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• W2571331444 abstract "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. 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. CME Information and DisclosuresThe Journal of Hand Surgery will contain at least 2 clinically relevant articles selected by the editor to be offered for CME in each issue. For CME credit, the participant must read the articles in print or online and correctly answer all related questions through an online examination. The questions on the test are designed to make the reader think and will occasionally require the reader to go back and scrutinize the article for details.The JHS CME Activity fee of $15.00 includes the exam questions/answers only and does not include access to the JHS articles referenced.Statement of Need: This CME activity was developed by the JHS editors as a convenient education tool to help increase or affirm reader’s knowledge. The overall goal of the activity is for participants to evaluate the appropriateness of clinical data and apply it to their practice and the provision of patient care.Accreditation: The ASSH is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.AMA PRA Credit Designation: The American Society for Surgery of the Hand designates this Journal-Based CME activity for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.ASSH Disclaimer: The material presented in this CME activity is made available by the ASSH for educational purposes only. This material is not intended to represent the only methods or the best procedures appropriate for the medical situation(s) discussed, but rather it is intended to present an approach, view, statement, or opinion of the authors that may be helpful, or of interest, to other practitioners. Examinees agree to participate in this medical education activity, sponsored by the ASSH, with full knowledge and awareness that they waive any claim they may have against the ASSH for reliance on any information presented. The approval of the US Food and Drug Administration is required for procedures and drugs that are considered experimental. Instrumentation systems discussed or reviewed during this educational activity may not yet have received FDA approval.Provider Information can be found at http://www.assh.org/Pages/ContactUs.aspx.Technical Requirements for the Online Examination can be found at http://jhandsurg.org/cme/home.Privacy Policy can be found at http://www.assh.org/pages/ASSHPrivacyPolicy.aspx.ASSH Disclosure Policy: As a provider accredited by the ACCME, the ASSH must ensure balance, independence, objectivity, and scientific rigor in all its activities.Disclosures for this ArticleEditorsDavid T. Netscher, MD, has no relevant conflicts of interest to disclose.AuthorsAll authors of this journal-based CME activity have no relevant conflicts of interest to disclose. In the printed or PDF version of this article, author affiliations can be found at the bottom of the first page.PlannersDavid T. Netscher, MD, has no relevant conflicts of interest to disclose. The editorial and education staff involved with this journal-based CME activity has no relevant conflicts of interest to disclose.Learning ObjectivesUpon completion of this CME activity, the learner should achieve an understanding of:•Injury patterns leading to longitudinal forearm instability (Essex Lopresti)•Anatomy of the interosseous membrane•Structures involved that may lead to instability•Diagnosis of longitudinal forearm instability•Treatment options for forearm instabilityDeadline: Each examination purchased in 2017 must be completed by January 31, 2018, to be eligible for CME. A certificate will be issued upon completion of the activity. Estimated time to complete each JHS CME activity is up to one hour.Copyright © 2017 by the American Society for Surgery of the Hand. All rights reserved. The Journal of Hand Surgery will contain at least 2 clinically relevant articles selected by the editor to be offered for CME in each issue. For CME credit, the participant must read the articles in print or online and correctly answer all related questions through an online examination. The questions on the test are designed to make the reader think and will occasionally require the reader to go back and scrutinize the article for details. The JHS CME Activity fee of $15.00 includes the exam questions/answers only and does not include access to the JHS articles referenced. Statement of Need: This CME activity was developed by the JHS editors as a convenient education tool to help increase or affirm reader’s knowledge. The overall goal of the activity is for participants to evaluate the appropriateness