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Essex-Lopresti Injury Orthopaedic Exams
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Essex-Lopresti Injury Orthopaedic Exams
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Language: EN.
Segment:0 .
Hello, everyone. Good evening, and welcome to this orthopedic teaching session organized jointly by the FRCS group and orthopedic Research UK. And started out, I will be moderating the session tonight. The speaker this evening is Mr Raymond jamma.
He's a consultant at King's College in London, specializing in hand, wrist and upper limb surgery. He's been the convener of the King's or UK hand surgery FRC course since its inception in 2012. These dedicated teacher and contributes to numerous postgraduate. Teaching programs across the UK and Europe, we are very pleased that he has kindly accepted our invitation to teach today.
Which? so thank you very much for us. Thank you for the kind introduction and thank you for inviting me. As you mentioned, I've been involved in teaching for quite a few years, but this is my first webinar. I feel slightly, slightly nervous, actually, but excited at the same time.
So should we get going with a lecture? Yes, please. If you hope to get to the bottom of the screen, you will find the Manage participants option and then you could have an option to raise your hand if you want to talk directly or participate. After the meeting, after the lecture, we will have the hot seat Viva practice session.
These the questions will be asked by various host FARC as mentors and one candidate will be on the hot seat and will be given feedback. It will be a real life scenario. And these are very limited. And there are no there are hundreds plus participants tonight. So please, if anyone is interested to take part, it's on first come, first serve basis.
Please express your interest. Either send me a message or raise the hand symbol next to your name. And without further ado, I will leave you, Mr tuberosity, now. OK, Thanks very much. The title of today's talk was officially Essex Lopresti injuries, but I guess for the purposes of the exam, we need to refer them as longitudinal forearm injuries. Now these are unusual injuries that by no means things that you would see under normal circumstances in an ordinary day at work.
You you may see one, you know, once or twice a year, but the important things about them are number one, they're really significant injuries. And unless you have good awareness of them, then your management will be insufficient or incorrect. So one of the purposes of today's talk is definitely to try to raise awareness of this particular type of injury. But it is definitely one of these topics that does turn up in the exam for the exact same reasons because it can catch you out as a clinician, and therefore it's perfect for an examiner to try and catch you out with during a clinical or reviver.
It's actually quite a big and a fairly complicated, a fairly postgraduate type of a subject, and it's definitely 1 to be treated by a specialist or a subspecialist. So the purpose of the talk today is to not give you the finer details with regard to how the surgical technique. I mean, for certain things in the trauma viper, you should definitely be able to talk about surgical technique in a lot of detail for certain things, which I guess are fairly high up that scale, maybe incrementally nailing fixation of a distal radius fracture.
And you'd be actually required to talk about the finer points of surgical technique. I don't think that longitudinal forearm injuries is one of those topics. You need to be familiar with some of the potential options for fixation of the injury. But I don't think that you're going to be specifically asked about details and you'll see why. As we go through the talk, it's because there is no single best way to treat these.
And actually, there's a great deal of variability in how people do treat them. So we'll just kick off. So just to introduce myself again, we've already had an interruption. I work at Kings College hospital, where I'm the lead clinician for orthopedic surgery. I also work at 40th clinic London, where I have a specific injury in treating sports injuries of the hand, wrist, elbow.
And if you want to get in touch afterwards, you can obviously do so via kings and an NHS email address or via my website, which is the hand specialist. So the talk is going to be roughly 10 points and point number one, which is arguably the most important point of all, is that we have to start considering the forearm as a joint. Most people just think it's a kind of a gap between the wrist and the elbow, but actually it really is a unit.
And it should be considered as a joint. And when you do consider it as a joint, you can understand the pathology and the treatment a great deal better. So there's obviously the proximal radial Allen, the joint and the distal arm, the joint with which we're familiar. But the bit in the middle, which we're really going to focus on for the purposes of this talk is the intereses membrane.
Now, some people have even gone maybe a step further, and they've started to refer this refer to the interruptus membrane or the IOM as the middle radio on a joint because it plays such a pivotal part in maintenance of forearm function and stability. And as we will see when it is injured, then there are some really significant ramifications in terms of function thereafter that need to be addressed. So, S6, Lopresti, it's one of these anonymous names that lots of people have heard about, but the syndrome, if you like, is characterized by three main things in every asx Lopresti injury, there is a radial head fracture.
There is some kind of injury to the radius at its proximal end that results in either fracture dislocation, sometimes both. But invariably the length of the radius or the radial height, if you like in respect to the ulnar has been changed and it's been shortened. The second path egawa mnemonic injury of the ESXi Lopresti is the disruption to the interruptus membrane and by disruption that usually refers to a kind of a tear.
And you should consider this in some respects to being like an injury to the syndesmosis in a Weber type C injury. Obviously, you see energy go through one side of the ankle and then exit through the syndesmosis as it exits through the other side. And unless you have recognized the significance of the sender's multiple injury and have taken steps to stabilize it.
Of course, your webisode ankle fixation will obviously fail as your rate as your tibia and fibula dissociate, so the IOM disruption is key. Thirdly, as the energy extends distally. So it's gone from the radio head, it's gone through the intereses membrane, which has become torn or ruptured, and then it extends distally and it exits through the digital radio on the joint. And again, it's really similar to other injuries of the lower limb Mason nerve type injury being a classic example where the entire length of the unit between the radius and the ulnar or indeed of the tibia and fibula gets disrupted both proximally and distally.
So when you put all of these three things together, you get the longitudinal radioulnar nerve association or otherwise known as the ESXi Lopresti injury. Now, who was ESXi lopresti? Peter Gordon s6? Lopresti was a gentleman who actually unfortunately died very young. He described these injuries whilst he was working in the army during just after the Second World war, and he wrote several papers not just on forearm injuries, but he also wrote a couple of papers on injuries to the says for people who were jumping out of planes.
And he was quite a distinguished army doctor. Despite his very, very young age, he became a member of the Royal College of surgeons, I think at 27 and died under mysterious circumstances at home in his early 30s, but his name has forever been associated with his first original description of this injury. Here are some of the x-rays that were part of his original paper, and you can see that nothing has changed, you know, in the 70 years since he first described this, what we can see in these pictures is there is a fracture of the radius.
There is some kind of disruption to the proximal radial on the joint and of course, distally. You can see that there's gross migration of the radius, approximately a significant disruption of the drug probably associated with the fracture in this case as well. Point number three, if we're going to consider longitudinal stability of the forearm, the most important structure is, in fact, the radial head. Now this particular fact has been well established for some time, and we know this because of the fact that historically people have tried to undertake where your head incisions in circumstances where reconstruction, replacement or fixation was not possible or degenerative changes that occurred.
Now we know that if the radial head is exercised in a young patient and someone who has high demand and there is some kind of disruption to the proximal radial ulnar joint and there is dire stasis or separation of the two or dissociation, the outcomes are terrible and people do extremely badly. And now we know from experience that this is really only an operation that is reserved for elderly people who are extremely low demand in whom are very cautious.
Resection of the radial head has been undertaken, which is not excessive and not sufficient to destabilize that proximal radial Allen the joint. So if the radial head has been established as the most important longitudinal stabilizer, then of course, when we are considering longitudinal forearm instability, the key really is to replace or at least fix or restore the radial head in some way, shape or form, as that is likely to provide the most significant contribution to longitudinal stability of the forearm in the injured setting.
So point number 4 is that after the radial head, the structure, which is the second most longitudinal stabilizer, is in fact the intereses membrane. This is a very clever little study that was done by Hotchkiss. And it effectively measured deformation of the radius when certain structures had been divided.
So you can see that the first line up at the top is the amount of deformation when you have an intact interruptus membrane. So what happens is that as you apply, load to the forearm load is shared between the radius and the ulnar. The forces of then transmitted in a very controlled manner through the proximal and distal on the joints, and there is very little relative movement between the radius and the ulna if you simply just resect the TFCC.
And of course, we are all familiar with the importance of the TFCC in regards to rotational stability of the forearm. But if you resect the task completely, there's only an 8% reduction in the amount of deformation between the two bones. However, if you resect the intereses membrane, then you have a massive 71% reduction in the overall ability of the two bones to resist load and die status occurs with much less force.
The intereses membrane is actually a ligament complex, it's not really a single structure. So here what we see is a specimen with the forearm muscles removed and we can now start to see that the ligament complex has actually got three bands. Now the first of these is the most important, and that's the central band. It has this kind of an oblique pathway that runs from 1 bone to the other.
But this orientation of 20 to 24 degrees with respect to the long axis of the armor is significant because as we will see later on, the methods of fixation or reconstruction of the intereses membrane rely quite significantly on restoring that band and that orientation. So that central bank is the broadest, and it's the, I guess, the most important because it's the strongest.
