Essex-Lopresti Injury
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Direct answer
Essex-Lopresti injury is a longitudinal forearm injury in which a radial head fracture is associated with disruption of the interosseous membrane and of the distal radioulnar joint. The axial load pushes the radius proximally, shortening the forearm and destabilising both forearm joints. Treatment aims to restore radial length and stabilise the forearm, and radial head excision is contraindicated because it worsens the instability.
What you must remember
- Mechanism: an axial load through the hand, typically a fall on an outstretched hand with the forearm in some pronation, drives the radial head into the capitellum.
- Core lesions: a radial head fracture (often comminuted), a tear of the interosseous membrane and injury to the distal radioulnar joint or its ligaments.
- Radiographic clue: proximal migration of the radius, with a widened distal radioulnar joint on the posteroanterior view.
- Contraindication: excision of the radial head without replacement, because it allows proximal migration of the radius and worsens the instability.
- Treatment of head: fixation if the head is reconstructable, or replacement with a prosthesis if it is comminuted.
- Treatment of forearm: restore radial length, fix the interosseous membrane and stabilise the distal radioulnar joint with pinning or a repair, as the situation demands.
- Late problems: painful forearm, weak grip, ulnar-sided wrist pain and progressive distal radioulnar instability.
A pathway to restoring a stable forearm
The sequence matters because an unrecognised Essex-Lopresti lesion is a common reason for a poor late result. The steps below follow the logical order of assessment and repair, from first suspicion to rehabilitation.
- Suspect it: a radial head fracture with forearm or wrist pain after axial loading should prompt a search for interosseous disruption.
- Image the whole forearm: obtain views of the elbow and the wrist, since a single view misses the proximal migration of the radius.
- Measure the radius: assess radial length and the widening of the distal radioulnar joint on the posteroanterior view.
- Decide on the head: fix a reconstructable fracture, or replace a comminuted head with a prosthesis, and never simply excise it.
- Restore length and stability: correct the radial length and stabilise the interosseous membrane and the distal radioulnar joint.
- Protect and rehabilitate: immobilise for the period needed, then start movement, with reassessment for distal radioulnar instability.
Where the exam tries to catch you
Most lost marks come from missing the forearm injury behind a simple radial head fracture or from excising the head.
- Trap: a radial head fracture is treated by excision, which is simple and quick. Correct: excision without replacement in Essex-Lopresti allows proximal migration of the radius, so the head must be fixed or replaced.
- Trap: a wrist X-ray alone is enough to exclude a forearm injury. Correct: the elbow and wrist must both be imaged, because the proximal migration of the radius is seen best on a full forearm assessment.
- Trap: the distal radioulnar joint is left alone once the radial head is fixed. Correct: the interosseous membrane and distal radioulnar joint must be addressed, since the forearm remains unstable otherwise.
Frequently asked questions
What is an Essex-Lopresti injury?
An Essex-Lopresti injury is a longitudinal forearm injury in which a radial head fracture is associated with disruption of the interosseous membrane and the distal radioulnar joint. The forearm shortens and the radius migrates proximally after an axial load.
Why is radial head excision contraindicated in Essex-Lopresti injury?
Radial head excision is contraindicated in Essex-Lopresti injury because removing the head allows the radius to migrate proximally, worsening the forearm instability. The head must be fixed when reconstructable or replaced with a prosthesis.
What radiographic sign suggests an Essex-Lopresti injury?
Proximal migration of the radius with a widened distal radioulnar joint on the posteroanterior view suggests an Essex-Lopresti injury. Imaging both the elbow and the wrist is needed to see the full pattern.
What does treatment aim to restore in Essex-Lopresti injury?
Treatment aims to restore radial length and stabilise the forearm by fixing the interosseous membrane and the distal radioulnar joint. The radial head is fixed or replaced so the forearm can transmit load properly.