022
  8. Burkhart KJ, Mueller LP, Krezdorn D, Appelmann P, Prommersberger KJ, Sternstein W, Rommens PM (2007) Stability of radial head and neck fractures: a biomechanical study of six fixation constructs with consideration of three locking plates. J Hand Surg Am 32(10):1569-1575. doi:10.1016/j.jhsa.2007.08.023
  9. Burkhart KJ, Nowak TE, Appelmann P, Sternstein W, Rommens PM, Mueller LP (2010) Screw fixation of radial head fractures: compression screw versus lag screw—a biomechanical comparison. Injury 41(10):1015-1019. doi:10.1016/j.injury.2010.03.001
  10. Chen F, Culp RW, Schneider LH, Osterman AL (1998) Revision of the ununited one-bone forearm. J Hand Surg Am 23(6):1091-1096. doi:10.1016/S0363-5023(98)80021-X
  11. Chloros GD, Wiesler ER, Stabile KJ, Papadonikolakis A, Ruch DS, Kuzma GR (2008) Reconstruction of Essex-Lopresti injury of the forearm: technical note. J Hand Surg Am 33(1):124-130. doi:10.1016/j.jhsa.2007.09.008
  12. Christensen JB, Adams JP, Cho KO, Miller L (1968) A study of the interosseous distance between the radius and ulna during rotation of the forearm. Anat Rec 160(2):261-271. doi:10.1002/ar.1091600212
  13. Curr JF, Coe WA (1946) Dislocation of the inferior radio-ulnar joint. Br J Surg 34:74-77
  14. de Araujo W, Poehling GG, Kuzma GR (1996) New Tuohy needle technique for triangular fibrocartilage complex repair: preliminary studies. Arthroscopy 12(6):699-703
  15. Dodds SD, Yeh PC, Slade JF 3rd (2008) Essex-Lopresti injuries. Hand Clin 24(1):125-137. doi:10.1016/j.hcl.2007.11.009
  16. Drake ML, Farber GL, White KL, Parks BG, Segalman KA (2010) Restoration of longitudinal forearm stability using a suture button construct. J Hand Surg Am 35(12):1981-1985. doi: 10.1016/j.jhsa.2010.09.009
  17. Duckworth AD, Watson BS, Will EM, Petrisor BA, Walmsley PJ, Court-Brown CM, McQueen MM (2011) Radial shortening following a fracture of the proximal radius. Acta Orthop 82(3):356-359. doi:10.3109/17453674.2011.574563
  18. Edwards GS Jr, Jupiter JB (1988) Radial head fractures with acute distal radioulnar dislocation. Essex-Lopresti revisited. Clin Orthop Relat Res 234:61-69
  19. Epner RA, Bowers WH, Guilford WB (1982) Ulnar variance— the effect of wrist positioning and roentgen filming technique. J Hand Surg Am 7(3):298-305
  20. Erasmus PJ (2008) The medial patellofemoral ligament: function, injury, and treatment. Orthopade 37(9):858, 860-863. doi: 10.1007/s00132-008-1292-7
  21. Esser RD, Davis S, Taavao T (1995) Fractures of the radial head treated by internal fixation: late results in 26 cases. J Orthop Trauma 9(4):318-323
  22. Essex-Lopresti P (1951) Fractures of the radial head with distal radio-ulnar dislocation; report of two cases. J Bone Joint Surg Br 33B(2):244-247
  23. Failla JM, Jacobson J, van Holsbeeck M (1999) Ultrasound diagnosis and surgical pathology of the torn interosseous membrane in forearm fractures/dislocations. J Hand Surg Am 24(2):257-266. doi:10.1053/jhsu.1999.0257
  24. Fester EW, Murray PM, Sanders TG, Ingari JV, Leyendecker J, Leis HL (2002) The efficacy of magnetic resonance imaging and ultrasound in detecting disruptions of the forearm interosseous membrane: a cadaver study. J Hand Surg Am 27(3):418-424
  25. Gabriel MT, Pfaeffle HJ, Stabile KJ, Tomaino MM, Fischer KJ (2004) Passive strain distribution in the interosseous ligament of the forearm: implications for injury reconstruction. J Hand Surg Am 29(2):293-298. doi:10.1016/j.jhsa.2003.10.023
  26. Gofton WT, Gordon KD, Dunning CE, Johnson JA, King GJ (2004) Soft-tissue stabilizers of the distal radioulnar joint: an in vitro kinematic study. J Hand Surg Am 29(3):423-431. doi: 10.1016/j.jhsa.2004.01.020