The next is the distal cord. Now the distal cord is smaller, but it sits just below the ulna head and around the metathesis of the distal radius and the ulnar. Now this has a really significant contribution to drug stability. And so when I think quite often we sometimes overlook this because we do fixation of distal radius and distal on the fractures.
And people come along with secondary deluge, instability, problems, and of course, our natural tendency is to assume that this comes from some kind of TFCC problem. However, if your radius has not been anatomically fixed and quite often what we see is a kind of a real realization of the articular surface, which is very typical of a Colles fracture.
So the shaft of the radius moves in an ulnar direction with relation to the articular surface. And of course, what that does is it detentions the distal cord. So in the setting that people come along with DRUJ instability after a fracture? Yes, of course, you have to consider a TFCC problem or disruption, but have a look at the anatomy of the fracture. Have a look at the fixation, the potential for Mount Union.
And actually, you will probably find that in a lot of cases. And if you are a surgeon who's interested in doing wrist surgery, if you start doing corrective osteotomy, you will find that when you put the distal radius back into its correct position, you almost immediately restore WJZ stability by doing nothing at all to the TFCC. And that's because you have restored the tension in the distal cord. Finally, there is probably a slightly less important but still well recognized structure, which is the proximal oblique cord.
Although these are the three structures which have been largely described that there's huge variation and plenty of studies have shown that anatomic variations are the rule. But I guess if you were to look at these four specimens, you would probably still be able to make out a central band in all four specimens and probably a distal and proximal band in most of them as well, with some variations in between.
But certainly the consistent structures, I think, are there. So what does the intereses membrane do apart from holder two bones together? Well, we know that it has this function to control forearm pro and supine, and it becomes tense when it is in most tents, when it's in supination. And just like any other ligaments of structure, it has a very important role in kinematics.
Secondly, I alluded to this earlier, but it helps to transfer load from the radius to the ulnar, because if that didn't happen, you would have very, very preferential load transfer across one bone or the other, most likely the radius. And we see that in situations where the interosseous membrane has ruptured and there has been an Essex Lopresti injury. And the radius has been sort of the radial head has been fixed or replaced.
And in the setting that the interosseous membrane has not been reconstructed. All of the forces subsequently passed through the radius and very little through the armor. And the upshot of that is that you get premature failure of your radial head replacement or fixation just because the forces are so great and the interosseous membrane is not allowing that load share that load transfer onto the ulnar.
Of course, we have discussed the fact that the IOM is essential for longitudinal stability and for transfer stability. It provides additional stability over and above the ligaments of the proximal radial on the joint and the distal radio, while the joint. If you look through your forearm anatomy coming up to the exam, you will see that at least half of the forearm muscles have an origin somewhere on the interosseous membrane.
So it's a really important site. And this is potentially one of the reasons why people develop a significant lack of grip strength after Essex Lopresti injuries. It may well be that the proximal anchor to the muscle is now unstable. The final point is not so well proven, but I guess it's highly suspected like all ligament structures.
There is a role for proprioception, and we all know that people who have had, for instance, an ACL rupture or reconstruction have significant proprioception issues and they have to go through quite a lot of rehab to try to restore that after the reconstruction. So moving on now to how we might go about treating these injuries. Point number 5 is that if you have longitudinal instability, then you have to.
If you want to successfully treat it, you have to address it at all levels. And that means that you start off with the radial head and the proximal radial ulnar joint that needs to be stabilized. Of course, you need to stabilize the distal end of the joint as well, which involves a drug stabilization and a TFCC repair. But importantly, you have to consider what's in the middle as well.
So without addressing all three levels, you may well be insufficiently treating quite a significant injury. Point number 6 is your starting point, I guess, for any kind of treatment. So the first thing that you have to be able to do is to restore the radial head. And by that, I really mean you have to make sure that the congruence between the proximal radius and ulna has been restored and you have got good proximal radial ulnar joint alignment.
Now, in certain cases, it's difficult. It's harder to achieve that than you would think, mainly because there has been a very significant disruption. It's easy to overstuffed or under stuff, a radial head replacement and achieving an accurate restoration. The point that I was making is that if your radius is short, then it's going to be very difficult for you to orientate or to reduce your distal radial ulnar joint.
So obviously, everything that happens at the proximal end has a direct influence on what happens at the distal end. And if you don't get that right and it's very easy to get it wrong, then you have to start thinking about options to change the length of the ulnar. In order to match that of the radius, and that becomes quite a complicated task. But it's something that we'll be able to talk through in a little bit more detail as we go along.
So although restoring the radio height gives improvement to your longitudinal stability, it does not restore biomechanics because we know that the intereses membrane has been significantly disrupted. And as I mentioned before, if you do not undertake some kind of interosseous membrane reconstruction, then almost 100% of the forces that get transmitted go through the radius.
And of course, that far exceeds the capability of your implant or your fixation to survive those loads in a few animal or cadaveric studies that have been done. If you reconstruct the atrocious membrane. And in this particular one that I've quoted here, you take out an Achilles tendon allograft. Then all of a sudden you can reduce the force transmission quite significantly and almost achieve a 50% reduction in or improvement in low transmission from radius to ulna.
So after you have. Done the proximal aspect of your surgery. Then you can start to think about what's happening more distally now, this next step is kind of, I guess, simplified for the purposes of saying something in the exam. The actual treatment algorithm is somewhat more complicated because at this stage, I'm assuming or let's just assume for the purposes of this talk that by fixing the radial head or by replacing the radio head, you have achieved a fairly accurate or anatomic restoration of the length of the radius, and you do not have some kind of length discrepancy between the two bones.
Now, if that's the case, then you can proceed on to stabilizing the disk. So at that stage, you would really need to make sure that the distal redwan, a joint, is a congruent. There is no interposition of soft tissue and that on the head is sitting very neatly within the sigmoid notch. And at that stage, you would undertake a task repair.
Now, for those of you who are not particularly familiar, there's plenty of ways of doing this, but effectively you can either do a dorsal or a lateral type incision. There are plenty of descriptions of anatomical approaches to the task, and the majority of people now would probably place through an open approach a couple of decent, non-negotiable sutures through the periphery of the GFC and then anchor it down to a drill hole that has been made at the fovea, which sits just at the base of the armor.
Those sutures can then be pulled out of the hole, and that hole exits onto the lateral border of the armor and then you can do what you like with those sutures. Thereafter, you could tie them to themselves or lots of people now just use a push lock anchor and secure it into the shaft of the armor. Now, in all of these settings, these two tiny stitches are rarely sufficient to really be able to maintain decent stability of the DOJ.
The force is going through it are excessive. If you were doing an isolated task repair for some kind of other indication, you would definitely support your repair by placing someone in and above elbow cast. But in the setting where there's been gross disruption of the entire forearm, most people would probably advocate supporting the drug further with one or two Y's that are passed across.
You do have to be slightly careful here because if you have then passed these two wires and you're going to continue your surgery during which you're going to be prone and supine in the forearm, you certainly don't want those wires to break. And if they do break, you have to be able to make sure that you can retrieve them. So if you are passing a drug. Just make sure that you leave it proud, both on the radial side and on the ulna side so that you can retrieve it should it break.
And for most cases, I recommend that actually you don't pass them through until the very end. It's probably one of the final steps of the operation, otherwise they are prone to bending and breaking. So then I guess the million question is after you've done the proximal bit and the distal bit. What do you do with a bit in the middle?
Well, there's no best answer here. We know that if the intereses membrane is ruptured acutely, then transfer of load cannot occur. Then you have persistent instability and then in the presence of persistent instability, no ligament. A structure will really ever heal, especially if that's a longitudinal type of translational force.
So realistically, if we are hoping to achieve any kind of healing intrinsic, biological healing of the influences membrane, we do have to confer some kind of stability to it. One thing that can help determine the degree of injury is called the radial pull test and the radial pull test can really be done earlier on at the time of fixation of the radius and the radial head. And there are two ways of doing it, and it's been described in more than one way.
The first way is actually just by pulling on the radius at the beginning of the case. So effectively you take the thumb, you put on the thumb and you see whether or not there is greater than 6 millimeters of longitudinal displacement. And that indicates that there has been gross disruption of the intereses membrane, the pigeon. The equally a similar test can be undertaken using a clamp. So when you've done an approach to the proximal radius or the radial head, you simply take a clamp on the proximal aspect of the shaft and then you can effectively translate and push the radius backwards and forwards to effectively see whether or not the translation measures up.
So 3 millimeters indicates that there has been a disruption of some degree that obviously includes the radial head and the deluge. But if you have 6 millimeters or more, as is often the case, then you have a complete disruption of the IOM as well. So as we mentioned before as well, if the membrane does not heal, you're in big trouble because then your radial head fixation or replacement will soon fail. And then you are then realistically looking at a patient who's in significant pain, has poor forearm function, and soon after the primary injury, you'll be considering salvage options, which is not ideal.
