Skeletal Radiol (1992) 21 : 315-317
Skeletal Radiology
Fracture-dislocation of the elbow with inferior radioulnar dislocation: a variant of the the Essex-Lopresti injury G.W. Bock, M.D. 1, M.S. Cohen, M.D. z, and D. Resnick, M.D. 1 1 Department of Radiology, University of California San Diego, and Veterans Administration Center, San Diego, California, USA z Department of Orthopaedics, University of California San Diego Medical Ccntcr, San Diego, California, USA
Abstract. We describe two patients with an Essex-Lopresti fracture dislocation in association with a dislocation of the elbow. This combination of injuries has not been previously reported. The Essex-Lopresti fracture is a rare injury, and the associated distal radioulnar dislocation is often missed. Meticulous radiographic evaluation of the wrist, including dynamic stress radiographs of the forearm, can lead to an earlier diagnosis and improved care of these patients. Key words: Radial head fracture - F o r e a r m fracture Radioulnar dislocation
head (Fig. 1A). No neurovascular abnormalities were noted. The elbow fracture was reduced and splinted in the emergency r o o m (Fig. 1 B). Reexamination several days later revealed wrist discomfort, and additional films of the wrist showed a distal radioulnar joint disruption, proximal migration of the radius, and a concomitant, nondisplaced, scaphoid fracture (Fig. 1 C). The patient was taken to the operating r o o m where he underwent resection of the comminuted radial head fracture and reduction with pin fixation of the distal radioulnar joint. At 4 weeks after surgery, there is a significant distal radioulnar diastasis with limitation of elbow extension.
Case 2
Dislocations o f the inferior radioulnar joint associated with fractures o f the radial head are rare injuries [5, 7]. They have been well described in the orthopedic literature but have received little attention in the radiologic literature. The elbow injury, a fracture of the radial head with comminution, is easily identified. The associated distal radioulnar dislocation is often missed [3]. Two recent cases in our institution demonstrate the pitfalls in the radiologic and clinical assessment of this injury. Several methods for improved radiographic evaluation are discussed.
Case reports Case t
A 45-year-old m a n with a history of mental illness j u m p e d approximately 15 feet and landed on a concrete surface. Presenting injuries included multiple lacerations and abrasions, a cerebral contusion, and a dislocation of the elbow with a comminuted fracture of the radial Address reprint requests to: G.W. Bock, Department of Radiology,
Health Sciences Centre, 700 William Avenue Winnipeg, Manitoba, Canada R3E 023
A 23-year-old m a n fell approximately 30 feet while rock climbing. At admission, his injuries included a burst fracture of a lumbar vertebral body, a renal contusion, and a fracture-dislocation of the elbow (Fig. 2A). His neurovascular status was intact. The initial films were interpreted as showing a disruption of the distal radioulnar joint with an associated scaphoid fracture (Fig. 2 B). The patient was taken to the operating room, and the fracture of the radial head was treated with open reduction and internal fixation with Herbert screws. The distal radioulnar joint was disrupted and unstable in pronation. The injury was treated postoperatively in a long a r m cast brace in supination. At 18 months after treatment, the patient has mild limitation of elbow extension with no wrist pain or disability.
