Longitudinal Instability of the Forearm: Anatomy, Biomechanics, and Treatment Considerations

Sabo, Marlis T.; Watts, Adam C.

doi:10.1111/j.1758-5740.2011.00172.x

“…If distal radioulnar instability is not adequately appreciated and managed then chronic wrist symptoms, such as pain and instability, can develop 6 8 9. Distal arm pain should not simply be dismissed as referred pain 10. As such, a detailed examination and radiographs of the elbow, forearm and wrist should be conducted when Essex-Lopresti injuries are suspected 6.…”

Section: Discussionmentioning

confidence: 99%

“…This is essential as impairment of reduction can result in loss of forearm rotation, grip strength and function 11. In addition to this, maintenance of appropriate length relationships of the radius and the ulna are essential for load bearing and sharing 10. Stability of both the PRUJ and DRUJ should be directly verified under fluoroscopy and further addressed if indicated 12…”

Section: Discussionmentioning

confidence: 99%

An uncommon Essex-Lopresti fracture dislocation with radial displacement in distal direction: diagnosis and surgical treatment of a rare case

Hii

¹

,

Page

²

,

Prosser

³

et al. 2013

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Essex-Lopresti injuries are rare and present a clinical challenge. Incomplete diagnosis and treatment can lead to long-term instability, pain and functional impairment. We report on a clinical case of proximal radioulnar joint (PRUJ) and distal radioulnar joint (DRUJ) dislocation with unusual distal radial displacement and associated radial head shear fracture. The case was managed with closed reduction of the PRUJ and DRUJ followed by open reduction and fixation of the radial head. A high index of suspicion with thorough examination of the elbow, forearm and wrist and comprehensive imaging was important in reaching a complete diagnosis for appropriate treatment. Anatomical reduction of the PRUJ and DRUJ is essential to achieve optimal functional outcomes. Six months following the injury the patient made a satisfactory recovery with full range of movement; however, she continued to have mild to moderate general and moderate work-related disability.

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“…

We read with interest the recent review article by Sabo and Watts on 'Longitudinal instability of the forearm: anatomy, biomechanics, and treatment considerations' [1]. We commend the authors on their review, but would like to discuss some issues arising from this work.

…”

mentioning

confidence: 99%

Re: ‘Longitudinal Instability of the Forearm: Anatomy, Biomechanics, and Treatment Considerations’

Duckworth

¹

,

McQueen

²

2012

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We read with interest the recent review article by Sabo and Watts on 'Longitudinal instability of the forearm: anatomy, biomechanics, and treatment considerations' [1]. We commend the authors on their review, but would like to discuss some issues arising from this work. First, we would suggest that the degree of radial shortening indicative of an Essex-Lopresti lesion is debated throughout the literature, with values ranging from 2 mm to 1 cm [2,3]. Interestingly, the authors do not appear to discuss the commonly used intraoperative assessment of Essex-Lopresti lesions using the push-pull test (axial traction and compression of the hand and wrist looking for a more than 3 mm change in the distance between the radial neck and the capitellum) after radial head excision as a test for the diagnosis of interosseous ligament injury and forearm instability [4].We would also like to highlight some notable inaccuracies regarding the authors' discussion of our paper [5]. Our study documented that 60 of 237 patients had wrist and forearm pain 6 weeks after an ipsilateral radial head fracture, but only 22 (9%) had radial shortening of more than 2 mm (not 30% as the authors suggest) [5]. Furthermore, only one patient underwent operative intervention for a suspected true Essex-Lopresti lesion that was confirmed intraoperatively, which we state clearly in our paper. This would indicate a true incidence of less than 1%, consistent with the other available literature [6,7]. Radiographic follow-up was collected for all patients until discharge.Unlike the suggestion of Sabo and Watts, the primary findings of our paper were not to challenge the incidence of longitudinal instability or to determine the degree of shortening suggestive of an Essex-Lopresti lesion as we state. We feel that our study provides useful evidence that approximately 10% of patients with a fracture of the radial head may present with associated wrist pain and a degree of radial shortening, however, over 90% are not complete or true Essex-Lopresti lesions that do well with conservative management. Our paper adds to previous work examining the less complex fractures of the proximal radius and the potential association with a spectrum of Essex-Lopresti lesions [8,9], and we strongly disagree that describing these injuries as a spectrum is misleading. Furthermore, the concept of a spectrum of injury increases the index of suspicion for these lesions, as Sabo and Watts suggest themselves, particularly when associated with increasing fracture complexity and higher energy injuries [9,10]. References 1. Sabo MT, Watts AC. Longitudinal instability of the forearm: anatomy, biomechanics, and treatment considerations. Shoulder Elbow 2012; 4:119-26. 2. McGinley JC, Kozin SH. Interosseous membrane anatomy and functional mechanics. Clin Orthop Relat Res 2001; 383:108-22. 3. Dodds SD, Yeh PC, Slade JF III. Essex-lopresti injuries. HandClin 2008; 24:125-37. 4. Smith AM, Urbanosky LR, Castle JA, Rushing JT, Ruch DS. Radius pull test: predictor of longitudinal forearm instability...