So this has led people to consider acute primary interosseous membrane reconstruction. It's not really feasible to stitch it back together, mainly because you would have to peel off all of the muscles of forearm. It would be an unbelievably difficult thing to do in the acute setting. And it's a membrane, a structure and simply stitching it together, I think, has led to very, very poor results.
So this has led people to consider treatment in three main groups, and these are using tendon grafts, synthetic grafts and Allen. Now, there is no single best way to treat this by any stretch of the imagination if you look through the literature. And prior to this talk, I had another look through the literature. People are just presenting, you know, individual case reports or reviews with two or three cases in them outlining a particular technique.
And so there are definitely no significant studies that are in significant numbers or have decent long term outcome data. But people have been extremely inventive and under the banner of tendon grafts people have taken prone to break your radial scroll bone patellar tendon bone, Palomares flexor copy radiators. The problem with this is obviously donor site morbidity, and sometimes you need quite a big surgical exposure if you're going to take enough graft material.
Synthetic grafts have also been used for those of you who do a surgery or perhaps ACL surgery. You'll be familiar with large ligaments. But one device, which has certainly become more popular, is a tightrope. We use tight ropes again in lots of other limb surgery, and of course, we're using tight ropes in the syndesmosis and the ankle. There are flex products, and they have pros and cons.
I guess there's no donor site morbidity. But the issue with them is that they are a fixed length and whereas a biological graft may potentially have the opportunity to stretch with time, that could be a good or a bad thing, depending on how these synthetic grafts are tensions. Either you get it right first time or you're either a bit lax and a bit wobbly or a bit too tight, and then forearm rotation is significantly restricted.
Allograft have also been described, but these are mainly in cadaver studies. But perhaps there is some promising data from facial after tib and tend Achilles and again, bone patellar tendon bone. The final picture just here on the right of the screen gives you an idea of roughly how you would orientate your graft. And then it becomes kind of like doing an ACL. You pick your spot, you drill your tunnels, you pass your graft.
And then you secure it. And because of the knowledge that we have regarding the position of the central band of the atrocious membrane. Broadly speaking, there are some fairly reliable measurements that we can apply to the forearm in order to plan our tunnels. So you'll see that the Alma Tunnel is located at 33% of the ulnar length as a point measured from the tip of the arm on the stylized and the radial tunnel is at 60% of the length of the radius.
And that gives you the opportunity to try to restore that 21 degree angle, which is more or less the orientation of the central band. Here are just some pictures these are not mine. These are taken from one of the numerous studies that describe techniques. And you can see that a free tendon graft has been taken. In this case, I think it was a tibial.
It's been stitched at both ends using familiar equipment, which we all use for other indications. You pass a guidewire after you have made your measurements. You drill over it. You pass your whip stitched graft through. The surgical approach to the distal ulnar nerve is relatively straightforward. And as you can see, you effectively come along the subcutaneous border of the ulnar and expose the volar structures.
The surgical approach to the radius? Well, to a degree, the radius would have been exposed in order to fix the radial head. But that's not the same entry point really for the graph. That's a bit more distal. And so there is, I guess, a dorsal approach between the brachial radiators and the ACL that allows that entry point to be visualized and measured a bit better.
And then there is a kind of a sub muscular tunneling that's done of the graph before tensioning and fixation with an Arthrex end button. Now the important thing is that if you are then going to consider the length of the ulnar, you can't really do an ulnar shortening. After that part of the procedure, you would really significantly compromise your potential reconstruction.
So I guess an algorithm for treatment really would be to take the patient to a theater screen. Before you have done anything else, make sure that you have all of the equipment you need and you may need available. Do a radius pull test to either open or closed fix. Will replace the radial head and make sure that it's congruence with regard to the proximal redo on the joint is accurate, then consider whether or not your discharge is now the appropriate height and has been reduced.
If it has, then you can proceed onto fixing firstly reinforced or prophylactically plated the radius. And that's because there's a considerably there's quite a big tunnel that they've used to place that really big graft, and they were obviously somewhat concerned about fracture. So they in this particular case recommended a prophylactic plating of the radius in order to minimize the risk of fracture.
Then they have obviously undertaken an ulnar shortening osteotomy, and that's the plate that you can see in the distal ulnar. And that has been obviously to restore the correct, I guess, alignment or the relative length of the two bones allowing the DOJ to reduce. And then finally, you'll be able to see on the distal honor there is an button, which they have used as part of their reconstruction of the intereses membrane, and the corresponding hole can be seen on the radius where the graph exits.
Now, in terms of the management of late stage instability, again, there's huge variability. And variability because there are so many different variables in terms of how patients present and what their problems are. It's by no means a uniform picture or pattern. And as the clinician, you've got to try to unpick the puzzle and figure out which parts of it need to be addressed, but invariably it's just the same as treating the primary injury.
And by that, I mean all three cases, so all three levels still need to be addressed. So you have to be able to restore proximal and distal radioulnar joint stability using whichever method you feel are at your disposal, or depending on whichever soft or bony tissues you have left for use or for reconstruction. What you can see here is a little annotation. This picture here is an Adams procedure, which is a dirigé stabilization using a length of tendon that you harvest from wherever you like.
And then you effectively drill the ulnar hole through the overpass through the radius and then tie the graph back onto itself. These days, the more contemporary version of that is to fix the graph within the Allen tunnel using a bio tenodesis screw the X-ray on the right is a patient of mine who has had a dislocated ulnar joint replacement for a long standing, regular length discrepancy, and the results of that are actually very promising.
They've been published well. And this is a good implant to use. The reason why the late stage reconstruction is arguably more relevant than the acute stage is because I think that ethics press Lopresti injuries are still underappreciated. And a couple of studies have shown that the actual rate of detection of an Essex Lopresti in the acute setting is only 33% percent, so 60% to 70% of Essex Lopresti injuries are unappreciated at the original time of treatment, and that probably means that lots of the patients who you may have already seen who have got a, you know, a radial head fracture and have been treated in isolation for a radial hip microfracture or a fracture of the distal ulna, perhaps do, in fact, have an injury to the intereses membrane as well.
And then as a result, these are the patients who come back further down the line with a failed rate or head replacement or persistent pain, a prominent ulnar clicking or subluxation or dislocation of the deluge or pain around the elbow. And when it comes to fixing or addressing chronic problems, it's definitely fair to say that the majority of people are kind of freestyling. And unless you work in a very big unit that sees a high number of upper limb injuries or high energy injuries or complex problems, you're unlikely really to see many of these in high numbers of all in clinical practice outside of those settings.
Here are just some further examples of how some solutions, you know, approximate rate of Allen a joint reconstruction is a difficult operation. And it's by no means something that has reliable, medium or long term results. We have already talked about the huge reconstruction. And if you start looking through the literature, you can really take your pick with regard to how you want to reconstruct your interests membrane.
if you are going to undertake the reconstruction of the membrane, your treatment options are identical to the ones that you would have available in the acute setting, so the techniques are exactly the same ones. But I guess the only difference is the timing of which they are applied an early recognition.
And so the final point really is that the best treatment of chronic instability is to appreciate the acute instability and apply good treatment in the acute setting. So have a high suspicion index of suspicion of the injury in the acute setting. Certainly, every person that you see who has got a radial head fracture, you should be taking a look at the wrist as well, at least examining it to see if there's been any significant disruption to the drug, although you have fixed the radial head in the acute setting.
Just make sure that it is at the correct length and height and that it is congruent with the proximal radial arm, the joint, and that you can't pull on it and dissociate it from the proximal ulnar. And I'm just going to go back to this slide here, and you will see that on this particular slide. There is obviously a significant injury to the radial head that you can see.
And so the surgeon has elected to fix that. Sorry to replace that. But if you start to look at that X-ray rather critically, the first thing that you will see is that it's really significantly overstuffed. So the relationship between the proximal radius and ulna has been really significantly disrupted. The head of the radius is not sitting within the notch of the proximal ulna, and there is dire status between the two bones.
So under appreciation of that will invariably lead to a late stage problem. If you stabilize the intereses membrane and give a little bit of stability, there is a chance that it will heal. There is a trend towards using synthetic devices, whether they're large or tight ropes. But the jury is still definitely out and it's dealer's choice.
And if you think about the fact that you know, the reoperation rate for these patients is really very high, that if you use a sort of a synthetic device with no big dissection and no big donor site morbidity, it still leaves you options further down the line to do a later stage reconstruction using some kind of tendon graft, if you wish, so that you've got something in the bag.
You don't want to necessarily burn all your options in the acute setting and have nowhere to go to further down the line. So and that brings us to the end of the talk. So thank you very much, everybody. I hope you found it useful and I'll happily take some questions. Thank you very much indeed. I'm on this very comprehensive lecture.
