Introduction

The Essex-Lopresti injury (ELI) is an unusual condition, which is commonly overlooked. It is characterized by a radial head or neck fracture associated with a combination of a distal radioulnar joint (DRUJ) dislocation and a rupture of the interosseous membrane (IOM) and it is an extremely rare condition, although some uncommon varieties of this complex forearm injury have been reported.

We present an uncommon variety of the Essex-Lopresti injury combining a radial head dislocation, a radial shaft fracture, and a distal radio-ulnar joint dislocation. We aim to study by means of our case report and a review of the literature, the clinical features, the mechanism, and the management of these injuries.

Case report

A 46-year-old secretary fell down a flight of stairs onto her outstretched left hand. She presented to the emergency department with a forearm deformity and ache associated to an ipsilateral elbow and wrist tenderness. Plain radiographs revealed a posterior radial head dislocation without fracture, a transversal radial shaft fracture, and a distal radio-ulnar joint dislocation (Fig. 1).

Fig. 1
figure 1

Pre-operative plain radiographs showing posterior radial head dislocation, transversal radial shaft fracture, and distal radio-ulnar joint dislocation

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The radial shaft was managed by open reduction and internal fixation using an anterior dynamic compression plate. The dislocation of the radial head was reduced intraoperatively after the fracture stabilization. It was stable on supination. The distal radio-ulnar joint was reduced spontaneously and it was stable in all positions (Figs. 2 and 3).

Fig. 2
figure 2

Post-operative plain radiographs: Radial shaft managed by open reduction and internal fixation using an anterior dynamic compression plate. The radial head and the distal radio-ulnar joint are reduced

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A long elbow splint was applied in full supination, 90° of elbow flexion and the wrist in neutral position for 6 weeks. Plain radiographs were performed weekly to ensure that the reduction was maintained. The patient then had 24 physiotherapy sessions spread over 2 months.

At 18 months of follow-up, the patient was asymptomatic and had full pronation and 75° of supination. She had elbow flexion from 0° to 150°. Her wrist motion was from 80° of flexion to 70° of extension. The X-ray showed that the radial shaft fracture had healed and the radial head and the distal radioulnar joint were reduced (Fig. 3). She had resumed thoroughly her previous job.

Fig. 3
figure 3

Follow-up X-ray at 18 months showing that the radial shaft fracture had healed properly. The radial head and the distal radio-ulnar joint are reduced

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Discussion

It is fundamental for the understanding of the Essex-Lopresti injury to consider the forearm as a single functional unit rather than isolated structures acting separately. The forearm unit consists of the radius, the ulna, the proximal radio-ulnar joint (PRUJ), the DRUJ, and the IOM. Any injury affecting an element of this unit will affect inevitably the forearm function as a whole [1].

The IOM is in charge of several important biomechanical functions. It serves to transmit load from the wrist to the elbow, transfer load from the radius to the ulna, maintain forearm stability, and help to maintain the DRUJ stability. It comprises five distinct components, however only the central band was consistently identified as the most important component for radio-ulnar stability and force transmission [2].

The mechanism of injury is a fall on the outstretched hand, with forearm in pronation and elbow in flexion. It is caused by a violent load propagating and longitudinal compression force transmitted from wrist to elbow tearing the distal oblique ligament, the IOM, the supporting structures of the DRUJ, and the PRUJ [2, 3].

Some variety of the Essex-Lopresti injury have been reported in the literature with associated elbow dislocation [4], bilateral elbow dislocation [5], or radial displacement in distal direction [6]. However, only one case of Essex-Lopresti injury with associated radial shaft fracture has been reported in the literature [7].

Optimal outcome for this type of injury requires a prompt diagnosis [8, 9]. In fact, delayed diagnosis and treatment leads necessarily to proximal radius migration, and persistent DRUJ dislocation. This is the main cause of chronic instability, which is difficult to manage because of the sequelae of ulnar-sided wrist pain and both forearm and wrist weakness [8, 9].

The diagnosis of ELI in the acute setting can be challenging and requires a high index of suspicion. Patients presenting with radial head fracture should be examined for wrist and forearm, particularly in the presence of high energy and high radial head displacement [2, 8].

The tenderness on compression in the wrist is an early clue of IOM rupture [8]. Injury of the IOM is more frequent than it is generally known, even in association with a radial head fracture without dislocation of the DRUJ [10]. Dynamic X-rays, ultrasound, and MRI can be used to diagnose when this lesion is suspected [1, 8, 11].

Treatment of the ELI is a surgical challenge and is still a subject of controversy [12, 13]. Several methods have been reported in the literature, but there is no widely accepted technique for the surgical management of ELI. However, with current awareness of the importance of the radial head in maintaining stability of both the elbow and the forearm, most updated techniques emphasize the importance of open reduction and internal fixation (ORIF) or replacement of the radial head [8]. The stabilization of the DRUJ is constantly necessary for 6 weeks. It consists of either casting [14, 15] or K-wiring, always in supination [16, 17]. In fact, in order to avoid the limitation of DRUJ rotation, IOM must heal in supination because in this position the strain is higher on the distal part of the membrane than in pronation [18].

Some recent research has suggested that the healing potential of the IOM is hypothetical, and we should not rely on it. Therefore, the reconstruction of the IOM is a new therapeutic orientation that provides stability and a good functional outcome. There is a huge variety of graft choice used in the literature such as Achilles’ tendon, patella tendon, flexor carpi radialis, and palmaris longus. [12, 19, 20]. Currently, it is considered the reference treatment for IOM lesions and should give the best functional results [19].

Conclusions

The Essex-Lopresti injuries are a heterogeneous group of complex forearm injuries that include a rupture of interosseous membrane. Optimal outcome for this type of injury requires a prompt diagnosis. We recommend examining the distal radio-ulnar joint in all radial head fractures or dislocations and to perform a radiograph of the complete forearm and the wrist if concomitant injuries of the carpus or distal radio-ulnar joint are suspected. It is important to understand the pathoanatomy that leads to longitudinal instability and to consider the forearm as a functional unit to make the right management choice.