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FOREARM INSTABILITY DUE TO

FRACTURE AND LIGAMENT


INJURY (IN ADULTS)

Christian Dumontier, MD, PhD,


Marc Soubeyrand MD, PhD
Guadeloupe, France

WE WILL NOT DISCUSS ELBOW INSTABILITY


WHETHER OR NOT IT IS ASSOCIATED TO
FRACTURES BUT ONLY FOREARM INSTABILITY

WE USUALLY THINK AT
THE FOREARM AS A FRAME

Everything simple is false. Everything which is complex is unusable


(Paul Valery -Notre destin et les lettres, 1937) also known as Boninis paradox

THIS IS IMPORTANT TO REMEMBER AS A


FRAME, TO BE BROKEN, HAS TO FAIL AS
LEAST IN TWO POINTS

Everything simple is false. Everything which is complex is unusable


(Paul Valery -Notre destin et les lettres, 1937) also known as Boninis paradox

THIS FRAME HAS 2 PARTICULARITIES

Its a pivot joint (or trochoid)


at both ends

THIS FRAME HAS 2


PARTICULARITIES

The two sticks of the frame are not


straight (two radii of curvature for the
radius) and are linked by the interosseous
membrane

THIS IS BECAUSE THE FOREARM SHOULD BE


REGARDED AS
THE ASSOCIATION OF THREE JOINTS
WHOSE FUNCTION IS TO ALLOW FOR A
COMPLETE, NORMAL ROTATION PRONATION &
SUPINATION
ALONG AN AXIS STARTING AT THE RADIAL HEAD
AND ENDING AT THE ULNAR HEAD

WITH THIS IN MIND, ONE CAN EASILY


UNDERSTAND INSTABILITY OF THE FOREARM

Transversally

Convergent

Divergent

Longitudinally

TRANSVERSE INSTABILITY IS SEEN IN


FOREARM FRACTURES BUT SEVERITY
ALSO RELIES ON THE IOM

WHILE LONGITUDINAL INSTABILITY IS


OBVIOUS IN ESSEX-LOPRESTI LESIONS

FOREARM FRACTURE AND INSTABILITY

Andersons criteria only include bone healing, stiffness and


infectionnot instability

Literature review suggests that bone healing is obtained in 95%


of cases and that stiffness in rotation is the most frequent
complication

Good functional results and DASH 12/100 (Goldfarb, JBJS 2005).


worst results were correlated with loss of pronation and loss of
strength

Anderson LD, Sisk D, Tooms RE, Park WI 3rd. Compression-plate fixation in acute diaphyseal fractures of the
radius and ulna. J Bone Joint Surg 1975;57A:287297.

MONTEGGIAS FRACTURES
AND FOREARM INSTABILITY

Described in 1814 by Giovanni


Battista Monteggia of Milan

They do represent 1-2% of


forearm fractures

Classified by Jos Luis Bado, into


four different subtypes [according
to the type of dislocation(I-III) and
radial head/neck fracture (IV)]

Bado JL. The Monteggia lesion. Clin Orthop Relat Res 1967;50:7186.

WHAT DOES THE LITERATURE SAY ?

If ulnar length and alignment are restored in an


accurate and timely fashion with the use of modern plate
and screw internal fixation constructs, then it is now
widely accepted that good results can be attained

the proximal radioulnar joint is restored with


anatomic reduction of the ulnar fracture except in the
rare instances when there is soft tissue
interposition (George)

83% good-to-excellent results in a series of 48 adults at


6 years FU. (Ring)

George AV, Lawton JN. Management of Complications of Forearm Fractures. Hand Clin 2015; 31: 217233.
Ring D, Jupiter JB, Simpson NS. Monteggia fractures in adults. J Bone Joint Surg Am 1998;80(12):173344.

Complications of Monteggia lesions are


numerable and include persistent stiffness, malunion, nonunion, persistent subluxation or
dislocation of the radial head, radioulnar
synostosis, infections, and nerve palsies.
1,5,13,15,16,18,21,25,2834,41,42,44,46,54,57,60,62,69,79,83,84

FOREARM INSTABILITY ?

No: Except for the rare case


in which there is an
interposed annular ligament,
any residual subluxation of the
joint is almost always a
product of residual
malalignment of the ulna.