Discussion The Galeazzi and Monteggia fracture-dislocations of the forearm are well-known. The combination of a radial head fracture and distal radioulnar joint dislocation is a third fracture-dislocation of the forearm that is rare and often overlooked [3, 5, 7]. It has been referred to as the Essex-Lopresti injury after the investigator who 9 1992 International Skeletal Society
316
G.W. Bock et al. : Essex-Lopresti injury variant
Fig. 1A-C. Case 1. Initial radiograph of elbow demonstrating a comminuted radial head fracture and elbow dislocation (A). Follow-up radiograph of the elbow demonstrates reduction of elbow dislocation and comminution of radial head (B). Follow-up posteroanterior view of wrist demonstrating proximal migration of radius, disruption of radioulnar joint, and associated scaphoid fracture (arrow) (C) Fig. 2A, B. Case 2. Lateral radiograph of elbow demonstrating eomminuted radial head fracture and elbow dislocation (A). Posteroanterior radiograph of wrist demonstrating scaphoid fracture (arrows) and proximal migration of radius with disruption of radioulnar joint (B)
described two cases in 1951, although Curr and Coe in 1946 and Brockman in 1930 had reported similar injuries [~, 2]. These were the first descriptions of this complex injury. All reports indicate a similar causal mechanism. Longitudinal compression on the outstretched hand results in a comminuted radial head fracture. If the force is continued, acute proximal migration of the radius occurs (Fig. 3). Recent experimental work has shown that proximal migration of the radius can occur only if the triangular fibrocartilage complex and the interosseus membrane of the forearm have been disrupted [6, 9]. The degree of proximal migration is greater than 5 m m in these patients and occurs acutely at the time of injury. In contrast, as much as 2 m m of proximal radial migration is seen as a delayed complication after radial head fractures treated with surgical excision [8]. Clinical assessment of the wrist in patients with an Essex-Lopresti injury is often inadequate. Attention is focused on the proximal comminuted radial head fracture. Clinical clues to the identification of the associated
distal injury include tenderness or instability at the distal radioulnar joint, a prominent distal ulna, and limited ulnar deviation [3]. The radiographic evaluation is often compromised as attention is focused on the proximal radius and ulna. Accurate determination of the proximal radial migration requires properly positioned posteroanterior and lateral views of the wrist. The wrist should be radiographed with the shoulder abducted and the forearm in neutral rotation as described by Epner et al. [4]. True lateral views of the wrist will identify the commonly associated dorsal subluxation o f the distal ulna. Other fractures involving the wrist have been reported in these patients. Three of 7 cases reported by Edwards and Jupiter had associated carpal injuries [3]. These included scaphoid fractures in 2 cases, as seen in both of our patients. Although the incidence of combined radial head fractures and distal radioulnar joint injury is relatively low, it has been suggested that radiographs of the wrist be obtained in every patient with a radial head
G.W. Bock et al. : Essex-Lopresti injury variant
317 tion under load, and the radius remains displaced upon unloading. The identification of the distal radioulnar joint injury in these patients is important in determining the appropriate treatment. Failure to stabilize the distal radioulnar joint after reconstructing or replacing the radial head leads to a consistently poor outcome [3]. Careful radiographic evaluation of the wrist in seemingly isolated radial head fractures is recommended. Additional dynamic stress radiographs may be useful when an associated soft-tissue injury of the interosseous membrane and triangular fibrocartilage is clinically suspected but standard radiographs are equivocal.
~L ~IT US ULNA
References Fig. 3. Longitudinal com-
~EAD E
pression force drives radius proximally, with disruption of the distal radioulnar joint and interosseous membrane and fracture of the radial head. (Figure modified with permission from [3])
fracture [10]. I f clinical findings suggest distal injury but standard radiographs are equivocal, stress radiographs have been suggested. Mehlhoff has described an axial stress test performed with local anesthesia and sedation to evaluate the soft tissues in patients with radial head fractures [9]. Two anteroposterior radiographs of the forearm are obtained, one with the forearm under axial compression and the other with axial distraction. Isolated radial head fractures demonstrate 2-3 m m proximal migration under load with rebound to the original position upon unloading. With radial head fracture and disruption o f the interosseous membrane and the triangular fibrocartilage complex, there is 10 25 m m migra-