We have certainly learned a lot from you today. We definitely appreciate the process. My brain a lot more now. And I agree with you. It's underdiagnosed injury. And now we know that if the examination that passes by the table shows this radial head fracture, they don't just want us to talk about it. They want to talk more about the stability of the whole four arm stability of this joint.
And this way we get higher marks on the exam and covered the whole topic. And very interestingly, no interest in brain has many other functions stability. It's origin of muscles and also controls the movements. So I think talking about these concepts, that's not everyone knows about is it's very important exam setting. And I like the sequence you presented towards the end of the steps we are.
How do you approach this injury and how to present ourselves in a logical manner in the exam? I think a very useful sequence there. I think those guys who joined later, I assure you this is recorded and will be posted on the Fox mentor channel and on our UK. For you to go over this, I know some of us might find some of the concepts explained. They need to be revisited again, so I think we'll have another chance.
Robin, I just have a question. If you don't mind, I think you touched on it quite comprehensively covered the whole topic, but I have a question from Robert who asked what would be the best clinical test to assess for intrinsic muscles and brain injury? I know you said about the radial pull test, but I think you wanted to know if there's any other clinical test you could do in clinic or something like this.
I think that in the acute setting, it's very difficult because the clinical signs are not prominent, but you will find that the person who has turned up with a seemingly isolated injury to their elbow has got an asymmetry to their distal radiologists. So you will see that the distal ulna on one side is much more prominent than it is on the other. They would also have wrist pain or forearm pain as well, but because of the fact that they have had such a significant injury, like a meaningful clinical examination beyond that is really difficult. So in the same way that someone has a fracture of the medial malleolus and you are suspicious that they have an Mason nerve injury, you can palpate around the fibular head, but ultimately you are looking for a radiographic confirmation.
So if you have taken that X-ray of the elbow. And you are clinically suspicious or on the x-ray, you have seen that there is perhaps more of a disruption to the proximal radial ulnar joint. And there should be for an isolated passage or the mechanism of injury doesn't quite fit. So it was a high energy injury to fall from height, falling out onto an outstretched hand. Then you can also just be a bit more suspicious and confirm everything with an X-ray of the forearm and the wrist.
And I think when you put it all together, you're much more likely to pick it up rather than on clinical grounds alone. It's lovely. Just before I forget also, I would like to thank you for helping us to host this session. We couldn't have run it and distributed it so widely without their input. And I think, by the way, for us, I was just remembered something.
Yeah, I had a couple of slides to present at the end. Should I do that? Yes, please. If you don't mind. Take the patient to fair to do your radial pull test, fix the radial head, then reduce the deluge. And at that stage, you really have to make a decision as to whether or not you have restored adequately the length of the radius, because if you have not, then you have very limited options.
And what you don't want to do is to stabilize the radius and the ulnar if the judge or the deluge are subluxation dislocated, if you have not been able to really accurately restore the length of the radius. And at this stage as well, if you're really suspicious, you should screen the contralateral side because your patient may not be on a neutral variants, it could be positive or negative physiologically so compared to the other side.
And if you have got a suspicion that you're not going to make it all fit, then at that stage, you really need to think about shortening the ulnar in the acute setting because you need to do that first before you consider the intereses membrane reconstruction. So after you have made the two fit, then stabilize proximally and distally, do a TFCC repair and consider stabilizing that at the end with a transverse choir.
And then we talked about doing the religious membrane augmentation. Whichever way, whichever way you would, you would like to do is to thank Hawai Duke for a couple of reasons, really, mainly because they've been fantastic partners of mine over the past few years. I hope that some of the people who were on this webinar this evening have had the chance to come to one of my courses, or perhaps one of the courses that are run in conjunction with the people in London because there's a huge, fantastic postgraduate training program that they have supported over many years, not just with me, but lots of my colleagues from other London hospitals as well.
So we run courses that have helped innumerable people really pass the farke's course and without their support, we as teachers really wouldn't have been able to do the things that we enjoy doing, such as helping trainees along their career paths. They also published some pretty good revision books, and I'm hoping next year to be part of this illustrious group of people who have collaborated with our UK to publish books.
And hopefully you'll see something from me with a hand surgery for the Fox health exam, but there's an excellent basic science book and an excellent clinical science book for the exam. And for those of you who are interested in research, just to highlight that over the past few years, well, since 2004, our UK have given away nearly 10 million pounds in awards grants, and they've supported people doing independent research at all levels, whether it's basic science or clinical or molecular across the country.
And they are a charity, so they rely on everyone's kindness. And if anyone is interested in supporting our UK, then of course they can do through the website. I have one more, just one more, one more question. It's about how is the best way intraoperatively on image intensifier to assess the stability? Is there any, you know, because sometimes you see a little bit of subluxation or what looks like subluxation?
You're not sure. Is it truly subluxation? Should I be doing something? Is it stable or unstable? Is there any, any like hint on that? Yes Uh, so there's a couple of things, really, and I guess one way of doing it really is to make sure that when you're doing your X-rays. And this is not just true for the press, the injuries, this is a top tip for fixing distal radius fractures in general.
Quite often we are fixing a distal radius fracture through a volar approach. And so obviously the arm is supine natal and here's our incision along FCL. So at the time that the X-rays being wheeled in the forearm is in supine and the wrist X-ray is done as an anterior posterior X-ray. Now I think that it's actually quite difficult to judge the deluge through an X-ray.
And if you pronounce it and do a p.a., the X-ray is the one that we are all familiar with seeing on our X-rays. That's the one that's done in the Department by the radiographers, and that's done with the arm in full pronation. Now, the difference between the two will become increasingly obvious. The more you do it, you'll see that the position of the ulnar claw Allen.
It changes the orientation of the distal radius with regard to the arm changes. And then if on the table you undertake very gentle but subtle changes in the forearm rotation. What you're really looking for is the equivalent of a more view. Now we are all very familiar with trying to assess whether or not the ankle is perhaps reduced, whether the medial malodorous is on or off, whether there is instability of the syndesmosis.
And everybody will be able to look at the X-ray of the ankle and say this isn't mortise view. We say that all the time. Don't we go? This is not mortise view. The rotation of this X-ray is not correct. Therefore, we cannot make any judgments regarding the reduction of the microfracture or the position of the distal fibula with relation to the distal tibia.
And actually the same is true of the disk. So next time you're fixing a distal radius. Pro the forearm. And then just try to get an X-ray that allows you to shoot all the way through the disk without significant overlap and then with a little bit of tension and traction, you'll be able to see at that stage whether or not the two dissociate.
If in the case of a intereses membrane injury, you just put a clip, a sharp or a blunt clip on the distal Armour, you'll be able to pull it and you'll see a distance between the two. Otherwise, you'll be able to see perhaps a subtle separation and a distal radius fracture that hasn't been properly reduced. Or at that stage, you do a clinical assessment on the table at the end of your araf distal radius.
And if you have gross instability at that time, the likeliest cause is actually a malraux malreduction of your radius. If you find that your drug is wobbly, don't immediately assume that it's a TFCC problem, be really, really critical of your reduction because a disruption to the distal oblique band of the intereses membrane that has been caused by a reduction in its tension through malreduction will be as significant as an injury to the FCC.
Look, I think you did touch on your presentation. When you said reduction is very important and it achieves plays important part to achieve stability. So I think that's the key, I think. Now just one more question. I don't have another meeting to go to. I do. Is there a time for one more question or I'll be quick one. So you got the question from susanna?
She said. So basically, now we're sailing through this question in the exam, we went through various assessments, operating fixation and various more. And now the question is, how do you rehabilitate this? Is any particular points here, rehabilitation anything in particular? We should avoid any particular movements or. No, I think that the key is really not to load the forearm in any particular way.
The aim of all of this is obviously to get the forearm moving as soon as possible because otherwise, with a scale of injury like this, you would certainly find that stiffness sets in if you do what we all do and keep the patient and above elbow plaster because you're overly cautious. The forearm will never move again. So I think no specifics. Early mobilization if you're brave enough and you feel that your reconstruction has been good enough, passive range in your forearm as soon as possible, but without load.
So the loading has to be a very, very late stage thing. If you've got your wires in situ, but if you've achieved an early stabilization through a good interosseous membrane fixation, then the answer is Yes. You do have to load or get it moving relatively early because otherwise you will be fixed in quite significant fixed rotation. But definitely, if you have undertaken a drug fixation with wires, you will certainly not be able to immobilize that at all until the wires are out.
Robbie Ramone, thank you very much. We appreciate you kind of accepted our invitation to teach today, so we thank you very much. And we thank the team from all UK. We've learned a lot and we hope to see you again with us, either in another teaching session or in vivo practice session whenever your time allows. So thank you very much. Thank you.