of clinical data and apply it to their practice and the provision of patient care. Accreditation: The ASSH is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. AMA PRA Credit Designation: The American Society for Surgery of the Hand designates this Journal-Based CME activity for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. ASSH Disclaimer: The material presented in this CME activity is made available by the ASSH for educational purposes only. This material is not intended to represent the only methods or the best procedures appropriate for the medical situation(s) discussed, but rather it is intended to present an approach, view, statement, or opinion of the authors that may be helpful, or of interest, to other practitioners. Examinees agree to participate in this medical education activity, sponsored by the ASSH, with full knowledge and awareness that they waive any claim they may have against the ASSH for reliance on any information presented. The approval of the US Food and Drug Administration is required for procedures and drugs that are considered experimental. Instrumentation systems discussed or reviewed during this educational activity may not yet have received FDA approval. Provider Information can be found at http://www.assh.org/Pages/ContactUs.aspx. Technical Requirements for the Online Examination can be found at http://jhandsurg.org/cme/home. Privacy Policy can be found at http://www.assh.org/pages/ASSHPrivacyPolicy.aspx. ASSH Disclosure Policy: As a provider accredited by the ACCME, the ASSH must ensure balance, independence, objectivity, and scientific rigor in all its activities. David T. Netscher, MD, has no relevant conflicts of interest to disclose. All authors of this journal-based CME activity have no relevant conflicts of interest to disclose. In the printed or PDF version of this article, author affiliations can be found at the bottom of the first page. David T. Netscher, MD, has no relevant conflicts of interest to disclose. The editorial and education staff involved with this journal-based CME activity has no relevant conflicts of interest to disclose. Upon completion of this CME activity, the learner should achieve an understanding of:•Injury patterns leading to longitudinal forearm instability (Essex Lopresti)•Anatomy of the interosseous membrane•Structures involved that may lead to instability•Diagnosis of longitudinal forearm instability•Treatment options for forearm instability Deadline: Each examination purchased in 2017 must be completed by January 31, 2018, to be eligible for CME. A certificate will be issued upon completion of the activity. Estimated time to complete each JHS CME activity is up to one hour. Copyright © 2017 by the American Society for Surgery of the Hand. All rights reserved. The radial head is the primary contributor to longitudinal forearm stability. Secondary stabilizers are the triangular fibrocartilage complex (TFCC) and the interosseous membrane (IOM), particularly its most functionally important component, the central band (CB), which functions as a restraining ligament. The roles of the TFCC and the IOM in forearm stability after radial head excision seem to be equivalent in importance.1Gofton W.T. Gordon K.D. Dunning C.E. Johnson J.A. King G.J. Soft-tissue stabilizers of the distal radioulnar joint: an in vitro kinematic study.J Hand Surg Am. 2004; 29: 423-431Abstract Full Text Full Text PDF PubMed Scopus (105) Google Scholar, 2Skahen III, J.R. Palmer A.K. Werner F.W. Fortino M.D. The interosseous membrane of the forearm: anatomy and function.J Hand Surg Am. 1997; 22: 981-985Abstract Full Text PDF PubMed Scopus (139) Google Scholar, 3Sowa D.T. Hotchkiss R.N. Weiland A.J. Symptomatic proximal translation of the radius following radial head resection.Clin Orthop Relat Res. 1995; 317: 106-113PubMed Google Scholar The IOM is a structure arising between the radius and the ulna that has multiple roles (Fig. 1).4Noda K. Goto A. Murase T. Sugamoto K. Yoshikawa H. Moritomo H. Interosseous membrane of the forearm: an anatomical study of ligament attachment locations.J Hand Surg Am. 2009; 34: 415-422Abstract Full Text Full Text PDF PubMed Scopus (122) Google Scholar, aAnatomy of the Interosseous Membrane [See Video]. Talwalkar SC. Talk presented at: American Society for Surgery of the Hand Annual Meeting: October 3-5, 2013; San Francisco, CA. Also available on Hand-e: http://www.assh.org/Hand-e.Google Scholar We now know that it confers stability to the distal radioulnar joint (DRUJ) as well as providing longitudinal stability to the forearm and an origin for forearm musculature. Five discrete components of the IOM have been identified: the CB, the distal oblique bundle (DOB), an accessory band, a dorsal oblique accessory cord, and a proximal oblique cord. One of the most important functional components of the IOM is the central band which has a 21° proximal-radial to distal-ulnar orientation to the long axis of the ulna. The radial origin, which is slightly more narrow than the ulnar insertion, lies at approximately 60% of the length of the radius from the styloid, whereas the wider ulnar insertion is at about the junction of the middle two-thirds and the distal one-third of the ulna.4Noda K. Goto A. Murase T. Sugamoto K. Yoshikawa H. Moritomo H. Interosseous membrane of the forearm: an anatomical study of ligament attachment locations.J Hand Surg Am. 2009; 34: 415-422Abstract Full Text Full Text PDF PubMed Scopus (122) Google Scholar, 5Adams J.E. Culp R.W. Osterman A.L. Interosseous membrane reconstruction for the Essex-Lopresti injury.J Hand Surg Am. 2010; 35: 129-136Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar The DOB of the IOM is a component running from the dorsal ulna, arising at approximately the level of the pronator quadratus, to the inferior rim of the sigmoid notch and the DRUJ capsule. Although the presence and anatomy of this bundle is variable across specimens, when present, it is involved in stability of the DRUJ in all forearm rotation positions and seems to be isometric in all positions.4Noda K. Goto A. Murase T. Sugamoto K. Yoshikawa H. Moritomo H. Interosseous membrane of the forearm: an anatomical study of ligament attachment locations.J Hand Surg Am. 2009; 34: 415-422Abstract Full Text Full Text PDF PubMed Scopus (122) Google Scholar, 6Arimitsu S. Moritomo H. Kitamura T. et al.The stabilizing effect of the distal interosseous membrane on the distal radioulnar joint in an ulnar shortening procedure: a biomechanical study.J Bone Joint Surg Am. 2011; 93: 2022-2030Crossref PubMed Scopus (45) Google Scholar, 7Moritomo H. The distal interosseous membrane: current concepts in wrist anatomy and biomechanics.J Hand Surg Am. 2012; 37: 1501-1507Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar A fracture of the radial shaft, typically at the junction of the middle and distal thirds, may result in shortening and angulation and, therefore, disruption of the DRUJ. The typical mechanism of injury involves direct impact to the radius with forearm pronation.8Rettig M.E. Raskin K.B. Galeazzi fracture-dislocation: a new treatment-oriented classification.J Hand Surg Am. 2001; 26: 228-235Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar Cadaver studies demonstrate that shortening of 0.5 cm or more is accompanied by DRUJ instability and shortening of > 1 cm occurs with concomitant disruption of the TFCC and the IOM, whereas shortening of 0.5 to 1 cm presents with disruption of either the TFCC or the IOM.9Moore T.M. Lester D.K. Sarmiento A. The stabilizing effect of soft tissue constraints in artificial Galeazzi fractures.Clin Orthop Relat Res. 1985; 194: 189-194PubMed Google Scholar Treatment of Galeazzi fractures is surgical fixation of the radius and stabilization of the DRUJ. The eponym “fracture of necessity” was coined to emphasize that surgical treatment is typically necessary. The diaphyseal bow of the radius is critical to restoring pronation and supination of the forearm as the radius rotates about the fixed ulna. If the DRUJ is stable following fixation of the fracture, typically immobilization in neutral or supination for 2 to 4 weeks is adequate. If the DRUJ is unstable, the TFCC may be repaired and/or the forearm pinned in supination in a reduced position.10Park M.J. Pappas N. Steinberg D.R. Bozentka D.J. Immobilization in supination versus neutral following surgical treatment of Galeazzi fracture-dislocations in adults.J Hand Surg Am. 2012; 37: 528-531Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Various authors have sought to predict which injuries are likely to remain unstable after fixation of the radius. Typically, these fractures tend to be less stable the more distal the radial fracture. Fractures that were within 7.5 cm or less from the radiocarpal joint in 1 series or those in the distal third of the radius (from the metaphyseal flare distally to the area at which the diaphysis begins to straighten proximally) were more likely to be unstable.8Rettig M.E. Raskin K.B. Galeazzi fracture-dislocation: a new treatment-oriented classification.J Hand Surg Am. 2001; 26: 228-235Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar, 11Korompilias A.V. Lykissas M.G. Kostas-Agnantis I.P. Beris A.E. Soucacos P.N. Distal radioulnar joint instability (Galeazzi type injury) after internal fixation