  27. Goldberg I, Peylan J, Yosipovitch Z (1986) Late results of excision of the radial head for an isolated closed fracture. J Bone Joint Surg Am 68(5):675-679
  28. Gong HS, Chung MS, Oh JH, Lee YH, Kim SH, Baek GH (2010) 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 Am 35(6):976-980. doi:10.1016/j.jhsa.2010.03.004
  29. Green JB, Zelouf DS (2009) Forearm instability. J Hand Surg Am 34(5):953-961. doi:10.1016/j.jhsa.2009.03.018
  30. Hagert E, Hagert CG (2010) Understanding stability of the distal radioulnar joint through an understanding of its anatomy. Hand Clin 26(4):459-466. doi:10.1016/j.hcl.2010.05.002
  31. Halls AA, Travill A (1964) Transmission of pressures across the elbow joint. Anat Rec 150:243-247
  32. Hausmann JT, Vekszler G, Breitenseher M, Braunsteiner T, Vecsei V, Gabler C (2009) Mason type-I radial head fractures and interosseous membrane lesions—a prospective study. J Trauma 66(2):457-461. doi:10.1097/TA.0b013e31817fdedd
  33. Herbertsson P, Josefsson PO, Hasserius R, Besjakov J, Nyqvist F, Karlsson MK (2004) Fractures of the radial head and neck treated with radial head excision. J Bone Joint Surg Am 86-A(9): 1925-1930
  34. Hotchkiss RN (1997) Displaced fractures of the radial head: internal fixation or excision? J Am Acad Orthop Surg 5(1):1-10
  35. Hotchkiss RN (1994) Injuries to the interosseous ligament of the forearm. Hand Clin 10(3):391-398
  36. Hotchkiss RN, An KN, Sowa DT, Basta S, Weiland AJ (1989) An anatomic and mechanical study of the interosseous membrane of the forearm: pathomechanics of proximal migration of the radius. J Hand Surg Am 14(2 Pt 1):256-261
  37. Hsu SL, Liang R, Woo SL (2010) Functional tissue engineering of ligament healing. Sports Med Arthrosc Rehabil Ther Technol 2:12. doi:10.1186/1758-2555-2-12
  38. Jaakkola JI, Riggans DH, Lourie GM, Lang CJ, Elhassan BT, Rosenthal SJ (2001) Ultrasonography for the evaluation of forearm interosseous membrane disruption in a cadaver model. J Hand Surg Am 26(6):1053-1057
  39. Jung JM, Baek GH, Kim JH, Lee YH, Chung MS (2001) Changes in ulnar variance in relation to forearm rotation and grip. J Bone Joint Surg Br 83(7):1029-1033
  40. Kaas L, van Riet RP, Vroemen JP, Eygendaal D (2008) The incidence of associated fractures of the upper limb in fractures of the radial head. Strateg Trauma Limb Reconstr 3(2):71-74. doi: 10.1007/s11751-008-0038-8
  41. Kakar S, Carlsen BT, Moran SL, Berger RA (2010) The management of chronic distal radioulnar instability. Hand Clin 26(4):517-528. doi:10.1016/j.hcl.2010.05.010
  42. Kam CC, Jones CM, Fennema JL, Latta LL, Ouellette EA, Evans PJ (2010) Suture-button construct for interosseous ligament reconstruction in longitudinal radioulnar dissociations: a biomechanical study. J Hand Surg Am 35(10):1626-1632. doi: 10.1016/j.jhsa.2010.07.020
  43. Kannus P, Jarvinen M (1990) Nonoperative treatment of acute knee ligament injuries. A review with special reference to indications and methods. Sports Med 9(4):244-260
  44. Kapandji A (2001) Biomechanics of pronation and supination of the forearm. Hand Clin 17(1):111-122 vii
  45. Karlstad R, Morrey BF, Cooney WP (2005) Failure of freshfrozen radial head allografts in the treatment of Essex-Lopresti injury. A report of four cases. J Bone Joint Surg Am 87(8):1828-1833. doi:10.2106/JBJS.D.02351
  46. Kim JP, Park MJ (2008) Assessment of distal radioulnar joint instability after distal radius fracture: comparison of computed tomography and clinical examination results. J Hand Surg Am 33(9):1486-1492. doi:10.1016/j.jhsa.2008.05.017
  47. King GJ (2004) Management of comminuted radial head fractures with replacement arthroplasty. Hand Clin 20(4):429-441. doi:10.1016/j.hcl.2004.06.003 vi