Anatomical reduction can be


difficult to achieve

ANATOMY OF THE PROXIMAL ULNA


5 cm

Physiological dorsal
angulation of 5,7 (0-14) at
47 mm (34-78) distal to the
tip of olecranon

a 5 malreduction leads to
radial head subluxation.

The center of the radial head


should face the center of the
capitellum (range 1 mm
posterior to 3 mm anterior)

Rouleau DM, Sandman E, Canet F, et al. Radial head translation measurement in healthy individuals: the
radiocapitellar ratio. J Shoulder Elb Surg 2012;21:5749.

IT IS MALALIGNMENT NOT INSTABILITY

PRUJ stabilizers are


ruptured (annular and
quadrate ligament)

But the IOM is for its most


part remains intact +++

INSTABILITY AND BADO II TYPE LESIONS

During posterior dislocation,


the radial head fractures in
up to 70% of cases

Lesions are associated with


osteoporosis, lateral
collateral ligament (LCL)
injuries, associated coronoid
fracture

Jupiter JB, Leibovic SJ, Ribbans W, Wilk RM. The posterior Monteggia lesion. J Orthop Trauma 1991;5(4):395402.
Parisi TJ, Jupiter JB. Fractures of the proximal radius and ulna: Monteggia injuries. Shoulder and Elbow Trauma and its
Complications, 2016, Pages 193-222

BADO TYPE II MAY LEAD TO ELBOW INSTABILITY

Instability when present is due to LCL disruption


or radial head fracture, i.e. it is an elbow joint
instability, not a forearm instability

The radial head may be difficult to reduce due to


interposition, or difficult to fix. RHR can be
considered but as the MCL is intact, RH is
only a secondary stabilizer

Ring et al. had satisfactory results in 10 of 12


patients who had resection without replacement
of comminuted radial head fractures.
25

Complications in 21 patients (38.9%)

Only in that paper did I found one DRUJ instability that could
have been part of a forearm instability

GALEAZZIS FRACTURES AND FOREARM INSTABILITY

First described by Sir Astley


Cooper in 1822,

Galeazzi in 1934 presented a


series of 18 patients: I
believe that the fracture happens
first and the luxation is the
outcome of it.

Isolated radius fractures may be


more frequent than real
Galeazzis (Ring)

Ring D, Rhim R, Carpenter C, Jupiter J. Isolated radial shaft fractures are more common than Galeazzi
fractures. J Hand Surg. 2006; 31A:1721.

GALEAZZI AND RADIUS FRACTURES

Location of the fracture IS NOT a


predictor of instability

However: Radius fracture > 7,5 cm


over the DRUJ are not associated with
DRUJ injury (Rettig)

Half of fractures of the distal third had


DRUJ instability, it was anecdotical for
more proximal lesions (Korompilas)

Rettig M, Raskin K. Galeazzi fracture-dislocation: a new treatment-oriented classification. J Hand Surg 2001;26A:
228235.
Korompilias AV, Lykissas MG, Kostas-Agnantis IP, Beris AE, Soucacos PN. Distal Radioulnar Joint Instability
(Galeazzi Type Injury) After Internal Fixation in Relation to the Radius Fracture Pattern. J Hand Surg 2011;36A:
847852

THERE IS NO VALID TEST TO PREDICT


DRUJ INSTABILITY

Radius Shortening (5 mm), or distal fracture (< 7,5 cm-Rettig)


are not adequate (Tsismenakis).

Ulnar variance > 2 mm on injury films (79% DRUJ instability vs


21%) (Takemoto).

Surgeons should be aware of these associations but rely


primarily on intraoperative assessment of the DRUJ after
radial fixation to determine treatment.

Tsismenakis T, Tornetta P III. Galeazzi fractures: Is DRUJ instability predicted by current guidelines? Injury 2016; 47(7):
14721477
Takemoto R, Sugi M, Immerman I, et al. Ulnar variance as a predictor of persistent instability following Galeazzi
fracture-dislocations. J Orthop Trauma 2014;15(1):416.

GALEAZZIS FRACTURES

Reduce and fix the radius


first ANATOMICALLY

Then check for DRUJ


instability

Stable, OK,

No immobilization is
required

van Duijvenbode,DC et al.. Long-term Outcome of Isolated Diaphyseal Radius Fractures With and
Without Dislocation of the Distal Radioulnar Joint. J Hand Surg 2012;37A:523527.