in relation to the radius fracture pattern.J Hand Surg Am. 2011; 36: 847-852Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar The reason for this is that the TFCC is more likely to be disrupted as well as the distal portion of the IOM, including the DOB. Longitudinal forearm instability does not occur because the central portion of the IOM remains intact.11Korompilias A.V. Lykissas M.G. Kostas-Agnantis I.P. Beris A.E. Soucacos P.N. Distal radioulnar joint instability (Galeazzi type injury) after internal fixation in relation to the radius fracture pattern.J Hand Surg Am. 2011; 36: 847-852Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar Monteggia fracture-dislocations represent a fracture of the proximal ulna with associated radial head dislocation. These should be distinguished from a transolecranon fracture-dislocation, which is a fracture of the olecranon with dislocation of the radiocapitellar rather than the proximal radioulnar joint. In contrast, a Monteggia fracture involves a fracture of the ulna distal to the base of the olecranon with a dislocation of the radiocapitellar and proximal radioulnar joints.12Ring D. Jupiter J.B. Waters P.M. Monteggia fractures in children and adults.J Am Acad Orthop Surg. 1998; 6: 215-224Crossref PubMed Scopus (113) Google Scholar Bado13Bado J.L. The Monteggia lesion.Clin Orthop Relat Res. 1967; 50: 71-86Crossref PubMed Google Scholar classified them into 4 types based upon the direction the radial head is dislocated and the apex of the ulnar fracture, which is directed in the same direction as the radial head dislocation. Type I is anterior dislocation of the radial head and is the most common (55%–78%). The ulna fracture is diaphyseal. Type II fractures are those with posterior dislocation and account for 10% to 15% of all cases. These usually have a concomitant radial head fracture and are commonly open injuries; they are rare in children. They are often very unstable owing to the presence of a triangular or quadrangular fragment in the defect at the anterior cortex of the ulnar diaphysis. Type II fractures tend to have poorer outcomes than the other types.12Ring D. Jupiter J.B. Waters P.M. Monteggia fractures in children and adults.J Am Acad Orthop Surg. 1998; 6: 215-224Crossref PubMed Scopus (113) Google Scholar, 14Jupiter J.B. Leibovic S.J. Ribbans W. Wilk R.M. The posterior Monteggia lesion.J Orthop Trauma. 1991; 5: 395-402Crossref PubMed Scopus (162) Google Scholar Type III (6.7%–20%) are fractures of the metaphyseal ulna with lateral or anterolateral dislocation of the radial head. These occur primarily in children. Finally, type IV fractures (5%) are those with diaphyseal ulnar fractures with anterior dislocation of the radial head and a concomitant radial proximal one-third shaft fracture. Management is predicated upon recognition, particularly of the radial head dislocation. The basic principle of treatment hinges upon anatomical reduction and fixation of the ulnar fracture, which will result in radial head reduction in the great majority of cases without needing a dedicated approach to the radial head. Failure of the radial head to reduce may be secondary to interposed annular ligament, joint capsule, or osteochondral fragments. Malunion of the ulna and failure to achieve reduction of the radial head may lead to valgus instability of the elbow, arthritis at the radiohumeral joint and proximal radioulnar joint, and restricted forearm rotation.12Ring D. Jupiter J.B. Waters P.M. Monteggia fractures in children and adults.J Am Acad Orthop Surg. 1998; 6: 215-224Crossref PubMed Scopus (113) Google Scholar, 13Bado J.L. The Monteggia lesion.Clin Orthop Relat Res. 1967; 50: 71-86Crossref PubMed Google Scholar, 15Bae D.S. Successful strategies for managing Monteggia injuries.J Pediatr Orthop. 2016; 36: S67-S70Crossref Scopus (20) Google Scholar The Essex-Lopresti injury occurs with a constellation of injuries at all 3 forearm stabilizing structures: the radial head, the IOM, and the DRUJ (TFCC).16Essex-Lopresti P. Fractures of the radial head with distal radio-ulnar dislocation: report of two cases.J Bone Joint Surg Br. 1951; 33: 244-247Google Scholar Classification of these injuries was described by Edwards and Jupiter17Edwards Jr., G.S. Jupiter J.B. Radial head fractures with acute distal radioulnar dislocation. Essex-Lopresti revisited.Clin Orthop Relat Res. 1988; 234: 61-69Crossref PubMed Google Scholar as type I (associated with radial head fracture with a large fragment amenable to open reduction internal fixation), type II (associated with a fracture of the radial head that is not reconstructable and requires replacement arthroplasty), or