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FRACTURES OF THE RADIAL HEAD & ESSEX-LOPRESTI

LESIONS

INTRODUCTION
Radial head fractures are one of the most common types of forearm injuries.
These injuries may be uncomplicated or have complex injury patterns. The EssexLopresti lesion is an example of such an injury. The treatment options for radial head
fractures are excision, open reduction with internal fixation and arthroplasty. With
improved fixation devices and techniques, the role of open reduction and internal
fixation is expanding. However arthroplasty is becoming more reproducible and
successful with improvements in techniques and material making the role of excision
of the radial head become more limited. Essex-Lopresti injuries are more complex
and difficult to treat than uncomplicated radial head fractures. We shall highlight an
example of a treatment option at the end of the discussion.
CASE REPORT
JK is a 54 year old, Indian, male, is a right hand dominant Pajero driver who
works with an engineering firm. On the 21 April, 2003, he was involved in a motor
vehicle accident in which he was riding a motorcycle and was knocked down by a
lorry. He was unable to recall the exact mechanism of injury but his main complaint
was right forearm pain. He had no previous medical illnesses. On physical
examination, his Glasgow Coma scale was full and he had a right periorbital
haematoma. His right arm was tender and swollen at the elbow, the whole length of
the forearm and the wrist. There was limited elbow flexion-extension as well as
pronation-supination. His range of wrist motion was also markedly reduced. There
was a transverse laceration wound over the palm of his right hand extending from the
1st web space, overlying the MCP joints of the index, middle and ring fingers up to the
little finger. Fortunately there was no neurovascular deficit and function of all the
flexor tendons to the fingers were intact.

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Plain radiographs of the hand, wrist and forearm of the patient revealed a
comminuted fracture of the base of the 4th and 5th metacarpal, comminuted fracture of
the radial styloid process, a disrupted DRUJ joint, an undisplaced segmental fracture
of the proximal and distal 3rd of the ulna and a comminuted and separated fracture of
the radial head Mason Type 3. The elbow joint was however not dislocated. The
radius had migrated proximally and a diagnosis of an Essex-Lopresti lesion with
disruption of the intraosseous membrane was made.
The patient was started on IV Zinacef 750 mg tds, the wound was irrigated
with copious amounts of normal saline, a backslab applied and he was planned for an
emergency operation under the trauma list the following day.
The following morning, the emergency operation was done under general
anaesthesia. A tourniquet was applied and the forearm was cleaned and draped in the
usual manner. The palm wound was explored and debrided and sutured with dafilon
4/0 sutures.
An intramedullary K-wire measuring 2.0 mm was inserted through the
olecranon to stabilize the ulna under image intensifier guidance and was subsequently
buried. A lateral Kocher approach was utilized to gain access to the radiocapittelar
joint. There were three large radial head fragments, consisting of half the radial head
and 2 quarter fragments. The half and one of the quarter fragments was excised but
the other quarter piece was left in situ as it was inaccessible through the lateral
wound. The fragment was not in the elbow joint. The lateral wound was closed in
layers. The base of the 4th and 4th metacarpals were then reduced and fixed with 2 Kwires size 1.6 mm through a incision made at the fracture site. Attempted reduction of
the DRUJ failed and it was subsequently stabilized in situ with a transverse K-wire
size 2.0 mm. A backslab was applied to immobilize the forearm.
Post-operatively the arm was elevated on a dripstand and the patient was
started on Cap Indomethacin 25mg bd to prevent heterotopic ossification. Intravenous
antibiotics were continued. Check radiographs noted a well fixed ulna bone. The

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radius however was proximally migrated as seen in preoperative radiographs and

