Essex-Lopresti injuries are often unrecognized acutely with resulting debilitating adverse effects. Persistent axial forearm instability may affect load transmission at both the elbow and wrist, resulting in significant pain. In the setting of both acute and chronic injuries metallic radial head arthroplasty has been advocated, however there is little information regarding their outcome. The purpose of this study was to assess the efficacy of a radial head arthroplasty to address both acute and chronic Essex-Lopresti type injuries. A retrospective review from 2006 to 2016 identified 11 Essex-Lopresti type injuries at a mean follow-up of 18 months. Five were diagnosed and treated acutely at a mean of 11 days (range, 8 to 19 days) from injury, while 6 were treated in a delayed fashion at a mean of 1.9 years (range, 2.7 months to 6.2 years) from injury with a mean 1.5 (range, 0 to 4) prior procedures. The cohort included 10 males with a mean age was 44.5 years (range, 28 to 71 years). A smooth stem, modular radial head arthroplasty was used in all cases. Outcomes included range of motion and radiographic findings such as ulnar variance, capitellar erosion, implant positioning and implant lucency using a modification of the method described by Gruen. Reoperations, including the need for ulnar shortening osteotomy, were also recorded. Three patients in each group (55%) reported persistent wrist pain. The mean ulnar variance improved from +5 mm (range, 1.8 to 7 mm) to +3.7 mm (range, 1 to 6.3 mm) at the time of final follow-up or prior to reoperation. Three (50%) patients in the chronic group underwent a staged ulnar shortening osteotomy (USO) to correct residual ulnar positive variance and to manage residual wrist pain. There were no reoperations in the acute group. Following USO, the ulnar variance in those three cases improved further to +3.5, +2.1, and −1.1 mm. No radial head prostheses required removal. Capitellar erosion was noted in five (45%) elbows, and was rated severe in one, moderate in two, and mild in two. Lucency about the radial head prosthesis stem was noted in eight (73%) cases, and rated as severe in 2 (18%), based on Gruen zones. Treatment of acute and chronic Essex-Lopresti lesions with radial head arthroplasty often results in persistent wrist pain. In the chronic setting, a planned USO was often necessary to restore axial forearm stability after radial head arthroplasty. Essex-Lopresti lesions represent a rare clinical entity that are difficult treat, particularly in the chronic setting. Early recognition and management with a smooth stem modular radial head arthroplasty may provide improved outcomes compared to chronic reconstruction

It is known that the delayed diagnosis of Essex-Lopresti injury can lead to devastating results concerning the function of the upper extremity. The aim of our study is to suggest methods of early diagnosis and treatment based on our experience on ten patients who were treated for this rare injury. We studied 10 patients (9 male and 1 female), average 36,5 years old (25–53) who sustained comminuted fracture of the radial head, isolated (3 patients) or with concomitant injury of the ipsilateral (3 patients) or the contralateral upper extremity (4 patients). Initially, 8 patients were treated with excision and 2 with internal fixation of the radial head and radioulnar transfixing pin. Gradually, they all developed subluxation of the DRUJ and they were treated for established Essex-Lopresti injury, 1–7 months after initial injury. Six patients were treated with reduction of radioulnar length (ulnar shortening osteotomy, with or without distraction with an external fixator) and TFC suturing. In 4 patients the radial head was replaced with a metallic implant, joint levelling and TFC suturing. The results were estimated after an average follow-up of 67 months (1–10 years) based on radiological (radioulnar equivalence) and clinical criteria (wrist and elbow range of motion, forearm rotation and grip strength). Excellent results were achieved in 4 patients who underwent metallic radial head replacement. Conversely, in the rest patients the radioulnar discrepancy relapsed in various degrees but the radiological result does not correlate with the clinical picture. We concluded that early diagnosis is necessary but not the only prerequisite for a good long-term result. Replacement of the radial head with titanium implant, offers good result at least in the short and mid-term period

In Essex-Lopresti injuries, the prevailing concept, according to which the stability of the forearm can be restored after fixation of the fracture or replacement of the radial head by a metallic implant, is disputable. The aim of this study is to evaluate the midterm results in 12 patients with an Essex-Lopresti injury who were treated operatively. We studied 12 patients, with comminuted fracture of the radial head, either isolated (4 patients) or with injury of the ipsilateral (4 patients) or the contralateral (4 patients) arm. Initially, 10 patients were treated with excision of the radial head whereas 2 underwent internal fixation of the radial head and pinning of the DRUJ. Eventually, everyone developed a subluxation of DRUJ and had to be treated for an established Essex-Lopresti injury, 1–7 months after the initial injury. Six patients were treated with equalization of the radioulnar length (ulnar shortening osteotomy with or without a distractor-external fixator) and restoration of the TFC, while six patients underwent replacement of the radial head with a titanium implant, equalization of the radioulnar length and restoration of the TFC. The results were evaluated after a mean follow-up of 4 years (1–12 years), based on radiological and clinical criteria. The six patients in whom the titanium radial head implant was used presented with good results, even though two of them reported forearm pain during activity. On the contrary, in the rest of the patients the radioulnar incongruity reappeared in varying degrees. However the poor radiological result was not consistent to the clinical one. We conclude that in cases of complete rupture of the interosseous membrane, internal fixation or replacement of the radial head with a metallic implant will not probably provide us with a good long-term functional result