type III (chronic case with proximal irreducible migration of the radius). The described mechanism of injury that results in an Essex-Lopresti pattern occurs following an axial injury to the forearm with injury at the lateral elbow with a radial head fracture and/or lateral-sided elbow ligament injury, the forearm with IOM disruption, and at the wrist with disruption of the DRUJ and a tear of the TFCC. The issues with forearm longitudinal instability may be evident acutely or alternatively present over time in the chronic setting, classically following radial head excision. The end result, however, is the same. The clinical problems associated with Essex-Lopresti injury include wrist pain secondary to ulnar impaction, forearm instability and pain secondary to longitudinal instability of the radius and ulna, and pain at the lateral elbow due to radiocapitellar impingement.1Gofton W.T. Gordon K.D. Dunning C.E. Johnson J.A. King G.J. Soft-tissue stabilizers of the distal radioulnar joint: an in vitro kinematic study.J Hand Surg Am. 2004; 29: 423-431Abstract Full Text Full Text PDF PubMed Scopus (105) Google Scholar, 16Essex-Lopresti P. Fractures of the radial head with distal radio-ulnar dislocation: report of two cases.J Bone Joint Surg Br. 1951; 33: 244-247Google Scholar, 18Brockman E.P. Two cases of disability at the wrist-joint following excision of the head of the radius.Proc R Soc Med. 1931; 24: 904-905PubMed Google Scholar, 19Hotchkiss R.N. An K.N. Sowa D.T. Basta S. Weiland A.J. An anatomic and mechanical study of the interosseous membrane of the forearm: pathomechanics of proximal migration of the radius.J Hand Surg Am. 1989; 14: 256-261Abstract Full Text PDF PubMed Scopus (248) Google Scholar, 20Sellman D.C. Seitz Jr., W.H. Postak P.D. Greenwald A.S. Reconstructive strategies for radioulnar dissociation: a biomechanical study.J Orthop Trauma. 1995; 9: 516-522Crossref PubMed Scopus (86) Google Scholar There is no universal consensus upon the optimal treatment of the Essex-Lopresti injury. However, there is good evidence that early recognition and intervention improves the ultimate outcome. Trousdale and colleagues21Troudale R.T. Amadio P.C. Cooney W.P. Morrey B.F. Radio-ulnar dissociation. A review of twenty cases.J Bone Joint Surg Am. 1992; 74: 1486-1497Crossref Scopus (140) Google Scholar found that, in patients in whom the diagnosis was made acutely and treatment initiated acutely, 4 of 5 patients had a satisfactory result whereas in 15 patients with delayed diagnosis and treatment (average, nearly 8 years), satisfactory results were found in only 3 of those 15 patients. Therefore, in the acute setting, optimal treatment is predicated upon recognition. A high suspicion for injury in the forearm axis should be held. The common orthopedic caveat to “examine a joint above and below” the obvious injury is appropriate to remember. Thus, patients presenting with an acute lateral-sided elbow joint injury should have inspection and palpation of the forearm and wrist. Occasionally the true extent of injuries is not recognized by the patient owing to a “distracting injury” or is not queried, examined, or inspected by the physician. In a series of 106 referral cases seen by Adams and colleagues,5Adams J.E. Culp R.W. Osterman A.L. Interosseous membrane reconstruction for the Essex-Lopresti injury.J Hand Surg Am. 2010; 35: 129-136Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar the correct diagnosis was made prior to referral in only 38%, and in another series, the diagnosis was delayed on average for a period of 7.92 years after injury.21Troudale R.T. Amadio P.C. Cooney W.P. Morrey B.F. Radio-ulnar dissociation. A review of twenty cases.J Bone Joint Surg Am. 1992; 74: 1486-1497Crossref Scopus (140) Google Scholar If, however, in the acute setting, examination reveals tenderness, appropriate radiographs may be obtained. In patients with a diagnosis of an acute Essex-Lopresti injury, management of the elbow, forearm, and wrist components is undertaken. The radial head is reconstructed with open reduction and internal fixation or replaced with metallic prosthetic arthroplasty and the lateral-sided ligaments restored. Radial head resection in the presence of an acute Essex-Lopresti lesion is to be avoided. The radial pull test can help determine the status of the forearm stabilizers during surgery, in the presence of an unreconstructable radial head, to determine if radial head excision is an option or if the radial head should be replaced. In the patient with an unreconstructable radial head, the radial head is excised and 20 pounds of in-line traction placed on the radial neck while examining the