there was a positive ulnar variance of appromately 8 mm. The DRUJ was fixed in that
position. There was no evidence of any nerve injuries post-op. The case was discussed
during census and the decision was to maintain the current fixation as it was and
mobilize the hand as soon as possible to maintain the function of the hand in view of
the wound in the palm. The wound was clean and the patient was discharged at 1
week post-op.
DISCUSSION
In 1951, Essex-Lopresti described a combination of radial head fractures,
interosseous membrane disruption, and triangular fibrocartilage complex injury with
subsequent longitudinal forearm instability. [5] Fractures of the radial head are
relatively common injuries, accounting up to 5% of all fractures and over 30% of all
elbow fractures. [1]
Longitudinal forearm stability is maintained through the interaction of several
anatomic structures including the interosseous membrane, a fibrous tissue with an
oblique orientation form the radius to the ulna. The interosseous membranes load
transferring ability reduces the forces placed on the radiocapitellar articulation,
thereby protecting this joint. Large sustained loads occur after radial head resection
with concurrent interosseous membrane tears resulting in the proximal migration of
the radius and disruption of the distal radioulnar joint. There are three specific types
of injuries related to proximal migration of the radius. These are the Essex-Lopresti
lesions, Galleazi fractures, and distal radius fractures. [5]
The elbow joint is a trochoginglymoid providing arcs of motion in two axes,
flexion-extension and pronation-supination. The radial head has various functions.
Firstly, it articulates with the ulna forming the proximal radio-ulnar joint. This
articulation consists of a 260-degree arc that is covered by articular cartilage. The
safe zone was introduced by Smith and Hotchkiss to determine the arc of the radial
head that tolerates prominent hardware without limiting prono-supination. The safe

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zone is an arc of approximately 110 of the outer radius of the radial head that does
not articulate with the proximal ulna. Intraoperatively, this zone is defined roughly as
65 anterior and 45 posterior to the line bisecting the anterior and posterior head with
the forearm in neutral rotation. [1]
The second function of the radial head to articulate with the capitellum at the
radiocapitellar joint. It transmits up to 60% of the axial load from the forearm through
the radiocapitellar joint. In complex injuries such as Essex-Lopresti lesions as seen in
this patient, the intact radial head becomes important in preventing proximal
migration of the radius with resultant wrist pain and disability. [1]
Thirdly, it transmits axial loads to the capitellum at this joint; and fourthly the
radial head acts as a secondary stabilizer to valgus stress in the intact elbow. [1]
The antebrachial interosseous membrane is a fibrous structure located in the
midsubstance of the forearm. It lies between the radius and ulna and possesses distinct
orientation and direction. All the fiber bundles except the proximal band are directed
in an oblique direction from the radius to the ulna at an average angle of 20. The
proximal band is directed at an angle of -20. The average length of the radial origin
and ulnar insertion is 10.6 cm. The functions of the membrane include forearm
stability, a tendon for deep extensor and flexor muscle attachment, reduction of bone
separation, and force transfer. [5] When a force is applied to the wrist, the distal radius
carries 68% of the load and the distal ulna carried 32%. Proximally, the radius
maintained 51% of the force whereas the proximal ulna 49%. With subsequent
sectioning of the interosseous membrane, the forces measured at the proximal and
distal radius and ulna were equal. [5]
In radial head fractures, the detection of a combined injury is the first step in
its treatment. Approximately 5% of radial head fractures is complicated by distal
ligamentous disruption. There must be a high index of suspicion to avoid missing this
injury because it is very difficult to treat when not properly treated inititally. [6]

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Mason in 1954 classified radial head fractures into three types: Type I nondisplaced fractures; Type II displaced fractures; and Type III comminuted
fractures. Johnston in 1962 further classified a radial head fracture and concurrent
elbow dislocation as Type IV. The concomitant ligament injury is not addressed by the
classification system. [4]
Treatment options for radial head fractures include, i) nonoperative treatment;
ii) excision; iii) open reduction and internal fixation; and iv) excision with
arthroplasty.
In the past, the radial head was once considered a surplus, or expendable part
of the skeleton. [7] Historically, the primary surgical treatment for radial head
fractures was simple excision. [2] It is now recognized that the radial head is an
important stabilizer of the elbow and forearm articulations. [7]
Non-operative treatment is generally recommended for the treatment of nonor minimally displaced Mason type 1 radial head fractures. The mainstay is early,
active range of motion of the elbow both in flexion-extension and prono-supination
arcs. A posterior splint may be provided for comfort but should be removed for active
range of motion. [1]
The indications for excision of the radial head for displaced radial head
fractures have dwindled with advances in the operative reconstruction of the radial
head. [Carroll 1998] Primary excision is most commonly recommended for
unreconstructable, displaced radial head fractures in an otherwise stable elbow.
Sanchez-Sotelo et al. concluded in a small study of 10 patients that acute radial head
excision provides satisfactory short-term clinical results and a high rate of patient
satisfaction in the treatment of elbow fracture-dislocations when there is comminuted
nonsalvageable radial head fractures with no other associated intraarticular fractures.
[8] Conversely, there are many potential complications associated with radial head
excision. These include pain, instability, new bone formation around the resection site,
and cubitus valgus. [2] Other published late findings include minor losses in elbow