show abstract

“…We read with interest the recent review article by Sabo and Watts on ‘Longitudinal instability of the forearm: anatomy, biomechanics, and treatment considerations' [1]. We commend the authors on their review, but would like to discuss some issues arising from this work.…”

mentioning

confidence: 99%

Re: ‘Longitudinal instability of the forearm: anatomy, biomechanics, and treatment considerations’

Duckworth

¹

,

McQueen

²

2012

Shoulder &Amp; Elbow

View full text Add to dashboard Cite

We read with interest the recent review article by Sabo and Watts on 'Longitudinal instability of the forearm: anatomy, biomechanics, and treatment considerations' [1]. We commend the authors on their review, but would like to discuss some issues arising from this work. First, we would suggest that the degree of radial shortening indicative of an Essex-Lopresti lesion is debated throughout the literature, with values ranging from 2 mm to 1 cm [2,3]. Interestingly, the authors do not appear to discuss the commonly used intraoperative assessment of Essex-Lopresti lesions using the push-pull test (axial traction and compression of the hand and wrist looking for a more than 3 mm change in the distance between the radial neck and the capitellum) after radial head excision as a test for the diagnosis of interosseous ligament injury and forearm instability [4].We would also like to highlight some notable inaccuracies regarding the authors' discussion of our paper [5]. Our study documented that 60 of 237 patients had wrist and forearm pain 6 weeks after an ipsilateral radial head fracture, but only 22 (9%) had radial shortening of more than 2 mm (not 30% as the authors suggest) [5]. Furthermore, only one patient underwent operative intervention for a suspected true Essex-Lopresti lesion that was confirmed intraoperatively, which we state clearly in our paper. This would indicate a true incidence of less than 1%, consistent with the other available literature [6,7]. Radiographic follow-up was collected for all patients until discharge.Unlike the suggestion of Sabo and Watts, the primary findings of our paper were not to challenge the incidence of longitudinal instability or to determine the degree of shortening suggestive of an Essex-Lopresti lesion as we state. We feel that our study provides useful evidence that approximately 10% of patients with a fracture of the radial head may present with associated wrist pain and a degree of radial shortening, however, over 90% are not complete or true Essex-Lopresti lesions that do well with conservative management. Our paper adds to previous work examining the less complex fractures of the proximal radius and the potential association with a spectrum of Essex-Lopresti lesions [8,9], and we strongly disagree that describing these injuries as a spectrum is misleading. Furthermore, the concept of a spectrum of injury increases the index of suspicion for these lesions, as Sabo and Watts suggest themselves, particularly when associated with increasing fracture complexity and higher energy injuries [9,10]. References 1. Sabo MT, Watts AC. Longitudinal instability of the forearm: anatomy, biomechanics, and treatment considerations. Shoulder Elbow 2012; 4:119-26. 2. McGinley JC, Kozin SH. Interosseous membrane anatomy and functional mechanics. Clin Orthop Relat Res 2001; 383:108-22. 3. Dodds SD, Yeh PC, Slade JF III. Essex-lopresti injuries. HandClin 2008; 24:125-37. 4. Smith AM, Urbanosky LR, Castle JA, Rushing JT, Ruch DS. Radius pull test: predictor of longitudinal forearm instability...

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Longitudinal Instability of the Forearm: Anatomy, Biomechanics, and Treatment Considerations

Cited by 9 publications

References 57 publications

An uncommon Essex-Lopresti fracture dislocation with radial displacement in distal direction: diagnosis and surgical treatment of a rare case

An uncommon Essex-Lopresti fracture dislocation with radial displacement in distal direction: diagnosis and surgical treatment of a rare case

Re: ‘Longitudinal Instability of the Forearm: Anatomy, Biomechanics, and Treatment Considerations’

Re: ‘Longitudinal instability of the forearm: anatomy, biomechanics, and treatment considerations’

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