Thank you. Thank you. Four other guys, please don't log off. Now the recording is.
Segment:0 .
Hello, everyone. Good evening, and welcome to this orthopedic teaching session organized jointly by the FRCS group and orthopedic Research UK. And started out, I will be moderating the session tonight. The speaker this evening is Mr Raymond jamma.
He's a consultant at King's College in London, specializing in hand, wrist and upper limb surgery. He's been the convener of the King's or UK hand surgery FRC course since its inception in 2012. These dedicated teacher and contributes to numerous postgraduate. Teaching programs across the UK and Europe, we are very pleased that he has kindly accepted our invitation to teach today.
Which? so thank you very much for us. Thank you for the kind introduction and thank you for inviting me. As you mentioned, I've been involved in teaching for quite a few years, but this is my first webinar. I feel slightly, slightly nervous, actually, but excited at the same time.
So should we get going with a lecture? Yes, please. If you hope to get to the bottom of the screen, you will find the Manage participants option and then you could have an option to raise your hand if you want to talk directly or participate. After the meeting, after the lecture, we will have the hot seat Viva practice session.
These the questions will be asked by various host FARC as mentors and one candidate will be on the hot seat and will be given feedback. It will be a real life scenario. And these are very limited. And there are no there are hundreds plus participants tonight. So please, if anyone is interested to take part, it's on first come, first serve basis.
Please express your interest. Either send me a message or raise the hand symbol next to your name. And without further ado, I will leave you, Mr tuberosity, now. OK, Thanks very much. The title of today's talk was officially Essex Lopresti injuries, but I guess for the purposes of the exam, we need to refer them as longitudinal forearm injuries. Now these are unusual injuries that by no means things that you would see under normal circumstances in an ordinary day at work.
You you may see one, you know, once or twice a year, but the important things about them are number one, they're really significant injuries. And unless you have good awareness of them, then your management will be insufficient or incorrect. So one of the purposes of today's talk is definitely to try to raise awareness of this particular type of injury. But it is definitely one of these topics that does turn up in the exam for the exact same reasons because it can catch you out as a clinician, and therefore it's perfect for an examiner to try and catch you out with during a clinical or reviver.
It's actually quite a big and a fairly complicated, a fairly postgraduate type of a subject, and it's definitely 1 to be treated by a specialist or a subspecialist. So the purpose of the talk today is to not give you the finer details with regard to how the surgical technique. I mean, for certain things in the trauma viper, you should definitely be able to talk about surgical technique in a lot of detail for certain things, which I guess are fairly high up that scale, maybe incrementally nailing fixation of a distal radius fracture.
And you'd be actually required to talk about the finer points of surgical technique. I don't think that longitudinal forearm injuries is one of those topics. You need to be familiar with some of the potential options for fixation of the injury. But I don't think that you're going to be specifically asked about details and you'll see why. As we go through the talk, it's because there is no single best way to treat these.
And actually, there's a great deal of variability in how people do treat them. So we'll just kick off. So just to introduce myself again, we've already had an interruption. I work at Kings College hospital, where I'm the lead clinician for orthopedic surgery. I also work at 40th clinic London, where I have a specific injury in treating sports injuries of the hand, wrist, elbow.
And if you want to get in touch afterwards, you can obviously do so via kings and an NHS email address or via my website, which is the hand specialist. So the talk is going to be roughly 10 points and point number one, which is arguably the most important point of all, is that we have to start considering the forearm as a joint. Most people just think it's a kind of a gap between the wrist and the elbow, but actually it really is a unit.
And it should be considered as a joint. And when you do consider it as a joint, you can understand the pathology and the treatment a great deal better. So there's obviously the proximal radial Allen, the joint and the distal arm, the joint with which we're familiar. But the bit in the middle, which we're really going to focus on for the purposes of this talk is the intereses membrane.
Now, some people have even gone maybe a step further, and they've started to refer this refer to the interruptus membrane or the IOM as the middle radio on a joint because it plays such a pivotal part in maintenance of forearm function and stability. And as we will see when it is injured, then there are some really significant ramifications in terms of function thereafter that need to be addressed. So, S6, Lopresti, it's one of these anonymous names that lots of people have heard about, but the syndrome, if you like, is characterized by three main things in every asx Lopresti injury, there is a radial head fracture.
There is some kind of injury to the radius at its proximal end that results in either fracture dislocation, sometimes both. But invariably the length of the radius or the radial height, if you like in respect to the ulnar has been changed and it's been shortened. The second path egawa mnemonic injury of the ESXi Lopresti is the disruption to the interruptus membrane and by disruption that usually refers to a kind of a tear.
And you should consider this in some respects to being like an injury to the syndesmosis in a Weber type C injury. Obviously, you see energy go through one side of the ankle and then exit through the syndesmosis as it exits through the other side. And unless you have recognized the significance of the sender's multiple injury and have taken steps to stabilize it.
Of course, your webisode ankle fixation will obviously fail as your rate as your tibia and fibula dissociate, so the IOM disruption is key. Thirdly, as the energy extends distally. So it's gone from the radio head, it's gone through the intereses membrane, which has become torn or ruptured, and then it extends distally and it exits through the digital radio on the joint. And again, it's really similar to other injuries of the lower limb Mason nerve type injury being a classic example where the entire length of the unit between the radius and the ulnar or indeed of the tibia and fibula gets disrupted both proximally and distally.
So when you put all of these three things together, you get the longitudinal radioulnar nerve association or otherwise known as the ESXi Lopresti injury. Now, who was ESXi lopresti? Peter Gordon s6? Lopresti was a gentleman who actually unfortunately died very young. He described these injuries whilst he was working in the army during just after the Second World war, and he wrote several papers not just on forearm injuries, but he also wrote a couple of papers on injuries to the says for people who were jumping out of planes.
And he was quite a distinguished army doctor. Despite his very, very young age, he became a member of the Royal College of surgeons, I think at 27 and died under mysterious circumstances at home in his early 30s, but his name has forever been associated with his first original description of this injury. Here are some of the x-rays that were part of his original paper, and you can see that nothing has changed, you know, in the 70 years since he first described this, what we can see in these pictures is there is a fracture of the radius.
There is some kind of disruption to the proximal radial on the joint and of course, distally. You can see that there's gross migration of the radius, approximately a significant disruption of the drug probably associated with the fracture in this case as well. Point number three, if we're going to consider longitudinal stability of the forearm, the most important structure is, in fact, the radial head. Now this particular fact has been well established for some time, and we know this because of the fact that historically people have tried to undertake where your head incisions in circumstances where reconstruction, replacement or fixation was not possible or degenerative changes that occurred.
Now we know that if the radial head is exercised in a young patient and someone who has high demand and there is some kind of disruption to the proximal radial ulnar joint and there is dire stasis or separation of the two or dissociation, the outcomes are terrible and people do extremely badly. And now we know from experience that this is really only an operation that is reserved for elderly people who are extremely low demand in whom are very cautious.
Resection of the radial head has been undertaken, which is not excessive and not sufficient to destabilize that proximal radial Allen the joint. So if the radial head has been established as the most important longitudinal stabilizer, then of course, when we are considering longitudinal forearm instability, the key really is to replace or at least fix or restore the radial head in some way, shape or form, as that is likely to provide the most significant contribution to longitudinal stability of the forearm in the injured setting.
So point number 4 is that after the radial head, the structure, which is the second most longitudinal stabilizer, is in fact the intereses membrane. This is a very clever little study that was done by Hotchkiss. And it effectively measured deformation of the radius when certain structures had been divided.
So you can see that the first line up at the top is the amount of deformation when you have an intact interruptus membrane. So what happens is that as you apply, load to the forearm load is shared between the radius and the ulnar. The forces of then transmitted in a very controlled manner through the proximal and distal on the joints, and there is very little relative movement between the radius and the ulna if you simply just resect the TFCC.
And of course, we are all familiar with the importance of the TFCC in regards to rotational stability of the forearm. But if you resect the task completely, there's only an 8% reduction in the amount of deformation between the two bones. However, if you resect the intereses membrane, then you have a massive 71% reduction in the overall ability of the two bones to resist load and die status occurs with much less force.
The intereses membrane is actually a ligament complex, it's not really a single structure. So here what we see is a specimen with the forearm muscles removed and we can now start to see that the ligament complex has actually got three bands. Now the first of these is the most important, and that's the central band. It has this kind of an oblique pathway that runs from 1 bone to the other.
But this orientation of 20 to 24 degrees with respect to the long axis of the armor is significant because as we will see later on, the methods of fixation or reconstruction of the intereses membrane rely quite significantly on restoring that band and that orientation. So that central bank is the broadest, and it's the, I guess, the most important because it's the strongest.