wrist fluoroscopically, specifically, inspecting for a change in ulnar variance. A change of 3 mm or more in the ulnar variance indicates disruption of the IOM, while a change of 6 mm or more indicates disruption of both the IOM and the TFCC.22Smith A.M. Urbanosky L.R. Castle J.A. Rushing J.T. Ruch D.S. Radius pull test: predictor of longitudinal forearm instability.J Bone Joint Surg Am. 2002; 84: 1970-1976Crossref PubMed Scopus (101) Google Scholar At the wrist, the DRUJ is reduced and stabilized by repair of the TFCC. A variety of treatment options have been proposed for the forearm, ranging from observation, interosseous ligament repair, stabilization via immobilization with pinning or orthosis fabrication, or ligament reconstruction or augmentation, which are described in detail later in the chronic setting. If treatment of the forearm axis instability is addressed with stabilization of the DRUJ and radial head replacement, some argue that this allows the forearm to be positioned and stabilized such that healing of the IOM may occur, which seems to be at least somewhat supported by the finding that early recognition and treatment has a far better outcome than treatment in the delayed setting.21Troudale R.T. Amadio P.C. Cooney W.P. Morrey B.F. Radio-ulnar dissociation. A review of twenty cases.J Bone Joint Surg Am. 1992; 74: 1486-1497Crossref Scopus (140) Google Scholar In the chronic setting, the issues are ulnar impaction syndrome from ulnar-positive variance, radiocapitellar pain and impingement, and forearm pain, weakness, and/or instability. Typically in the chronic setting, treatment involves a joint-leveling procedure at the wrist (usually an ulnar-shortening osteotomy), addressing the elbow pain with a procedure at the elbow, and often but not always, a procedure to reconstruct the IOM of the forearm.23Failla J.M. Jacobson J. van Holsbeeck M. Ultrasound diagnosis and surgical pathology of the torn interosseous membrane in forearm fractures/dislocations.J Hand Surg Am. 1999; 24: 257-266Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar, 24Osterman AL, Warhold L, Culp RW, Bednar JM. Reconstruction of the interosseous membrane using a bone-ligament-bone graft. Paper presented at: 52nd Annual Meeting of the American Society for Surgery of the Hand; September 11–13, 1997; Denver CO.Google Scholar, 25Grassmann J.P. Hakimi M. Gehrmann S.V. et al.The treatment of acute Essex-Lopresti injury.Bone Joint J. 2014; 96: 1385-1391Crossref Scopus (29) Google Scholar, 26Ruch D.S. Chang D.S. Koman L.A. Reconstruction of longitudinal stability of the forearm after disruption of interosseous ligament and radial head excision (Essex-Lopresti lesion).J South Orthop Assoc. 1999; 8: 47-52PubMed Google Scholar, 27Pfaeffle H.J. Stabile K.J. Li Z.M. Tomaino M.M. Reconstruction of the interosseous ligament unloads metallic radial head arthroplasty and the distal ulna in cadavers.J Hand Surg Am. 2006; 31: 269-278Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar, 28Pfaeffle H.J. Stabile K.J. Li Z.M. Tomaino M.M. Reconstruction of the interosseous ligament restores normal forearm compressive load transfer in cadavers.J Hand Surg Am. 2005; 30: 319-325Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar, 29Tomaino M.M. Pfaeffle J. Stabile K. Li Z.M. Reconstruction of the interosseous ligament of the forearm reduces load on the radial head in cadavers.J Hand Surg Br. 2003; 28: 267-270Crossref PubMed Scopus (61) Google Scholar, 30Chloros G.D. Wiesler E.R. Stabile K.J. Papadonikolakis A. Ruch D.S. Kuzma D.R. Reconstruction of Essex-Lopresti injury of the forearm: technical note.J Hand Surg Am. 2008; 33: 124-310Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar Controversies remain regarding how best to address the problems at the elbow and forearm. Radial head allograft has been proposed; however, results are unpredictable.31Karlstad R. Morrey B.F. Cooney W.P. Failure of fresh-frozen radial head allografts in the treatment of Essex-Lopresti injury. A report of four cases.J Bone Joint Surg Am. 2005; 87: 1828-1833Crossref PubMed Scopus (32) Google Scholar, 32Szabo R.M. Hotchkiss R.N. Slater Jr., R.R. 