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motion, loss of strength, radiographic evidence of osteoarthritis, and some degree of

proximal radial migration (average 2 mm). [1] The radial head of this patient was
excised as the surgeon believed that the radial head would undergo avascular necrosis
as there was no soft tissue attachment whatsoever. The radius had already migrated
approximately 8 mm at the time of injury in view of the interosseous membrane
rupture hence the diagnosis of an Essex-Lopresti lesion.
The indications for open reduction and internal fixation include mechanical
block of motion, greater than 1/3 of the articular surface involved, 2 to 3 mm
displacement, and 2 to 3 mm articular depression. Other indications include lesions of
the capitellum cartilage, a proximal ulnar fracture, an injury to the ulnar collateral
ligament and an injury to the DRUJ. Contraindications include older age of patients,
underlying osteoarthritis and injury to the capitellum [2]
Ring et al in 2002 retrospectively analyzed the functional results following
open reduction and internal fixation of 56 patients with radial head fractures (Mason
type II 30 patients; Mason type III 26 patients). The authors noted that 13 of the
14 patients with Mason Type III comminuted fracture with more than 3 articular
fragments had unsatisfactory results. In contrast, all 15 patients with an isolated,
noncomminuted type II fracture had a satisfactory result. There were no early failures,
only one nonunion, and the arc of forearm rotation was 100 in twelve patients with
type III fracture with 2 or 3 simple fragments. They concluded that open reduction
and internal fixation is best reserved for minimally comminuted fractures with 3 or
fewer articular fragments. [7]
Schuind in 1999 observed some major complications after osteosynthesis not
found after resection. These include radial head osteonecrosis, nonunion, intermittent
locking and secondary displacement justifying a reoperation in 32%. However, at
final follow-up, the results were significantly better after osteosynthesis (excellent or
good in 80% versus 59% after resection. The complications after radial head resection
included ulnocarpal abutment in 15%, cubitus valgus in 85%, elbow instability in
37%, and ulnohumeral ostoearthrosis in 2%. The author concluded that the tendency

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is now to internally fix displaced radial head fractures. However, serious

complications and poor results sometimes occur after this procedure. Radial resection
remains a valuable alternative, especial when it is impossible to obtain an anatomical
and stable reduction allowing early mobilization. [9]
Replacement arthroplasty was first described in 1941 by Speed using ferrule
capsules. Since then there has been multiple designs and materials used for prosthetic
reconstruction of the radial head. [1] These include acrylic, stainless steel, silastic, and
articulating CoCr prosthesis. [2] Open reduction and internal fixation has been
advocated by numerous authors, however there are fractures that are not amenable to
successful internal fixation, such as severely comminuted fractures that are difficult to
fix because of poor bone quality or inadequate fixation of very small fragments. Such
fractures are probably better treated with arthroplasty, especially if there is
concomitant elbow or wrist instability. Replacement provides temporary or permanent
lateral instability for associated ulnar collateral ligament healing and axial stability for
interosseous membrane and distal radioulnar joint healing. [2]
The silicone prosthesis has the worst outcome as a result of its poor wear
characterisitics in the elbow and its tendency to induce an aggressive synovitis. [1]
Silicone implants have an overall increased failure rate as compared with metallic
implants, including reactive synovitis, inflammatory arthritis, and fractures of silastic
implants. The amount of axial stability is also questionable. [2] This implant has been
all but abandoned in the United States. [6]
Use of the metal radial-head have been described from the 1950s with reports
of satisfactory outcome. Metallic implants have better force transmission and less
tendency to failure. [2] Knight et al. in 1993 published their results using Vitallium
prosthesis in Mason III and IV injuries. Twenty-four out of 31 patients had negligible
elbow pain and only 2 required removal for painful loosening. Minimum problems
with dislocation or prosthetic failure were encountered. They concluded that metallic
prosthesis have a role in the treatment of comminuted fractures of the radial head in
complex elbow injuries. [3] A review of the literature by Furry however does not