The next is the distal cord. Now the distal cord is smaller, but it sits just below the ulna head and around the metathesis of the distal radius and the ulnar. Now this has a really significant contribution to drug stability. And so when I think quite often we sometimes overlook this because we do fixation of distal radius and distal on the fractures.
And people come along with secondary deluge, instability, problems, and of course, our natural tendency is to assume that this comes from some kind of TFCC problem. However, if your radius has not been anatomically fixed and quite often what we see is a kind of a real realization of the articular surface, which is very typical of a Colles fracture.
So the shaft of the radius moves in an ulnar direction with relation to the articular surface. And of course, what that does is it detentions the distal cord. So in the setting that people come along with DRUJ instability after a fracture? Yes, of course, you have to consider a TFCC problem or disruption, but have a look at the anatomy of the fracture. Have a look at the fixation, the potential for Mount Union.
And actually, you will probably find that in a lot of cases. And if you are a surgeon who's interested in doing wrist surgery, if you start doing corrective osteotomy, you will find that when you put the distal radius back into its correct position, you almost immediately restore WJZ stability by doing nothing at all to the TFCC. And that's because you have restored the tension in the distal cord. Finally, there is probably a slightly less important but still well recognized structure, which is the proximal oblique cord.
Although these are the three structures which have been largely described that there's huge variation and plenty of studies have shown that anatomic variations are the rule. But I guess if you were to look at these four specimens, you would probably still be able to make out a central band in all four specimens and probably a distal and proximal band in most of them as well, with some variations in between.
But certainly the consistent structures, I think, are there. So what does the intereses membrane do apart from holder two bones together? Well, we know that it has this function to control forearm pro and supine, and it becomes tense when it is in most tents, when it's in supination. And just like any other ligaments of structure, it has a very important role in kinematics.
Secondly, I alluded to this earlier, but it helps to transfer load from the radius to the ulnar, because if that didn't happen, you would have very, very preferential load transfer across one bone or the other, most likely the radius. And we see that in situations where the interosseous membrane has ruptured and there has been an Essex Lopresti injury. And the radius has been sort of the radial head has been fixed or replaced.
And in the setting that the interosseous membrane has not been reconstructed. All of the forces subsequently passed through the radius and very little through the armor. And the upshot of that is that you get premature failure of your radial head replacement or fixation just because the forces are so great and the interosseous membrane is not allowing that load share that load transfer onto the ulnar.
Of course, we have discussed the fact that the IOM is essential for longitudinal stability and for transfer stability. It provides additional stability over and above the ligaments of the proximal radial on the joint and the distal radio, while the joint. If you look through your forearm anatomy coming up to the exam, you will see that at least half of the forearm muscles have an origin somewhere on the interosseous membrane.
So it's a really important site. And this is potentially one of the reasons why people develop a significant lack of grip strength after Essex Lopresti injuries. It may well be that the proximal anchor to the muscle is now unstable. The final point is not so well proven, but I guess it's highly suspected like all ligament structures.
There is a role for proprioception, and we all know that people who have had, for instance, an ACL rupture or reconstruction have significant proprioception issues and they have to go through quite a lot of rehab to try to restore that after the reconstruction. So moving on now to how we might go about treating these injuries. Point number 5 is that if you have longitudinal instability, then you have to.
If you want to successfully treat it, you have to address it at all levels. And that means that you start off with the radial head and the proximal radial ulnar joint that needs to be stabilized. Of course, you need to stabilize the distal end of the joint as well, which involves a drug stabilization and a TFCC repair. But importantly, you have to consider what's in the middle as well.
So without addressing all three levels, you may well be insufficiently treating quite a significant injury. Point number 6 is your starting point, I guess, for any kind of treatment. So the first thing that you have to be able to do is to restore the radial head. And by that, I really mean you have to make sure that the congruence between the proximal radius and ulna has been restored and you have got good proximal radial ulnar joint alignment.
Now, in certain cases, it's difficult. It's harder to achieve that than you would think, mainly because there has been a very significant disruption. It's easy to overstuffed or under stuff, a radial head replacement and achieving an accurate restoration. The point that I was making is that if your radius is short, then it's going to be very difficult for you to orientate or to reduce your distal radial ulnar joint.
So obviously, everything that happens at the proximal end has a direct influence on what happens at the distal end. And if you don't get that right and it's very easy to get it wrong, then you have to start thinking about options to change the length of the ulnar. In order to match that of the radius, and that becomes quite a complicated task. But it's something that we'll be able to talk through in a little bit more detail as we go along.
So although restoring the radio height gives improvement to your longitudinal stability, it does not restore biomechanics because we know that the intereses membrane has been significantly disrupted. And as I mentioned before, if you do not undertake some kind of interosseous membrane reconstruction, then almost 100% of the forces that get transmitted go through the radius.
And of course, that far exceeds the capability of your implant or your fixation to survive those loads in a few animal or cadaveric studies that have been done. If you reconstruct the atrocious membrane. And in this particular one that I've quoted here, you take out an Achilles tendon allograft. Then all of a sudden you can reduce the force transmission quite significantly and almost achieve a 50% reduction in or improvement in low transmission from radius to ulna.
So after you have. Done the proximal aspect of your surgery. Then you can start to think about what's happening more distally now, this next step is kind of, I guess, simplified for the purposes of saying something in the exam. The actual treatment algorithm is somewhat more complicated because at this stage, I'm assuming or let's just assume for the purposes of this talk that by fixing the radial head or by replacing the radio head, you have achieved a fairly accurate or anatomic restoration of the length of the radius, and you do not have some kind of length discrepancy between the two bones.
Now, if that's the case, then you can proceed on to stabilizing the disk. So at that stage, you would really need to make sure that the distal redwan, a joint, is a congruent. There is no interposition of soft tissue and that on the head is sitting very neatly within the sigmoid notch. And at that stage, you would undertake a task repair.
Now, for those of you who are not particularly familiar, there's plenty of ways of doing this, but effectively you can either do a dorsal or a lateral type incision. There are plenty of descriptions of anatomical approaches to the task, and the majority of people now would probably place through an open approach a couple of decent, non-negotiable sutures through the periphery of the GFC and then anchor it down to a drill hole that has been made at the fovea, which sits just at the base of the armor.
Those sutures can then be pulled out of the hole, and that hole exits onto the lateral border of the armor and then you can do what you like with those sutures. Thereafter, you could tie them to themselves or lots of people now just use a push lock anchor and secure it into the shaft of the armor. Now, in all of these settings, these two tiny stitches are rarely sufficient to really be able to maintain decent stability of the DOJ.
The force is going through it are excessive. If you were doing an isolated task repair for some kind of other indication, you would definitely support your repair by placing someone in and above elbow cast. But in the setting where there's been gross disruption of the entire forearm, most people would probably advocate supporting the drug further with one or two Y's that are passed across.
You do have to be slightly careful here because if you have then passed these two wires and you're going to continue your surgery during which you're going to be prone and supine in the forearm, you certainly don't want those wires to break. And if they do break, you have to be able to make sure that you can retrieve them. So if you are passing a drug. Just make sure that you leave it proud, both on the radial side and on the ulna side so that you can retrieve it should it break.
And for most cases, I recommend that actually you don't pass them through until the very end. It's probably one of the final steps of the operation, otherwise they are prone to bending and breaking. So then I guess the million question is after you've done the proximal bit and the distal bit. What do you do with a bit in the middle?
Well, there's no best answer here. We know that if the intereses membrane is ruptured acutely, then transfer of load cannot occur. Then you have persistent instability and then in the presence of persistent instability, no ligament. A structure will really ever heal, especially if that's a longitudinal type of translational force.
So realistically, if we are hoping to achieve any kind of healing intrinsic, biological healing of the influences membrane, we do have to confer some kind of stability to it. One thing that can help determine the degree of injury is called the radial pull test and the radial pull test can really be done earlier on at the time of fixation of the radius and the radial head. And there are two ways of doing it, and it's been described in more than one way.
The first way is actually just by pulling on the radius at the beginning of the case. So effectively you take the thumb, you put on the thumb and you see whether or not there is greater than 6 millimeters of longitudinal displacement. And that indicates that there has been gross disruption of the intereses membrane, the pigeon. The equally a similar test can be undertaken using a clamp. So when you've done an approach to the proximal radius or the radial head, you simply take a clamp on the proximal aspect of the shaft and then you can effectively translate and push the radius backwards and forwards to effectively see whether or not the translation measures up.
So 3 millimeters indicates that there has been a disruption of some degree that obviously includes the radial head and the deluge. But if you have 6 millimeters or more, as is often the case, then you have a complete disruption of the IOM as well. So as we mentioned before as well, if the membrane does not heal, you're in big trouble because then your radial head fixation or replacement will soon fail. And then you are then realistically looking at a patient who's in significant pain, has poor forearm function, and soon after the primary injury, you'll be considering salvage options, which is not ideal.