1. Brockman EP (1930) Two cases of disability at the wrist joint following excision of the head of the radius. Proc R Soc Med 24: 904 2. Curr JF, Coe WA (1946) Dislocation of the inferior radioulnar joint. Br J Surg 34:74 3. Edwards GS, Jupiter JB (1988) Radial head fractures with acute distal radioulnar dislocation. Clin Orthop 234:61 4. Epner RA, Bowers WH, Guilford WB (1982) Ulnar variance the effect of wrist positioning and roentgen filming technique. J Hand Surg [Am] 7:298 5. Essex-Lopresti P (1951) Fractures of the radial head with inferior radioulnar dislocation. J Bone Joint Surg [Br] 33 : 244 6. Hotchkiss RN, An K-N, 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] 14:256 7. McDougall A, White J (1957) Subluxation of the inferior ulnar joint complicating fracture of the radial head. J Bone Joint Surg [Br] 39:278 8. Morrey BF, Chao EY, Hui FC (1979) Biomechanical study of the elbow following excision of the radial head. J Bone Joint Surg [Am] 61:63 9. Reardon JP, Davidson PA, Noble PC, Kamaric E, Bell DM, Tullos HS (1991) The isolated radial head fracture. Presented at the 58th annual meeting of the American Academy of Orthopaedic Surgeons, Anaheim, California, March 7-12, 1991 10. Rockwood CA, Green DP (1984) Fractures in adults, 2nd edn. JB Lippincott, Philadelphia, p 638
Skeletal Radiology
Fracture-dislocation of the elbow with inferior radioulnar dislocation: a variant of the the Essex-Lopresti injury G.W. Bock, M.D. 1, M.S. Cohen, M.D. z, and D. Resnick, M.D. 1 1 Department of Radiology, University of California San Diego, and Veterans Administration Center, San Diego, California, USA z Department of Orthopaedics, University of California San Diego Medical Ccntcr, San Diego, California, USA
Abstract. We describe two patients with an Essex-Lopresti fracture dislocation in association with a dislocation of the elbow. This combination of injuries has not been previously reported. The Essex-Lopresti fracture is a rare injury, and the associated distal radioulnar dislocation is often missed. Meticulous radiographic evaluation of the wrist, including dynamic stress radiographs of the forearm, can lead to an earlier diagnosis and improved care of these patients. Key words: Radial head fracture - F o r e a r m fracture Radioulnar dislocation
head (Fig. 1A). No neurovascular abnormalities were noted. The elbow fracture was reduced and splinted in the emergency r o o m (Fig. 1 B). Reexamination several days later revealed wrist discomfort, and additional films of the wrist showed a distal radioulnar joint disruption, proximal migration of the radius, and a concomitant, nondisplaced, scaphoid fracture (Fig. 1 C). The patient was taken to the operating r o o m where he underwent resection of the comminuted radial head fracture and reduction with pin fixation of the distal radioulnar joint. At 4 weeks after surgery, there is a significant distal radioulnar diastasis with limitation of elbow extension.
Case 2
Dislocations o f the inferior radioulnar joint associated with fractures o f the radial head are rare injuries [5, 7]. They have been well described in the orthopedic literature but have received little attention in the radiologic literature. The elbow injury, a fracture of the radial head with comminution, is easily identified. The associated distal radioulnar dislocation is often missed [3]. Two recent cases in our institution demonstrate the pitfalls in the radiologic and clinical assessment of this injury. Several methods for improved radiographic evaluation are discussed.
Case reports Case t
A 45-year-old m a n with a history of mental illness j u m p e d approximately 15 feet and landed on a concrete surface. Presenting injuries included multiple lacerations and abrasions, a cerebral contusion, and a dislocation of the elbow with a comminuted fracture of the radial Address reprint requests to: G.W. Bock, Department of Radiology,
Health Sciences Centre, 700 William Avenue Winnipeg, Manitoba, Canada R3E 023
A 23-year-old m a n fell approximately 30 feet while rock climbing. At admission, his injuries included a burst fracture of a lumbar vertebral body, a renal contusion, and a fracture-dislocation of the elbow (Fig. 2A). His neurovascular status was intact. The initial films were interpreted as showing a disruption of the distal radioulnar joint with an associated scaphoid fracture (Fig. 2 B). The patient was taken to the operating room, and the fracture of the radial head was treated with open reduction and internal fixation with Herbert screws. The distal radioulnar joint was disrupted and unstable in pronation. The injury was treated postoperatively in a long a r m cast brace in supination. At 18 months after treatment, the patient has mild limitation of elbow extension with no wrist pain or disability.