The June 2014 Wrist & Hand Roundup360 looks at: aart throwing not quite as we thought; two-gear, four-bar linkage in the wrist?; assessing outcomes in distal radial fractures; gold standard Swanson’s?; multistrand repairs of unclear benefit in flexor tendon release; for goodness’ sake, leave the thumb alone in scaphoid fractures; horizons in carpal tunnel surgery; treading the Essex-Lopresti tightrope; wrist replacement in trauma? and radial shortening reliable in the long term for Kienbock’s disease

The lack of a universal, consistent protocol for the subjective, objective and radiographic evaluation of these injuries has hampered the comparison of results. Methods. 45 patients with complex fractures of the calcaneus were included in this prospective study, which was undertaken from July 2003 to December 2005. The fracture classification of Essex-Lopresti was used. We also observed the extent of secondary fracture lines extending from the primary shear line (on axial and external oblique plain radiographs) to establish comminution. The external oblique view for subtalar joint was performed with the patient supine, the knee at about 60 degree of flexion and the limb rotated externally 45 degree with a vertical X ray beam. All of these patients were managed by an external fixator using the principle of ligamentotaxis. Patients were evaluated by AOFAS. Results. We identified two broad patterns of secondary lines on plain X-rays:. with anterior secondary fracture lines and. with posterior secondary fracture lines. There were 20 cases of tongue type and 25 of joint depression type fracture pattern by the Essex-Lopresti classification. Forty two (93.4%) patients had fractures with posterior secondary fracture line and 3 (6.7%) patients had anterior secondary lines. The calcaneo-cuboid type of anterior secondary line pattern was present in 2 (4.5%) cases, and the plantar type in only 1 (2.5%) case. We observed posterior secondary line Type A pattern in 2 (4.5%) cases, depression / central depression type B in 20 (44.5%) cases, tongue shaped Type C pattern in 16 (36.5%) cases and Type D severely comminuted fracture line pattern in 4 (8.7%) cases. Conclusion. Comminution was significantly associated with prognosis and final outcome. Evaluation of secondary fracture lines corresponds with comminution of fractures of the calcaneus and the final outcome of these fractures. NO DISCLOSURES

Introduction: The aim of our study was to assess any difference in outcome between non-surgical and surgical treatment of displaced calcaneal fractures. Materials and Methods: We studied 40 patients between 2000 to 2005 with displaced calcaneal fractures. Patients with significant co-morbidities were excluded. Two groups of 14 patients, surgery vs. no surgery were compared for age, sex, length of follow-up, fracture type by Essex-Lopresti classification and SF-36 outcome score. The non-surgical group underwent treatment with rest, ice, compression, elevation and the surgical group underwent fixation with an AO calcaneal plate through an extended lateral approach. Results: There was no statistically significant difference between the surgical and conservatively treated groups for age, sex, time since injury and fracture type according to Essex-Lopresti but a highly statistically significant difference in SF-36 outcomes between the two groups favouring surgically treated calcaneal fractures. Summary: Displaced fractures of the calcaneum are a significant injury affecting patients general health. In the literature controversy exists as to whether operative or non-operative treatment is better for this type of fracture. Conclusion: Although the numbers are small, our study favours operative intervention, if possible, for this controversial fracture

Radial head fractures are the most common fractures occurring around the elbow and are often associated with other fractures or soft tissue injuries in the elbow. The purpose of this study was to characterise the morphology and to evaluate the outcome of the surgical management of radial head fractures in complex elbow injuries. Nineteen patients with this pattern of injury underwent surgical treatment in our unit. In addition, seven patients had posterior dislocation of the elbow, 2 medial collateral ligament rupture, one capitellar fracture, 3 posterior Monteggia, 1 Essex-Lopresti lesion and 5 coronoid fracture plus posterior dislocation. Non comminuted radial head fractures were treated by open reduction and internal fixation or simple excision of small fragments. Patients with comminuted, displaced radial head fractures underwent radial head replacement. The average follow up was 44 months. Two patients developed post-traumatic elbow contractures, one elbow instability and 2 mild arthritis. Overall, according to the DASH Outcome Measure, the results were excellent in 12 patients, fair in 3 and poor in 4. In complex injuries of the elbow the characteristics of the radial head fracture and in particular the comminution, the fragment number, the displacement as well as the age of the patient should determine the appropriate surgical technique which will lead to satisfactory long-term results. Anatomical restoration and maintenance of elbow stability will allow early mobilisation of the elbow joint and should be the goals of surgical management