  48. Knight DJ, Rymaszewski LA, Amis AA, Miller JH (1993) Primary replacement of the fractured radial head with a metal prosthesis. J Bone Joint Surg Br 75(4):572-576
  49. Koslowsky TC, Mader K, Gausepohl T, Pennig D (2007) Reconstruction of Mason type-III and type-IV radial head fractures with a new fixation device: 23 patients followed 1-4 years. Acta Orthop 78(1):151-156. doi:10.1080/17453670610013565
  50. Lee SJ, Jazrawi LM, Ong BC, Raskin KB (2000) Long-term follow-up of the one-bone forearm procedure. Am J Orthop 29(12):969-972
  51. Marcotte AL, Osterman AL (2007) Longitudinal radioulnar dissociation: identification and treatment of acute and chronic injuries. Hand Clin 23(2):195-208. doi:10.1016/j.hcl.2007.01.005 vi
  52. Mason ML (1954) Some observations on fractures of the head of the radius with a review of one hundred cases. Br J Surg 42(172):123-132
  53. Mayhall WS, Tiley FT, Paluska DJ (1981) Fracture of silastic radial-head prosthesis. Case report. J Bone Joint Surg Am 63(3):459-460
  54. McAdams TR, Swan J, Yao J (2009) Arthroscopic treatment of triangular fibrocartilage wrist injuries in the athlete. Am J Sports Med 37(2):291-297. doi:10.1177/0363546508325921
  55. McGinley JC, Hopgood BC, Gaughan JP, Sadeghipour K, Kozin SH (2003) Forearm and elbow injury: the influence of rotational position. J Bone Joint Surg Am 85-A(12):2403-2409
  56. McGinley JC, Kozin SH (2001) Interosseous membrane anatomy and functional mechanics. Clin Orthop Relat Res 383:108-122
  57. McGinley JC, Roach N, Hopgood BC, Limmer K, Kozin SH (2006) Forearm interosseous membrane trauma: MRI diagnostic criteria and injury patterns. Skeletal Radiol 35(5):275-281. doi: 10.1007/s00256-005-0069-x
  58. Mikic ZD, Vukadinovic SM (1983) Late results in fractures of the radial head treated by excision. Clin Orthop Relat Res 181:220-228
  59. Morgan WJ, Breen TF (1994) Complex fractures of the forearm. Hand Clin 10(3):375-390
  60. Moro JK, Werier J, MacDermid JC, Patterson SD, King GJ (2001) Arthroplasty with a metal radial head for unreconstructible fractures of the radial head. J Bone Joint Surg Am 83-A(8): 1201-1211
  61. Morrey BF, Askew L, Chao EY (1981) Silastic prosthetic replacement for the radial head. J Bone Joint Surg Am 63(3):454-458
  62. Morrey BF, Askew LJ, Chao EY (1981) A biomechanical study of normal functional elbow motion. J Bone Joint Surg Am 63(6):872-877
  63. Murray PM (2005) Diagnosis and treatment of longitudinal instability of the forearm. Tech Hand Up Extrem Surg 9(1):29-34
  64. Neuber M, Joist A, Joosten U, Rieger H (2000) Consequences and possible treatment of distal radio-ulnar dislocation after Essex-Lopresti lesion. Unfallchirurg 103:1093-1096
  65. Peterson CA 2nd, Maki S, Wood MB (1995) Clinical results of the one-bone forearm. J Hand Surg Am 20(4):609-618. doi: 10.1016/S0363-5023(05)80277-1
  66. Pfaeffle HJ, Stabile KJ, Li ZM, Tomaino MM (2005) Reconstruction of the interosseous ligament restores normal forearm compressive load transfer in cadavers. J Hand Surg Am 30(2):319-325. doi:10.1016/j.jhsa.2004.10.005
  67. Poitevin LA (2001) Anatomy and biomechanics of the interosseous membrane: its importance in the longitudinal stability of the forearm. Hand Clin 17(1):97-110 vii
  68. Rabinowitz RS, Light TR, Havey RM, Gourineni P, Patwardhan AG, Sartori MJ, Vrbos L (1994) The role of the interosseous membrane and triangular fibrocartilage complex in forearm stability. J Hand Surg Am 19(3):385-393. doi:10.1016/0363-5023(94)90050-7
  69. Rodriguez-Martin J, Pretell-Mazzini J, Vidal-Bujanda C (2010) Unusual pattern of Essex-Lopresti injury with negative plain radiographs of the wrist: a case report and literature review. Hand Surg 15(1):41-45
