Essex-Lopresti Injury

The Essex-Lopresti injury is a severe and often underdiagnosed forearm injury characterized by a triad of:

• Radial head fracture
• Disruption of the interosseous membrane (IOM)
• Dislocation or instability of the distal radioulnar joint (DRUJ)

This injury leads to longitudinal radioulnar dissociation and forearm instability.

Epidemiology

• Considered rare but clinically significant
• Frequently missed at initial presentation (up to 60% of cases)
• Commonly associated with high-energy trauma

Mechanism of Injury

The classic mechanism of Essex-Lopresti injury involves:

• Axial load applied to the forearm, typically from a fall on an outstretched hand (FOOSH)
• Elbow usually in extension at impact

This force transmits proximally, causing:

1. Radial head fracture
2. Disruption of the interosseous membrane
3. DRUJ instability

See Also: Radial Head Fractures

Pathoanatomy

Key Structures Involved

• Radial head → primary stabilizer against proximal migration
• Interosseous membrane (central band) → load-sharing structure
• Distal radioulnar joint (DRUJ) → distal forearm stability

Loss of these stabilizers results in:

• Proximal migration of the radius
• Ulnar-positive variance at the wrist
• Global forearm instability

Clinical Presentation

Acute Phase

• Lateral elbow pain (radial head fracture)
• Wrist pain (often overlooked)
• Forearm tenderness

Chronic/Missed Cases

• Persistent wrist pain (ulnar impaction)
• Decreased grip strength
• Limited pronation/supination
• Elbow pain due to radiocapitellar degeneration

Diagnosis

Key Point

High index of suspicion is essential—radiographs may appear normal initially.

Imaging

• X-ray: radial head fracture ± DRUJ widening
• Ulna variance: increased (suggests proximal radial migration)
• MRI: evaluates interosseous membrane injury
• CT scan: better fracture characterization

See Also: Elbow X-Ray Views

Clinical Clues

• Wrist pain with radial head fracture = assume Essex-Lopresti until proven otherwise

Complications

Missed or untreated injuries can lead to:

• Chronic wrist pain (ulnar abutment syndrome)
• Radiocapitellar arthritis
• Forearm instability
• Loss of rotation and function

Essex-Lopresti injury Treatment

Acute Management

Early recognition is critical.

Surgical Principles

1. Radial head preservation or replacement
   • Essential to prevent proximal migration
2. DRUJ stabilization
   • Temporary pinning or repair
3. Interosseous membrane management
   • Reconstruction may be required

Chronic Injury Management

• Often more complex and less predictable
• Options include:
  • IOM reconstruction (e.g., tendon graft)
  • Radial head prosthesis
  • Ulnar shortening osteotomy

Evidence-Based Insight

Biomechanical studies show:

• Loss of the radial head + IOM disruption leads to dramatic instability
• Combined radial head replacement and IOM reconstruction can restore near-normal stability

Prognosis

• Good outcomes if Essex-Lopresti injury is treated early
• Poor outcomes if diagnosis is delayed
• Chronic cases often result in permanent functional limitations

Key Takeaways

• Essex-Lopresti injury = radial head fracture + IOM rupture + DRUJ instability
• Frequently missed → always examine the wrist
• Radial head must be preserved or replaced
• Early treatment prevents devastating long-term complications

References & More

1. Matson AP, Ruch DS. Management of the Essex-Lopresti Injury. J Wrist Surg. 2016 Aug;5(3):172-8. doi: 10.1055/s-0036-1584544. Epub 2016 Jun 20. PMID: 27468366; PMCID: PMC4959902. Pubmed
2. Masouros PT, Apergis EP, Babis GC, Pernientakis SS, Igoumenou VG, Mavrogenis AF, Nikolaou VS. Essex-Lopresti injuries: an update. EFORT Open Rev. 2019 Apr 29;4(4):143-150. doi: 10.1302/2058-5241.4.180072. PMID: 31057951; PMCID: PMC6491950. Pubmed
3. Kholinne E, Jeon IH. Quantitative analysis of forearm instability in an Essex-Lopresti injury model: effects of radial head replacement and interosseous membrane reconstruction. Int Orthop. 2026 Jan;50(1):141-150. doi: 10.1007/s00264-025-06699-7. Epub 2025 Nov 14. PMID: 41238929. Pubmed
4. Egol KA. Handbook of fractures. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2019.