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 Am. 1997; 22: 269-278Abstract Full Text PDF PubMed Scopus (73) Google Scholar Although prosthetic radial head replacement at the elbow results in improved load transmission, use of a radial head replacement alone in the setting of IOM disruption is not adequate to restore distal ulnar contact pressures to those seen in the intact forearm.33Tejwani S.G. Markolf K.L. Benhaim P. Graft reconstruction of the interosseous membrane in conjunction with metallic radial head replacement: a cadaveric study.J Hand Surg Am. 2005; 30: 335-342Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar, 34Markolf K.L. Tejwani S.G. O'Neil G. Benhaim P. Load-sharing at the wrist following radial head replacement with a metal implant. A cadaveric study.J Bone Joint Surg Am. 2004; 86: 1023-1030Crossref PubMed Scopus (28) Google Scholar, bEssex Lopresti Injury: Radial Head Replacement and/or Ulna Shortening [See Video]. Trail IA. Talk presented at: American Society for Surgery of the Hand Annual Meeting: October 3-5, 2013; San Francisco, CA. Also available on Hand-e: http://www.assh.org/Hand-e.Google Scholar In addition, concern exists over the implications of metallic wear on the already abnormal capitellar cartilage; thus, radiocapitellar replacement arthroplasty has been used in the setting of chronic Essex-Lopresti instability in select cases with gratifying outcomes.35Heijink A. Morrey B.F. Cooney III, W.P. Radiocapitellar hemiarthroplasty for radiocapitellar arthritis: a report of three cases.J Shoulder Elbow Surg. 2008; 17: e12-e15Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar Others argue that, in the chronic setting, removal of the radial head to remove the source of impingement together with forearm reconstruction and a joint-leveling procedure at the wrist is one solution.24Osterman AL, Warhold L, Culp RW, Bednar JM. Reconstruction of the interosseous membrane using a bone-ligament-bone graft. Paper presented at: 52nd Annual Meeting of the American Society for Surgery of the Hand; September 11–13, 1997; Denver CO.Google Scholar At the forearm, various strategies have been employed including attempted direct repair, immobilization, augmentation, or reconstruction. The ultimate salvage, however, is a 1-bone forearm. Direct repair, particularly in the acute setting, has been proposed, but others suggest that these may be midsubstance tears with limited capability for repair or intrinsic healing due to interposition of soft tissues and difficulty with immobilization.23Failla J.M. Jacobson J. van Holsbeeck M. Ultrasound diagnosis and surgical pathology of the torn interosseous membrane in forearm fractures/dislocations.J Hand Surg Am. 1999; 24: 257-266Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar, 24Osterman AL, Warhold L, Culp RW, Bednar JM. Reconstruction of the interosseous membrane using a bone-ligament-bone graft. Paper presented at: 52nd Annual Meeting of the American Society for Surgery of the Hand; September 11–13, 1997; Denver CO.Google Scholar, cEssex Lopresti Injury: Reconstructive Techniques – Interosseous Membrane Repair & Dissipation of Load [See Video]. Watts A. Talk presented at: American Society for Surgery of the Hand Annual Meeting: October 3-5, 2013; San Francisco, CA. Also available on Hand-e: http://www.assh.org/Hand-e.Google Scholar Augmentation or reconstruction of the IOM has been described with use of a variety of materials, including palmaris longus, bone-ligament-bone from patellar tendon, a strip of the pronator tendon, suture button configurations, flexor carpi radialis, and Achilles allograft.5Adams J.E. Culp R.W. Osterman A.L. Interosseous membrane reconstruction for the Essex-Lopresti injury.J Hand Surg Am. 2010; 35: 129-136Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar, 20Sellman D.C. Seitz Jr., W.H. Postak P.D. Greenwald A.S. Reconstructive strategies for radioulnar dissociation: a biomechanical study.J Orthop Trauma. 1995; 9: 516-522Crossref PubMed Scopus (86) Google Scholar, 28Pfaeffle H.J. Stabile K.J. Li Z.M. Tomaino M.M. Reconstruction of the interosseous ligament restores normal forearm compressive load transfer in cadavers.J Hand Surg Am. 2005; 30: 319-325Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar, 29Tomaino M.M. Pfaeffle J. Stabile K. Li Z.M. Reconstruction of the interosseous ligament of the forearm reduces load on the radial head in cadavers.J Hand Surg Br. 2003; 28: 267-270Crossref PubMed Scopus (61) Google Scholar, 30Chloros G.D. Wiesler E.R. Stabile K.J. Papadonikolakis A. Ruch D.S. Kuzma D.R. Reconstruction of Essex-Lopresti injury of the forearm: technical note.J Hand Surg Am. 2008; 33: 124-310Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar, 36Skahen III, J.R. Palmer A.K. Werner F.W. Fortino M.D. Reconstruction of the interosseous membrane of the forearm in cadavers.J Hand Surg Am. 1997; 22: 986-994Abstract Full Text PDF PubMed Scopus (93) Google Scholar, cEssex Lopresti Injury: Reconstructive Techniques – Interosseous Membrane Repair & Dissipation of Load [See Video]. Watts A. Talk presented at: American Society for Surgery of the Hand Annual Meeting: October 3-5, 2013; San