  70. Ruch DS, Chang DS, Koman LA (1999) Reconstruction of longitudinal stability of the forearm after disruption of interosseous ligament and radial head excision (Essex-Lopresti lesion). J South Orthop Assoc 8(1):47-52
  71. Sagerman SD, Short W (1996) Arthroscopic repair of radial-sided triangular fibrocartilage complex tears. Arthroscopy 12(3): 339-342
  72. Sellman DC, Seitz WH Jr, Postak PD, Greenwald AS (1995) Reconstructive strategies for radioulnar dissociation: a biomechanical study. J Orthop Trauma 9(6):516-522
  73. Seo KN, Park MJ, Kang HJ (2009) Anatomic reconstruction of the distal radioulnar ligament for posttraumatic distal radioulnar joint instability. Clin Orthop Surg 1(3):138-145. doi:10.4055/cios.2009.1.3.138
  74. Shepard MF, Markolf KL, Dunbar AM (2001) Effects of radial head excision and distal radial shortening on load-sharing in cadaver forearms. J Bone Joint Surg Am 83-A(1):92-100
  75. Skahen JR 3rd, Palmer AK, Werner FW, Fortino MD (1997) Reconstruction of the interosseous membrane of the forearm in cadavers. J Hand Surg Am 22(6):986-994. doi:10.1016/S0363-5023(97)80037-8
  76. Smith AM, Urbanosky LR, Castle JA, Rushing JT, Ruch DS (2002) Radius pull test: predictor of longitudinal forearm instability. J Bone Joint Surg Am 84-A(11):1970-1976
  77. Soubeyrand M, Ciais G, Wassermann V, Kalouche I, Gagey O, Biau D, Dumontier C (2011) The intra-operative radius joystick test to diagnose complete disruption of the interosseous membrane. J Bone Joint Surg Br 93(10):1389-1394. doi:10.1302/0301-620X.93B10.26590
  78. Stabile KJ, Pfaeffle J, Saris I, Li ZM, Tomaino MM (2005) Structural properties of reconstruction constructs for the interosseous ligament of the forearm. J Hand Surg Am 30(2):312-318. doi:10.1016/j.jhsa.2004.11.018
  79. Starch DW, Dabezies EJ (2001) Magnetic resonance imaging of the interosseous membrane of the forearm. J Bone Joint Surg Am 83-A(2):235-238
  80. Stevenson JD, Radesh L, Pickard S, Adrian S, Hay SM (2010) Falsely reassuring magnetic resonance imaging appearance of the forearm interosseous membrane following an Essex-Lopresti injury: does it ever completely heal? Should Elb 2(4):287-290
  81. Tejwani SG, Markolf KL, Benhaim P (2005) Reconstruction of the interosseous membrane of the forearm with a graft substitute: a cadaveric study. J Hand Surg Am 30(2):326-334. doi: 10.1016/j.jhsa.2004.05.017
  82. Teoh LC, Yam AK (2005) Anatomic reconstruction of the distal radioulnar ligaments: long-term results. J Hand Surg Br 30(2):185-193. doi:10.1016/j.jhsb.2004.10.017
  83. Tomaino MM, Pfaeffle J, Stabile K, Li ZM (2003) Reconstruction of the interosseous ligament of the forearm reduces load on the radial head in cadavers. J Hand Surg Br 28(3):267-270
  84. Trousdale RT, Amadio PC, Cooney WP, Morrey BF (1992) Radio-ulnar dissociation. A review of twenty cases. J Bone Joint Surg Am 74(10):1486-1497
  85. Trumble TE, Gilbert M, Vedder N (1997) Isolated tears of the triangular fibrocartilage: management by early arthroscopic repair. J Hand Surg Am 22(1):57-65. doi:10.1016/S0363-5023(05)80180-7
  86. Vanderwilde RS, Morrey BF, Melberg MW, Vinh TN (1994) Inflammatory arthritis after failure of silicone rubber replacement of the radial head. J Bone Joint Surg Br 76(1):78-81
  87. Wassink S, Lisowski LA, Schutte BG (2009) Traumatic recurrent distal radioulnar joint dislocation: a case report. Strateg Trauma Limb Reconstr. doi:10.1007/s11751-009-0073-0
  88. Worsing RA Jr, Engber WD, Lange TA (1982) Reactive synovitis from particulate silastic. J Bone Joint Surg Am 64(4):581-585
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.