So this has led people to consider acute primary interosseous membrane reconstruction. It's not really feasible to stitch it back together, mainly because you would have to peel off all of the muscles of forearm. It would be an unbelievably difficult thing to do in the acute setting. And it's a membrane, a structure and simply stitching it together, I think, has led to very, very poor results.
So this has led people to consider treatment in three main groups, and these are using tendon grafts, synthetic grafts and Allen. Now, there is no single best way to treat this by any stretch of the imagination if you look through the literature. And prior to this talk, I had another look through the literature. People are just presenting, you know, individual case reports or reviews with two or three cases in them outlining a particular technique.
And so there are definitely no significant studies that are in significant numbers or have decent long term outcome data. But people have been extremely inventive and under the banner of tendon grafts people have taken prone to break your radial scroll bone patellar tendon bone, Palomares flexor copy radiators. The problem with this is obviously donor site morbidity, and sometimes you need quite a big surgical exposure if you're going to take enough graft material.
Synthetic grafts have also been used for those of you who do a surgery or perhaps ACL surgery. You'll be familiar with large ligaments. But one device, which has certainly become more popular, is a tightrope. We use tight ropes again in lots of other limb surgery, and of course, we're using tight ropes in the syndesmosis and the ankle. There are flex products, and they have pros and cons.
I guess there's no donor site morbidity. But the issue with them is that they are a fixed length and whereas a biological graft may potentially have the opportunity to stretch with time, that could be a good or a bad thing, depending on how these synthetic grafts are tensions. Either you get it right first time or you're either a bit lax and a bit wobbly or a bit too tight, and then forearm rotation is significantly restricted.
Allograft have also been described, but these are mainly in cadaver studies. But perhaps there is some promising data from facial after tib and tend Achilles and again, bone patellar tendon bone. The final picture just here on the right of the screen gives you an idea of roughly how you would orientate your graft. And then it becomes kind of like doing an ACL. You pick your spot, you drill your tunnels, you pass your graft.
And then you secure it. And because of the knowledge that we have regarding the position of the central band of the atrocious membrane. Broadly speaking, there are some fairly reliable measurements that we can apply to the forearm in order to plan our tunnels. So you'll see that the Alma Tunnel is located at 33% of the ulnar length as a point measured from the tip of the arm on the stylized and the radial tunnel is at 60% of the length of the radius.
And that gives you the opportunity to try to restore that 21 degree angle, which is more or less the orientation of the central band. Here are just some pictures these are not mine. These are taken from one of the numerous studies that describe techniques. And you can see that a free tendon graft has been taken. In this case, I think it was a tibial.
It's been stitched at both ends using familiar equipment, which we all use for other indications. You pass a guidewire after you have made your measurements. You drill over it. You pass your whip stitched graft through. The surgical approach to the distal ulnar nerve is relatively straightforward. And as you can see, you effectively come along the subcutaneous border of the ulnar and expose the volar structures.
The surgical approach to the radius? Well, to a degree, the radius would have been exposed in order to fix the radial head. But that's not the same entry point really for the graph. That's a bit more distal. And so there is, I guess, a dorsal approach between the brachial radiators and the ACL that allows that entry point to be visualized and measured a bit better.
And then there is a kind of a sub muscular tunneling that's done of the graph before tensioning and fixation with an Arthrex end button. Now the important thing is that if you are then going to consider the length of the ulnar, you can't really do an ulnar shortening. After that part of the procedure, you would really significantly compromise your potential reconstruction.
So I guess an algorithm for treatment really would be to take the patient to a theater screen. Before you have done anything else, make sure that you have all of the equipment you need and you may need available. Do a radius pull test to either open or closed fix. Will replace the radial head and make sure that it's congruence with regard to the proximal redo on the joint is accurate, then consider whether or not your discharge is now the appropriate height and has been reduced.
If it has, then you can proceed onto fixing firstly reinforced or prophylactically plated the radius. And that's because there's a considerably there's quite a big tunnel that they've used to place that really big graft, and they were obviously somewhat concerned about fracture. So they in this particular case recommended a prophylactic plating of the radius in order to minimize the risk of fracture.
Then they have obviously undertaken an ulnar shortening osteotomy, and that's the plate that you can see in the distal ulnar. And that has been obviously to restore the correct, I guess, alignment or the relative length of the two bones allowing the DOJ to reduce. And then finally, you'll be able to see on the distal honor there is an button, which they have used as part of their reconstruction of the intereses membrane, and the corresponding hole can be seen on the radius where the graph exits.
Now, in terms of the management of late stage instability, again, there's huge variability. And variability because there are so many different variables in terms of how patients present and what their problems are. It's by no means a uniform picture or pattern. And as the clinician, you've got to try to unpick the puzzle and figure out which parts of it need to be addressed, but invariably it's just the same as treating the primary injury.
And by that, I mean all three cases, so all three levels still need to be addressed. So you have to be able to restore proximal and distal radioulnar joint stability using whichever method you feel are at your disposal, or depending on whichever soft or bony tissues you have left for use or for reconstruction. What you can see here is a little annotation. This picture here is an Adams procedure, which is a dirigé stabilization using a length of tendon that you harvest from wherever you like.
And then you effectively drill the ulnar hole through the overpass through the radius and then tie the graph back onto itself. These days, the more contemporary version of that is to fix the graph within the Allen tunnel using a bio tenodesis screw the X-ray on the right is a patient of mine who has had a dislocated ulnar joint replacement for a long standing, regular length discrepancy, and the results of that are actually very promising.
They've been published well. And this is a good implant to use. The reason why the late stage reconstruction is arguably more relevant than the acute stage is because I think that ethics press Lopresti injuries are still underappreciated. And a couple of studies have shown that the actual rate of detection of an Essex Lopresti in the acute setting is only 33% percent, so 60% to 70% of Essex Lopresti injuries are unappreciated at the original time of treatment, and that probably means that lots of the patients who you may have already seen who have got a, you know, a radial head fracture and have been treated in isolation for a radial hip microfracture or a fracture of the distal ulna, perhaps do, in fact, have an injury to the intereses membrane as well.
And then as a result, these are the patients who come back further down the line with a failed rate or head replacement or persistent pain, a prominent ulnar clicking or subluxation or dislocation of the deluge or pain around the elbow. And when it comes to fixing or addressing chronic problems, it's definitely fair to say that the majority of people are kind of freestyling. And unless you work in a very big unit that sees a high number of upper limb injuries or high energy injuries or complex problems, you're unlikely really to see many of these in high numbers of all in clinical practice outside of those settings.
Here are just some further examples of how some solutions, you know, approximate rate of Allen a joint reconstruction is a difficult operation. And it's by no means something that has reliable, medium or long term results. We have already talked about the huge reconstruction. And if you start looking through the literature, you can really take your pick with regard to how you want to reconstruct your interests membrane.
if you are going to undertake the reconstruction of the membrane, your treatment options are identical to the ones that you would have available in the acute setting, so the techniques are exactly the same ones. But I guess the only difference is the timing of which they are applied an early recognition.
And so the final point really is that the best treatment of chronic instability is to appreciate the acute instability and apply good treatment in the acute setting. So have a high suspicion index of suspicion of the injury in the acute setting. Certainly, every person that you see who has got a radial head fracture, you should be taking a look at the wrist as well, at least examining it to see if there's been any significant disruption to the drug, although you have fixed the radial head in the acute setting.
Just make sure that it is at the correct length and height and that it is congruent with the proximal radial arm, the joint, and that you can't pull on it and dissociate it from the proximal ulnar. And I'm just going to go back to this slide here, and you will see that on this particular slide. There is obviously a significant injury to the radial head that you can see.
And so the surgeon has elected to fix that. Sorry to replace that. But if you start to look at that X-ray rather critically, the first thing that you will see is that it's really significantly overstuffed. So the relationship between the proximal radius and ulna has been really significantly disrupted. The head of the radius is not sitting within the notch of the proximal ulna, and there is dire status between the two bones.
So under appreciation of that will invariably lead to a late stage problem. If you stabilize the intereses membrane and give a little bit of stability, there is a chance that it will heal. There is a trend towards using synthetic devices, whether they're large or tight ropes. But the jury is still definitely out and it's dealer's choice.
And if you think about the fact that you know, the reoperation rate for these patients is really very high, that if you use a sort of a synthetic device with no big dissection and no big donor site morbidity, it still leaves you options further down the line to do a later stage reconstruction using some kind of tendon graft, if you wish, so that you've got something in the bag.
You don't want to necessarily burn all your options in the acute setting and have nowhere to go to further down the line. So and that brings us to the end of the talk. So thank you very much, everybody. I hope you found it useful and I'll happily take some questions. Thank you very much indeed. I'm on this very comprehensive lecture.