GALEAZZIS FRACTURES

Stable only in certain position,


immobilize for 4-6 weeks in a
position of stability (supination)

Most often, 1 or 2 K-wires above


the DRUJ for 4-6 weeks

GALEAZZIS FRACTURES WITH PERSISTENT DRUJ


INSTABILITY OU IRREDUCIBLE DISLOCATION

Associated lesions of the DRUJ


stabilizers including the distal IOM
+++

Lesions should be checked and


fixed +++ but this is rare (3 /13
in Rettigs, 2/95 in Korompilias)

Cheng SL, Axelrod TS. Management of complex dislocations of the distal radioulnar joint. Clin Orthop
Relat Res 1997;341:18391

or K-Wires for
4-6 weeks

ESSEX-LOPRESTI INJURIES

Curr and Coe (1946)

EssexLopresti (1951)
in air-trooper of PRUJ
and DRUJ dislocation
w/wo radial head
fracture

LONGITUDINAL
INSTABILITY IS NOT ONLY
DUE TO IOM DISRUPTION

The association of lesion


(IOM + DRUJ and PRUJ) is
responsible for instability

Make the diagnosis of ALL


lesions

Think of it +++ (only


20% diagnosed early)

Treat ALL lesions

THINK OF IT DURING SURGERY

Radius pull test (Smith 2002) :


proximal migration of the
radius > 3 mm is associated
with IOM disruption (Se 83%,
Sp 83%)

Radius joystick test


(Soubeyrand 2011): PPV 90%,
NPV 100%

Smith AM, et al. Radius pull test: predictor of longitudinal forearm instability. J Bone Joint Surg Am 2002;84-A(11):19706.
Soubeyrand M, et al. The intra-operative radius joystick test to diagnose complete disruption of the interosseous
membrane. J Bone Joint Surg Br 2011;93(10):138994.

IMAGING TECHNIQUES

MRI has proven very


sensitive and specific IN
CADAVERS

Sonography has almost the


same sensitivity/specificity
and can be done during
surgery if needed

FesterEW, Murray PM, Sanders TG, et al. The efficacy of magnetic resonance imaging and ultra- sound in detecting
disruptions of the forearm interosseous membrane: a cadaver study. J Hand Surg Am 2002;27(3):41824.
Soubeyrand M et al. The muscular hernia sign: an original ultrasonographic sign to detect lesions of the forearms
interosseous membrane. Surg Radiol Anat 2006;28(3):3728.

TREAT ALL LESIONS

If all lesions are treated early, satisfactory


results can be expected

Radial head ORIF or replacement +++

TFCC fixation +/- pinning

IOM repair is unpredictable and should


not be done

Edwards GS, Jupiter JB. Radial head fractures with acute distal radioulnar dislocation. Essex-Lopresti revisited. Clin Orthop
Relat Res 1988;(234):619.
Grassmann JP, Hakimi M, Gehrmann SV, et al. The treatment of the acute Essex-Lopresti injury. Bone Joint J 2014;96-B(10):
138591.

IF NOT OR BADLY TREATED, IT ENDS UP AS A


CHRONIC ESSEX-LOPRESTI LESION WHICH
TREATMENT IS MORE DIFFICULT AND RESULTS
LESS SATISFACTORY

Replace the radial head

Fix the DRUJ +/- ulna


shortening)

Repair the IOM with a


ligamentoplasty +++

IOM REPAIR

Many techniques however they


place the transplant in the axis
of the ligament not in the axis
of the forearm rotation +++

1ST TAKE HOME MESSAGE: THE


THREE LOCKERS CONCEPTS

Think of the forearm as the association of three joints

If one is locked, rotation is lost

If one is unstable, the other two can compensate

If two or more are unstable, then the whole


forearm is unstable

2ND TAKE HOME MESSAGE: THE SAME

Prevention/ correction of forearm instability


needs to correct the bone FIRST +++

You cannot
build on sand:
Matthew 7-26

2ND TAKE HOME MESSAGE

Then to realize that interosseous membrane


lesion may be responsible for persistent
instability in PRUJ/DRUJ injuries +++

Or that IOM is injured in Essex-Loprestis


lesions

GRACIAS POR SU ATENCIN