Discussion The Galeazzi and Monteggia fracture-dislocations of the forearm are well-known. The combination of a radial head fracture and distal radioulnar joint dislocation is a third fracture-dislocation of the forearm that is rare and often overlooked [3, 5, 7]. It has been referred to as the Essex-Lopresti injury after the investigator who 9 1992 International Skeletal Society
316
G.W. Bock et al. : Essex-Lopresti injury variant
Fig. 1A-C. Case 1. Initial radiograph of elbow demonstrating a comminuted radial head fracture and elbow dislocation (A). Follow-up radiograph of the elbow demonstrates reduction of elbow dislocation and comminution of radial head (B). Follow-up posteroanterior view of wrist demonstrating proximal migration of radius, disruption of radioulnar joint, and associated scaphoid fracture (arrow) (C) Fig. 2A, B. Case 2. Lateral radiograph of elbow demonstrating eomminuted radial head fracture and elbow dislocation (A). Posteroanterior radiograph of wrist demonstrating scaphoid fracture (arrows) and proximal migration of radius with disruption of radioulnar joint (B)
described two cases in 1951, although Curr and Coe in 1946 and Brockman in 1930 had reported similar injuries [~, 2]. These were the first descriptions of this complex injury. All reports indicate a similar causal mechanism. Longitudinal compression on the outstretched hand results in a comminuted radial head fracture. If the force is continued, acute proximal migration of the radius occurs (Fig. 3). Recent experimental work has shown that proximal migration of the radius can occur only if the triangular fibrocartilage complex and the interosseus membrane of the forearm have been disrupted [6, 9]. The degree of proximal migration is greater than 5 m m in these patients and occurs acutely at the time of injury. In contrast, as much as 2 m m of proximal radial migration is seen as a delayed complication after radial head fractures treated with surgical excision [8]. Clinical assessment of the wrist in patients with an Essex-Lopresti injury is often inadequate. Attention is focused on the proximal comminuted radial head fracture. Clinical clues to the identification of the associated
distal injury include tenderness or instability at the distal radioulnar joint, a prominent distal ulna, and limited ulnar deviation [3]. The radiographic evaluation is often compromised as attention is focused on the proximal radius and ulna. Accurate determination of the proximal radial migration requires properly positioned posteroanterior and lateral views of the wrist. The wrist should be radiographed with the shoulder abducted and the forearm in neutral rotation as described by Epner et al. [4]. True lateral views of the wrist will identify the commonly associated dorsal subluxation o f the distal ulna. Other fractures involving the wrist have been reported in these patients. Three of 7 cases reported by Edwards and Jupiter had associated carpal injuries [3]. These included scaphoid fractures in 2 cases, as seen in both of our patients. Although the incidence of combined radial head fractures and distal radioulnar joint injury is relatively low, it has been suggested that radiographs of the wrist be obtained in every patient with a radial head
G.W. Bock et al. : Essex-Lopresti injury variant
317 tion under load, and the radius remains displaced upon unloading. The identification of the distal radioulnar joint injury in these patients is important in determining the appropriate treatment. Failure to stabilize the distal radioulnar joint after reconstructing or replacing the radial head leads to a consistently poor outcome [3]. Careful radiographic evaluation of the wrist in seemingly isolated radial head fractures is recommended. Additional dynamic stress radiographs may be useful when an associated soft-tissue injury of the interosseous membrane and triangular fibrocartilage is clinically suspected but standard radiographs are equivocal.
~L ~IT US ULNA
References Fig. 3. Longitudinal com-
~EAD E
pression force drives radius proximally, with disruption of the distal radioulnar joint and interosseous membrane and fracture of the radial head. (Figure modified with permission from [3])
fracture [10]. I f clinical findings suggest distal injury but standard radiographs are equivocal, stress radiographs have been suggested. Mehlhoff has described an axial stress test performed with local anesthesia and sedation to evaluate the soft tissues in patients with radial head fractures [9]. Two anteroposterior radiographs of the forearm are obtained, one with the forearm under axial compression and the other with axial distraction. Isolated radial head fractures demonstrate 2-3 m m proximal migration under load with rebound to the original position upon unloading. With radial head fracture and disruption o f the interosseous membrane and the triangular fibrocartilage complex, there is 10 25 m m migra-
1. Brockman EP (1930) Two cases of disability at the wrist joint following excision of the head of the radius. Proc R Soc Med 24: 904 2. Curr JF, Coe WA (1946) Dislocation of the inferior radioulnar joint. Br J Surg 34:74 3. Edwards GS, Jupiter JB (1988) Radial head fractures with acute distal radioulnar dislocation. Clin Orthop 234:61 4. Epner RA, Bowers WH, Guilford WB (1982) Ulnar variance the effect of wrist positioning and roentgen filming technique. J Hand Surg [Am] 7:298 5. Essex-Lopresti P (1951) Fractures of the radial head with inferior radioulnar dislocation. J Bone Joint Surg [Br] 33 : 244 6. Hotchkiss RN, An K-N, 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] 14:256 7. McDougall A, White J (1957) Subluxation of the inferior ulnar joint complicating fracture of the radial head. J Bone Joint Surg [Br] 39:278 8. Morrey BF, Chao EY, Hui FC (1979) Biomechanical study of the elbow following excision of the radial head. J Bone Joint Surg [Am] 61:63 9. Reardon JP, Davidson PA, Noble PC, Kamaric E, Bell DM, Tullos HS (1991) The isolated radial head fracture. Presented at the 58th annual meeting of the American Academy of Orthopaedic Surgeons, Anaheim, California, March 7-12, 1991 10. Rockwood CA, Green DP (1984) Fractures in adults, 2nd edn. JB Lippincott, Philadelphia, p 638