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show consistently better results with radial head arthroplasty versus open reduction
and internal fixation. Generally, the radial head should be preserved when technically
feasible and replaced when necessary. [2] With continued improvement in techniques
and materials, radial head arthroplasty may become the procedure of choice for all
non-reconstructable radial head fractures. [1]
The extent of the problem concerning this patient has not been fully addressed.
As stated earlier, this patient sustained a complex Essex-Lopresti lesion and not just
an isolated radial head fracture. McGinley in 2001 reported a similar case of a 30year-old left-hand dominant man who fell 25 feet from scaffolding resulting in a
comminuted fracture of the radial head and DRUJ disruption of his left upper limb.
Initial treatment consisted of an attempted open reduction and internal fixation of the
radial head fracture and Kirschner wire cross pinning of the DRUJ. Unfortunately the
radial head was highly comminuted and irreparable and a silicone radial head
replacement was inserted. The K wires were removed 6 weeks after surgery and ROM
was instituted. The radial head prosthesis was removed 3 months after surgery to
prevent silicon breakdown and synovitis. Three months later progressive ulnar sided
wrist pain had ensued and an 8 mm positive ulna variance was noted on radiographs.
The patient was managed with a rigidly fixed distal radioulnar arthrodesis and
creation of an ulnar pseudoarthrosis to allow early forearm rotation and wrist motion.
Nine months after injury, the patient complained of persistent elbow pain with flexion
and extension, and pronation and supination. Radiographs revealed loss of
radiocapitellar space and abutment between the radius and capitellum. Without any
viable technique to restore forearm stability, a single-bone forearm was recommended
and performed with transposition of the distal radius onto the proximal ulna with plate
fixation. [5]
CONCLUSION
Essex-Lopresti lesions are complex injuries that involve fractures of the radial
head with loss of the longitudinal forearm stability as a result of interosseous
membrane disruption leading to proximal migration of the radius and DRUJ

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disruption. The radial head in uncomplicated radial head injuries should in general be
preserved as far a possible, however radial head replacement is a viable alternative to
excision in non-reconstructable radial head fractures. In Essex-Lopresti injuries, the
radial head should be preserved. If immediate excision is indicated or unavoidable, a
prosthesis should be used to maintain the length of the radius while the interosseous
membrane heals. The Essex-Lopresti lesion remains a difficult injury to manage and
ultimately, the treatment option for severe membrane disruption combined with
proximal migration of the radius is the creation of a single bone forearm.
REFERENCE
1. Carroll RM, Osgood G, Blaine TA. Radial Head Fractures: Repair, Excise, or
Replace? Curr Opin Orthop 2002; 13: 315-22.
2. Furry KL, Clinkscales CM. Comminuted Fractures of the Radial Head:
Arthroplasty Versus Internal Fixation. Clin Orthop 1998; 353: 40-52.
3. Knight DJ, Rymaszewski LA, Amis AA. Primary Replacement of the Fractured
Radial Head with a Metal Prosthesis. J Bone Joint Surg 1993; 75-B: 572-6.
4. Kupersmith LM, Hausman MR. Fracture-dislocations of the Elbow. Curr Opin
Orthop 2001; 12: 356-63.
5. McGinley JC, Kozin SH. Interosseous Membrane Anatomy and Functional
Mechanics. Clin Orthop 2001; 382: 108-22.
6. Morrey BF. Instructional Course Lectures, the American Academy of
Orthopaedic Surgeons. Current Concepts in the Treatment of Fractures of the
Radial Head, the Olecranon, and the Coronoid. J Bone Joint Surg 1995; 77A(2): 316-27.
7. Ring D, Quintero J, Jupiter J. Open Reduction and Internal Fixation of
Fractures of the Radial Head. J Bone Joint Surg 2002; 84-A(10): 1811-5.
8. Sanchez-Sotelo J, Romanillos O, Garay EG. Results of Acute Excision of the
Radial Head in Elbow radial Head Fracture-Dislocations. J Orthop Trauma
2000; 14(5): 354-8.
9. Schuind F. Displaced Radial Head Fractures: Resection or Osteosynthesis? J
Bone Joint Surg 1999; 81-B Suppl II: 191.

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