Keywords Essex-Lopresti injury, longitudinal unstable radial head fracture of forearm, lower ulnar radial joint injury, Department of Orthopedics, Baicheng Central Hospital, Liu Xiang
1. Clinical data
1.1 General information Male patient, 44 years old. He was admitted to the hospital for about 2 hours with pain and limitation of movement in the right wrist and right elbow due to a fall injury from a height. On examination, the right elbow joint was swollen laterally, and the radial head was positive for pressure pain, with palpable bone rubbing and abnormal activity. The right forearm rotation function was limited, the right wrist joint was radially deformed, the ulnar head was positive for floating sensation, positive for “piano key syndrome”, and positive for pressure pain in the ulnar radial space and lower ulnar radial joint. The active flexion and extension of the right elbow and wrist were limited, and the forearm rotation was mildly limited, while the posterior rotation was significantly limited. Auxiliary examination: X-ray showed that the right radial head was comminuted fracture, the radius was displaced proximally, the lower ulnar radial joint gap was enlarged, the radius was shortened, the ulnar head was displaced dorsally, and the distal articular surface of the ulnar radius was stepped. Three-dimensional CT of the elbow joint showed a comminuted fracture of the right radial head with anterolateral displacement of the fracture. Admission diagnosis: Essex-Lopresti injury (Edwards typing type I)
1.2 Surgical method After brachial plexus anesthesia took effect, the surgical area and the skin of the affected limb were routinely disinfected with strong iodine, a sterile surgical towel was laid, and a tourniquet was driven on with appropriate pressure. The Kocher incision was made at the right elbow joint, about 6.0 cm long, and the interosseous muscle gap between the elbow and ulnar carpal extensor muscles was identified on the distal side of the incision, and the deep fascia was incised along the muscle gap. Protection. The annular ligament and joint capsule were incised longitudinally on the anterior side of the ulnar collateral ligament to form anterior and posterior flaps, and the joint cavity was exposed with two stitches of fine silk suture on each side; the radial head was crushed and completely displaced into three free fracture blocks, which were not connected with the joint capsule and synovial membrane, and the three fracture blocks were spliced in vitro, and the joint surface was fixed with 2.0 mm diameter screws under the articular surface to keep the joint surface intact and level. The three fracture blocks were fixed under the articular surface with 2.0 mm diameter screws to maintain the integrity and flatness of the articular surface. (Specifically: the shortest safe range of the lateral proximal radius segment revealed is 2.2 M when the forearm is fully rotated posteriorly; the shortest safe range of the lateral proximal radius segment revealed is 3.8 M when the forearm is fully rotated anteriorly). End of fixation of the radial head fracture. When the ulnar head was pressed, the “lymphoid” was positive, the floating sensation was obvious, and the ulnar head was still dislocated to the dorsal side, ulnar deviation traction of the wrist was performed, and the dislocated lower ulnar radial joint was repositioned by pulling down on the ulnar head, and two 2.0 mm kerf pins were fixed percutaneously on the proximal side of the lower ulnar radial joint in the posterior rotation position, and the C-arm fluoroscopy showed that the lower ulnar radial joint was well repositioned The lower ulnar radial joint was fixed in the posterior position. The lower ulnar radial joint was well repositioned on C-arm fluoroscopy.
2. Results
In this case, the pin fixing the lower ulnar radial joint was removed at 4 weeks after surgery, and the external plaster fixation was removed at 5 weeks, and functional exercises of the wrist and elbow were performed under the guidance of the physician. The patient’s limb was gradually weight-bearing exercises 2 months after surgery, and the review radiograph showed anatomical repositioning of the radial head fracture with blurred fracture line and normal position of the lower ulnar radial joint; the active flexion and extension activities of the elbow and wrist joints were normal; the right forearm was rotated 80° anteriorly and 60° posteriorly with mild limitation; there was no obvious pain and no significant difference in muscle strength compared with the healthy side, and the treatment effect was satisfactory.