Aims: The purpose of this study is comparative analysis of different surgical methods of calcaneal fractures treatment. Methods: From 1992 to 2001 we treated 132 patient (161 feet) with displaced intra-articular fractures of the calcaneus. All of these fractures have been classified according to the Essex-Lopresti Rx classification. 7 fractures were type A, 14 – type B1, 22 – type B2. Type C1 occurred in 51 cases, type C2- in 58 and type D – in 9 cases. 113 patients (134 feet) had fresh trauma (2–10 days after injury) and in 18 cases (27 feet) 3 up to 6 weeks passed from the moment of the injury. In 52 cases (62 feet) we used closed reduction and external fixation with Ilizarov apparatus. In other AO-implants were used: reconstruction 3,5 mm plate (19 cases), T-plate (12 cases), “Tampa plate”(59 feet) and new Locking Calcaneal Plate (9 feet). All patients underwent pre- and postoperative standard lateral and axial X-Ray and CT-scans. Follow-up results were analysed through 6 and 12 months. Results: Good and excellent results (no pain, no deformities and good function) were obtained in 74,2% patients, satisfactory results – in 18,2% of cases. In 7 patients the superficial skin necrosis was observed, in 5 cases deep wound infection developed. The best results are received in cases of Locking Calcaneal Plate application. Conclusions: Fractures of the calcaneus should be treated like other intra-articular fractures, i.e. careful reduction, stable fixation and early mobilization. Indirect reduction and external fixation can be applied only in A and B1-type of fractures. In fractures of B2 and C types good results can be obtained only by using stable osteosynthesis. In D-type fractures and neglected/delayed C2-fractures it is better to apply a primary sub-talar arthrodesis

Purpose of the study: Investigate the longitudinal stability and instability of the forearm. Material and methods: The interosseous membranes of 30 formol-treated forearms were dissected under 4-fold magnification and translumination. The radial and ulnar heads wee resected to eliminate the two radioulnar articulations before performing sequential cuts to identify the different networks of the interosseous membrane. The ulna was maintained in a fixed position allowing proximal and distal displacement of the radius. We studied the medial border of 100 radii, noting the bony eminences and their relations with the configuration of the membrane. Cases of neglected fractures of the radial cup without injury to the distal radioulnar joint and cases of polyarthritis treated by double resection radioulnar and Sauvé-Kapandji) presenting good longitudinal stability were studied. The possiblity of using the extensor indicis for primary reinforcement of the interosseous membrane was studied on cadaver specimens. Applied to an acute case of Essex-Lopresti syndrome, this original technique provided good intraoperative stability. Results: The fibers of the interosseous membrane design two planes, an anterior and a posterior plane. The anterior fibrrs descend distally and medially from the radius. They can be divided into proximal (horizontal) descending fibers, intermediary (short oblique) descending fibers, and distal (long oblique) descending fibers. The posterior fibers rise proximally and medially from the radius to reach the ulna. They form two planes: proximal ascending (short oblique) fibers and distal (long oblique) ascending fibers which are inconstant. These planes are in relation with the origin of the extrinsic wrist extensors. The main fibers are: the intermediary descending fibers and the proximal ascending fibers. They insert on the interosseous tubercle of the radius, a constant eminence situated on the medial border of the radius 8.4 cm from the elbow. The thre groups of descending fibers limit proximal translation of the radius. The proximal fibers can limit excessive distal translation. The proximal and distal ascending fibers limit distal translation of the radius. A full thicknes tear of the anterior plane is necessary to achieve proximal displacement. Longitudinal stability is maintained in neglected fractures of the distal without rupture of the interosseous membrane and in operated polyarthritis with resection of the two radioulnar joints. Conclusion: The fibers of the interosseous membrane describe two planes where the fibers run in opposing directions. Each plane limits radial displacement in a different direction. The ideal reconstruction would restore the two planes, but it is essential to reconstruct at least the intermediary descending fibers and the proximal ascending fibers. However, in routine practice, translation of the radius is generally proximal, so reconstruction of the middle segment appears to be sufficient if it associated with a reinforcement transfer of the extensor indicis to the proximal radius