We have certainly learned a lot from you today. We definitely appreciate the process. My brain a lot more now. And I agree with you. It's underdiagnosed injury. And now we know that if the examination that passes by the table shows this radial head fracture, they don't just want us to talk about it. They want to talk more about the stability of the whole four arm stability of this joint.
And this way we get higher marks on the exam and covered the whole topic. And very interestingly, no interest in brain has many other functions stability. It's origin of muscles and also controls the movements. So I think talking about these concepts, that's not everyone knows about is it's very important exam setting. And I like the sequence you presented towards the end of the steps we are.
How do you approach this injury and how to present ourselves in a logical manner in the exam? I think a very useful sequence there. I think those guys who joined later, I assure you this is recorded and will be posted on the Fox mentor channel and on our UK. For you to go over this, I know some of us might find some of the concepts explained. They need to be revisited again, so I think we'll have another chance.
Robin, I just have a question. If you don't mind, I think you touched on it quite comprehensively covered the whole topic, but I have a question from Robert who asked what would be the best clinical test to assess for intrinsic muscles and brain injury? I know you said about the radial pull test, but I think you wanted to know if there's any other clinical test you could do in clinic or something like this.
I think that in the acute setting, it's very difficult because the clinical signs are not prominent, but you will find that the person who has turned up with a seemingly isolated injury to their elbow has got an asymmetry to their distal radiologists. So you will see that the distal ulna on one side is much more prominent than it is on the other. They would also have wrist pain or forearm pain as well, but because of the fact that they have had such a significant injury, like a meaningful clinical examination beyond that is really difficult. So in the same way that someone has a fracture of the medial malleolus and you are suspicious that they have an Mason nerve injury, you can palpate around the fibular head, but ultimately you are looking for a radiographic confirmation.
So if you have taken that X-ray of the elbow. And you are clinically suspicious or on the x-ray, you have seen that there is perhaps more of a disruption to the proximal radial ulnar joint. And there should be for an isolated passage or the mechanism of injury doesn't quite fit. So it was a high energy injury to fall from height, falling out onto an outstretched hand. Then you can also just be a bit more suspicious and confirm everything with an X-ray of the forearm and the wrist.
And I think when you put it all together, you're much more likely to pick it up rather than on clinical grounds alone. It's lovely. Just before I forget also, I would like to thank you for helping us to host this session. We couldn't have run it and distributed it so widely without their input. And I think, by the way, for us, I was just remembered something.
Yeah, I had a couple of slides to present at the end. Should I do that? Yes, please. If you don't mind. Take the patient to fair to do your radial pull test, fix the radial head, then reduce the deluge. And at that stage, you really have to make a decision as to whether or not you have restored adequately the length of the radius, because if you have not, then you have very limited options.
And what you don't want to do is to stabilize the radius and the ulnar if the judge or the deluge are subluxation dislocated, if you have not been able to really accurately restore the length of the radius. And at this stage as well, if you're really suspicious, you should screen the contralateral side because your patient may not be on a neutral variants, it could be positive or negative physiologically so compared to the other side.
And if you have got a suspicion that you're not going to make it all fit, then at that stage, you really need to think about shortening the ulnar in the acute setting because you need to do that first before you consider the intereses membrane reconstruction. So after you have made the two fit, then stabilize proximally and distally, do a TFCC repair and consider stabilizing that at the end with a transverse choir.
And then we talked about doing the religious membrane augmentation. Whichever way, whichever way you would, you would like to do is to thank Hawai Duke for a couple of reasons, really, mainly because they've been fantastic partners of mine over the past few years. I hope that some of the people who were on this webinar this evening have had the chance to come to one of my courses, or perhaps one of the courses that are run in conjunction with the people in London because there's a huge, fantastic postgraduate training program that they have supported over many years, not just with me, but lots of my colleagues from other London hospitals as well.
So we run courses that have helped innumerable people really pass the farke's course and without their support, we as teachers really wouldn't have been able to do the things that we enjoy doing, such as helping trainees along their career paths. They also published some pretty good revision books, and I'm hoping next year to be part of this illustrious group of people who have collaborated with our UK to publish books.
And hopefully you'll see something from me with a hand surgery for the Fox health exam, but there's an excellent basic science book and an excellent clinical science book for the exam. And for those of you who are interested in research, just to highlight that over the past few years, well, since 2004, our UK have given away nearly 10 million pounds in awards grants, and they've supported people doing independent research at all levels, whether it's basic science or clinical or molecular across the country.
And they are a charity, so they rely on everyone's kindness. And if anyone is interested in supporting our UK, then of course they can do through the website. I have one more, just one more, one more question. It's about how is the best way intraoperatively on image intensifier to assess the stability? Is there any, you know, because sometimes you see a little bit of subluxation or what looks like subluxation?
You're not sure. Is it truly subluxation? Should I be doing something? Is it stable or unstable? Is there any, any like hint on that? Yes Uh, so there's a couple of things, really, and I guess one way of doing it really is to make sure that when you're doing your X-rays. And this is not just true for the press, the injuries, this is a top tip for fixing distal radius fractures in general.
Quite often we are fixing a distal radius fracture through a volar approach. And so obviously the arm is supine natal and here's our incision along FCL. So at the time that the X-rays being wheeled in the forearm is in supine and the wrist X-ray is done as an anterior posterior X-ray. Now I think that it's actually quite difficult to judge the deluge through an X-ray.
And if you pronounce it and do a p.a., the X-ray is the one that we are all familiar with seeing on our X-rays. That's the one that's done in the Department by the radiographers, and that's done with the arm in full pronation. Now, the difference between the two will become increasingly obvious. The more you do it, you'll see that the position of the ulnar claw Allen.
It changes the orientation of the distal radius with regard to the arm changes. And then if on the table you undertake very gentle but subtle changes in the forearm rotation. What you're really looking for is the equivalent of a more view. Now we are all very familiar with trying to assess whether or not the ankle is perhaps reduced, whether the medial malodorous is on or off, whether there is instability of the syndesmosis.
And everybody will be able to look at the X-ray of the ankle and say this isn't mortise view. We say that all the time. Don't we go? This is not mortise view. The rotation of this X-ray is not correct. Therefore, we cannot make any judgments regarding the reduction of the microfracture or the position of the distal fibula with relation to the distal tibia.
And actually the same is true of the disk. So next time you're fixing a distal radius. Pro the forearm. And then just try to get an X-ray that allows you to shoot all the way through the disk without significant overlap and then with a little bit of tension and traction, you'll be able to see at that stage whether or not the two dissociate.
If in the case of a intereses membrane injury, you just put a clip, a sharp or a blunt clip on the distal Armour, you'll be able to pull it and you'll see a distance between the two. Otherwise, you'll be able to see perhaps a subtle separation and a distal radius fracture that hasn't been properly reduced. Or at that stage, you do a clinical assessment on the table at the end of your araf distal radius.
And if you have gross instability at that time, the likeliest cause is actually a malraux malreduction of your radius. If you find that your drug is wobbly, don't immediately assume that it's a TFCC problem, be really, really critical of your reduction because a disruption to the distal oblique band of the intereses membrane that has been caused by a reduction in its tension through malreduction will be as significant as an injury to the FCC.
Look, I think you did touch on your presentation. When you said reduction is very important and it achieves plays important part to achieve stability. So I think that's the key, I think. Now just one more question. I don't have another meeting to go to. I do. Is there a time for one more question or I'll be quick one. So you got the question from susanna?
She said. So basically, now we're sailing through this question in the exam, we went through various assessments, operating fixation and various more. And now the question is, how do you rehabilitate this? Is any particular points here, rehabilitation anything in particular? We should avoid any particular movements or. No, I think that the key is really not to load the forearm in any particular way.
The aim of all of this is obviously to get the forearm moving as soon as possible because otherwise, with a scale of injury like this, you would certainly find that stiffness sets in if you do what we all do and keep the patient and above elbow plaster because you're overly cautious. The forearm will never move again. So I think no specifics. Early mobilization if you're brave enough and you feel that your reconstruction has been good enough, passive range in your forearm as soon as possible, but without load.
So the loading has to be a very, very late stage thing. If you've got your wires in situ, but if you've achieved an early stabilization through a good interosseous membrane fixation, then the answer is Yes. You do have to load or get it moving relatively early because otherwise you will be fixed in quite significant fixed rotation. But definitely, if you have undertaken a drug fixation with wires, you will certainly not be able to immobilize that at all until the wires are out.
Robbie Ramone, thank you very much. We appreciate you kind of accepted our invitation to teach today, so we thank you very much. And we thank the team from all UK. We've learned a lot and we hope to see you again with us, either in another teaching session or in vivo practice session whenever your time allows. So thank you very much. Thank you.
Thank you. Thank you. Four other guys, please don't log off. Now the recording is.
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