Francisco, CA. Also available on Hand-e: http://www.assh.org/Hand-e.Google Scholar Regardless of the specific material used for augmentation or reconstruction, typically the procedure involves placing the graft via 2 incisions to replicate the position and orientation of the CB of the IOM in the arm. Typically, in the chronic setting, an ulnar-shortening osteotomy has been performed, and the surgeon can use that incision for the more distal and ulnar incision. Some grafts are secured via a screw through bone whereas others are attached with a suture anchor or bony tunnel. Passage of the graft may be achieved by placing a large Kelly clamp under the extensor tendons and over the IOM, or drilling with a guide pin or drill oriented from distal-ulnar to proximal-radial at approximately 21° of angulation to the forearm in order to replicate the orientation of the fibers of the CB of the IOM. A counterincision is made over the radius at the interval between the brachioradialis and the extensor carpi radialis longus. The superficial radial nerve is identified and protected and the graft is passed. Typically, the graft is placed under tension with the forearm in semisupination and axial loading under fluoroscan visualization at the wrist and elbow confirms stability. The ultimate salvage for a painful and unstable forearm is creation of a 1-bone forearm.dOne Bone Forearm [See Video]. Hayton M. Talk presented at: American Society for Surgery of the Hand Annual Meeting: October 3-5, 2013; San Francisco, CA. Also available on Hand-e: http://www.assh.org/Hand-e.Google Scholar Complications following this procedure are frequent. A high reoperation rate can be anticipated and the sacrifice of forearm rotation is functionally limiting. Techniques vary, but typically, the position of forearm rotation is chosen to be neutral to slight pronation.37Jacoby S.M. Bachoura A. Diprinzio E.V. Culp R.W. Osterman A.L. Complications following one-bone forearm surgery for posttraumatic forearm and distal radioulnar joint instability.J Hand Surg Am. 2013; 38: 976-982Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar, 38Peterson II, C.A. Maki S. Wood M.B. Clinical results of the one bone forearm.J Hand Surg Am. 1995; 20: 609-618Abstract Full Text PDF PubMed Scopus (101) Google Scholar eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJlYzdjYzRlMGEwY2VjNjI3OWMzMTJkZTdkZmUzZTUyYiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc5MDM0Mzg3fQ.bCvU0l9nsrRIkXtOThQXTGmOFFR_eMBOasFGyGpWz9IxFsZm_rTa_lwdDfHaPK9TzPstG04Slv1ZbP4K49nT9kC0R1fq5aT5xKBtkKDiJlB2cklB6vp_W1KTHGWgT7pONSPbnc-RhCab-AFDhBLeAbcQXIrQTbp-7vlmSDdLyilYlXRa0VdOMlScPDSyOx-MD-FjuJemJbouNfRB0kiT7rTGwLLBoODYVtWrwO0G0mhJUoC9w3Bkeny9PQJWHOYW0c4bAJJlp1JHFS5h2QQrrQYbGNwumE-OR-k3ou53NJuT7MZ3WwQtzWuqTZNhDkqueWYGYdcSevkqKRdbNrTvhw Download .mp4 (41.41 MB) Help with .mp4 files Video AeyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI5NTEwOTcwM2UxZWQwNWQzOGRmOTM3ZTkyZGJjOTM0OCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc5MDM0Mzg3fQ.nfwfFkW_IbtY-5ZG73jtX8rt68NGVdwdLSd-nC8kufjBpR7gmnvDmlRokCp22OV7DnoUBaLyLHH71bzHVTQV3LOfhkO2Igt9ovbngQiEsidZAv6NOx_U5jCEUHC7gIhqS9feloeXTN3IjIIeswvHwytnxIGcpaBjgxsdtQfXzZ6zrBMfnSy0Fr8ilxX1yBHXMiuKQ50AKdcZm0PX70chPu59gmK81rTsq06RlLe_Un-1YT3-umWD1nPYnul0sl0N85UV9WVnfW8r3QtkLmQXidUAkKwX0jFX4hnmCD3mTER4Qte-KU6IOkL1eudCQ7hTUlbRhGKu7uafng65lsNfJQ Download .mp4 (15 MB) Help with .mp4 files Video BeyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI2NTdiOWNkMDhhMjg2OGI5NzdhYzZiYmIyOWRhYTYwMiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc5MDM0Mzg3fQ.R6kTw99dcKfSYP5CSji2KnPeEjcJYwvUyCw7rpISx_MbA0TBvEuAMbdrFfdJ39UT-CboAC3nKvHBlhPOScaX-kScNyDgFJoaK3AVwfijE2eEv-l16HE2EdHYVjvm1OnRfVwgqK2bcyip6jemqBFNZDN1ogmPOk7DhpWTTen9cLT0I97qbbQavI0Xx5sGg2GskNmM9xq8CIjdTUFTrPCKSpYCZyJzYHWPU3R494Rs0MtCK9o8TnA_x-qMznCSHn5YFH-kSnmP7hkxq_Qd7bu5hUiD2Cuw75F1-jCUDN1VX-Q9_FsdJ9jioLKaEgmLAqx7lP824NVUNQSnZZ-XaL_vwQ Download .mp4 (26.02 MB) Help with .mp4 files Video CeyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJmYmM2Zjg1ODAzNTRmNzUxOTM3OTgzYWZiYmUwYTRmZSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc5MDM0Mzg3fQ.PA2w2GY-Yb4pUT3L4J2LL9mRlqFmOIB4-3QImgvfnION8IqUbX5Rnw9oCntNkyXDuCdGP9YfEBUB162BOHp9o2AlSKGP3wr3HXIm_s3j0v5Kz_Ly07uqwyk4cGc1McZhcJZsAKOCNn_SXjNw7r-kardx3RhXSm0KDxJ9NSMMreoY0SMlzVXDoqDNf1BozBKnQnka9zka7u9shdOUrA0mpe8vppfOV2SXvl19YkDTHSqAofQzWGQuOtAULBHZd1YT9t7W4j8xWhgr9jJ3MIEbI00uxWbREUweXqhMs7q9VSpPADvyuHEdzmos-XX4bMWx0BDXyXvabtF-yBi-3ZVX_w Download .mp4 (18.04 MB) Help with .mp4 files Video D Journal CME QuestionsJournal of Hand SurgeryVol. 42Issue 1Preview Full-Text PDF" @default.
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