3. Discussion
The triad of fracture of the radial head or neck, interosseous injury combined with dislocation of the inferior radial-ulnar joint (including injury to the triangular fibrocartilage complex) is known as Essex-Lopresti injury. 1931 Brockrnan first reported a case of delayed proximal displacement of the radius in a patient with this injury. In 1951, Essex-Lopresti reported two patients with acute radial head fractures combined with dislocation of the lower ulnar radial joint and found that: (1) the mechanism of injury to the lower ulnar radial joint, forearm interosseous membrane, and radial head is transmitted from inferior to superior longitudinal violence and there is longitudinal instability; (2) the forearm interosseous membrane and lower ulnar radial joint The clinical manifestations of the injury are insidious, often leading to underdiagnosis and misdiagnosis; (3) if the radial head is removed, displacement of the radius to the proximal end can occur quickly, resulting in wrist pain due to ulnar-wrist impingement and elbow pain due to impingement of the radius and humeral head, hence the name Essex-Lopresti for such injuries. The mechanism of injury is mostly wrist abduction, elbow flexion or extension, forearm rotation forward, valgus and longitudinal violence. A severe fall with the upper extremity extended can result in fracture of the radial head or radial neck, injury to the distal ulnar radial joint and tearing of a long proximal interosseous membrane. Longitudinal instability of the forearm due to fracture of the radial head and interosseous tear is present. The ulnar radius is connected by the interosseous membrane of the forearm, which consists of a thin membranous portion and a thick tendinous portion (the central band). The central zone accounts for the middle third of the interosseous structure and is responsible for most of the stresses on the interosseous membrane. Proximally to the interosseous membrane, there is a tendinous oblique cord in the form of a flat band that starts at the lateral edge of the ulnar ridge and ends obliquely downward slightly below the radial ridge. The clinical interosseous injury is not a tear of the bone attachment but a tear of the central band, and the interosseous membrane acts as a redistributor of stress in the forearm, allowing stress to be further distributed in the proximal ulnar radius, with the stress distribution varying with rotation of the forearm. The triangular fibrocartilage complex is a complex of several ligaments on the ulnar side of the wrist, which also plays a very important role in the stability of the inferior ulnar radial ligament. The longitudinal stability of the forearm is mainly maintained by the radius, with the interosseous membrane and the triangular fibrocartilage complex being secondary stabilizing factors. When the radial tuberosity is removed the central bundle of the interosseous membrane is the predominant structure preventing displacement of the radius proximally, acting as a ligament-like structure providing longitudinal stability of the radius. The incidence of Essex-Lopresti injuries is extremely low, and it is estimated that radial head fractures account for about 6% of elbow fractures, while Essex-Lopresti injuries account for only 1% of radial head fractures, and the high rate of first misdiagnosis is one of its main features. Because of the serious consequences of these injuries, standard ortho-lateral radiographs of the full length of the wrist or forearm should be taken in suspected cases of these injuries to prevent missed diagnoses and misdiagnosis. On standard orthopantomographs, an injury to the lower ulnar radial joint can be considered when the affected ulnar orthogonal variation exceeds 2 mm (including 2 mm) on the healthy side, and a complete rupture of the interosseous membrane is indicated when it exceeds 7 mm on the healthy side.
Most of the previous cases of comminuted radial head fractures were performed early with simple radial head resection, but radial head resection can cause many complications, including elbow pain, elbow and wrist instability, new bone formation at the resected end, proximal displacement of the radius, lower ulnar radial joint subluxation, enlarged elbow valgus, and delayed ulnar neuritis. Therefore, the presence of forearm interosseous membrane and lower ulnar radial joint injury is the first issue that must be considered before treating radial head fracture, if there is forearm interosseous membrane and lower ulnar radial joint injury then radial head resection is contraindicated, it is very important to preserve the integrity of the radial head to maintain the radial length and humeral radial joint relationship and ensure the longitudinal stability of the forearm. The basic treatment principle of this disease is to restore or reconstruct the radial length, while repositioning and stabilizing the inferior ulnar radial joint. If possible, internal fixation of the radial head fracture should be performed at an early stage, or if the radial head fracture is too severely comminuted for internal fixation, an artificial radial head prosthesis can be considered. Biomechanical and clinical studies in recent years have shown that the metal radial head prosthesis provides more adequate biomechanical strength than the silicone radial head prosthesis, which can not only rebuild the biomechanical stability of the elbow, but also effectively prevent the radius from shifting proximally, so it is the more recognized choice of radial head prosthesis. For lower ulnar radial joint dislocation should be reset and fixed early. After restoration of the radial length, the lower ulnar radial joint is reset and checked for stability. If stable, the forearm can be fixed in a rotated posterior position with a cast, or if unstable, it can be fixed with a 2.0-mm gristle or screw. Failla suggested the importance of a one-stage repair of the interosseous membrane in the forearm, but also pointed out that surgical attack to repair the interosseous membrane may result in arm stiffness or formation of a bridge between the ulnar and radial bones, and that although oral indomethacin was given to prevent heterotopic ossification, its effectiveness was limited in clinical practice.
Reference.
1. Jiang Xieyuan, Gong Maoqi, Tension Dan et al. Surgical treatment of displaced humeral tuberosity fractures, Chinese Journal of Medicine, 2001, 81: 293-294
2. Wang Chuanshun, Zhou Jianwei, Huang Huang Yuan. diagnosis and treatment of Essex-Lopresti injury [ J]. International Journal of Orthopaedics, 2007, 28( 1): 13-14.
3. Li T, Jiang Xieyuan, Wang Manyi. Es sex-Loprest i injury [ J ]. Chinese Journal of Orthopaedics, 2003, 23( 12): 736- 737.
4. Zhang Lidan, Jiang Xieyuan, Wang Manyi et al. Surgical internal fixation treatment of radial head fracture, Chinese Journal of Traumatic Orthopedics 7 dbbd7 %’ dd&_dU.
Author: Liu Xiang, Department of Orthopaedics, Baicheng Central Hospital, Jilin Province, China
Published in Chinese Journal of Bone and Joint Injuries