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La membrana interosea,
anatoma, fisiologa y patologa
Christian Dumontier, MD, PhD
Guadeloupe
With the help of Marc Soubeyrand and Scott Kozin

Anatomy

Anatomy

Insertion on both radius and ulna

on more than 10 cm
Thickness: 2,18 mm
It belongs to the aponeurotic
system of the forearm
It is one part of the forearm
compartment

Composition
Prolongation of the
periosteum of ulna and
radius
Collagen (60-90%) and
elastin in the proximal
and distal part
Central band:
Intermediate structure
between a fascia and a
ligament

Anatomy
Two types of fibers that forms a
crisscross system
Fibers going from the ulna to the
radius and from proximal to distal
Fibers oriented from the ulna to the
radius and from distal to proximal
which are the most important

Fibers directed distally and radially

Oblique cord (Weitbrechts

ligament), thick structure (
1-3 mm)
Proximal band (inconstant 2,87 +/- 0,71 mm thickness)

Fibers directed proximally and

radially
Three parts: membranous - central band membranous
124

INTEROSSEOUS MEMBRANE OF THE FOREARM ! WRIGHT

Central band: 1,3 mm thick / 1 cm large

FIGURE 1. (A)
cadaveric spe
forearm with s
moved down
Note the CB is
area in the cen
tire IOM com
Camacho Garcia FJ et al. Descripcin anatmica de la membrana intersea del antebrazo: estudio
en
courtesy
of La
cadveres. Rev Colomb Ortop Traumatol. 2013;27(3):140-143
MD. (B) Same

Posterior view

1,1 to 2,6 cm
2,7-3,5 cm

57%

7,7 cm

25
13,2 cm

32%
Anterior view

Distal membranous portion

Presence of a distal oblique bundle in 12/30
specimens
Distal fibers blend with the DRUJ (even TFCC)

K. Noda et al. JHS 2009; 34A: 415-422

Physiology and
biomechanics of
the interosseous
membrane

Indirect physiological role

Limits one of the boarder of the forearm compartment

Indirect physiological role

It is the insertion site for

the muscles:
Anterior compartment:
FPL, FDP
Posterior: EPL, APL, EIP

EIP
EPL
APL

Direct physiological role

It is one of the elements of
the forearm and participates
in its physiology
The mechanical implications
are only known for the
central band
Transmission of axial and
transversal loads

Anatomical structures responsible of the forearm stability

Radial head, annular
ligament, Transverse
(Denuc) ligament

DRUJ, TFCC (+/DOB)

Interosseous membrane and the muscles

inserting on both ulna and radius

Transverse instability
The anatomy of the two radioulnar
joint tends to push apart the two
forearm bones and the IOM resists
Ulnar head resection tends to
diminish the interosseous space
between the ulna diaphysis and the
radius (radio-ulnar abutment)
The radial head also has the role of
a spacer

y correct
oduction

eect of
nar joint
erosseous
dierent
forearm
nt in the
ment.

d to ligaforearm
measured
the wrist
ton Hoscurely ata 5 mm
the ulna
pals (Fig.
the ulna,
d on two
vent rota-

tached to the pneumatic device pass along the frame

parallel to the steel rods and over pulleys at the other
end of the frame. Weights attached to these wires allow
a compressive axial load to be applied to the forearm
from the hand across the wrist.
A FlexiForce" A101 transducer (Tekscan, Boston,
USA) was inserted into the distal radioulnar joint
through the sacciform recess to measure the force in
the joint. The transducer was calibrated by connecting
to a digital multimeter (Model T110B, Beckman Industrial Ltd, Fullerton, California, USA) to measure the
resistance. A flat plastic disc was cut with dimensions
just covering the sensing area of the transducer. Weights
were balanced on the puck to load the transducer from 0
to 1100 grams, and the load was found to be proportional to inverse logarithm of the resistance.
A 3 mm microminature DVRT" (Microstrain, Burlington, Vermont, USA) was sutured to the central band
of the interosseous membrane on the dorsal surface and
parallel to the fibres (Fig. 2). The DVRT was connected
to a PC via the Microstrain motherboard. The Microstrain software allowed a continuous reading of linear
displacement shown as a displacement versus time graph
on the PC. The DVRT was calibrated by the manufacturer and the readings were in millimetres. The strain
was calculated as the change in length over the original
length of the DVRT at the start of a set of readings.

Longitudinal stability
Load transfer varies according to:
Frontal inclination of the wrist,
Wrist positioning in flexion or extension,
Forearm rotation

Elbow inclination in the frontal plane

What should we remember ?

Axial loads are shared

between radius and
ulna and go from the
distal part of the radius
to the ulna

Radial head resection

Allows proximal migration

of 7 mm, even if softtissues are intact

TFCC or IOM section

Combined section + radial head resection

Major displacement

Elbow:

Forearm :

Wrist :

Radius > annular ligament +++

Interosseous membrane
TFCC

Elements of longitudinal stability

The forearm as a functional unit

Hey! Im trying to pass the

potatoes! .Remember, my
forearms are just as useless
as yours!

Pronosupination

Occurs around an axis joining the

radial head and ulnar head -Going
along the IOM
Normal pronosupination: Integrity of:
proximal, distal AND middle
radioulnar joint

The middle radioulnar joint

The three lockers concept

Fragonard: the locker
Paris, the Louvre

Every forearm structure participates to the

pronosupination and constitutes a locker
Each locker can be absent, unstable or locked

Proximal locker = PRUJ

Locking

Proximal
radioulnar
synostosis

Absent

Radial head
resection

Unstable

Radial head
dislocation

Distal locker = DRUJ

Locking

DRUJ stiffness

Absent

Ulnar head
resection

Isolated ulnar
Unstable
head dislocation

Middle locker
Locking
Absent

Unstable

Synostosis

IOM lesion or
dyaphysal
fracture

Consequences in clinical
practice
Locking of any of the three lockers
locked all the forearm

Synostosis
IOM retraction in
pronosupination limitation

Okamoto et al. JHS 2006;31B:397-400

Consequences
An absent locker can be compensate by
the other two

Radial head resection

Ulnar head resection
Isolated section of the IOM

Consequences
Absence of two lockers cannot be compensate by
the last one

Radial head resection + IOM Lesion

TFCC disruption + IOM lesion

Pathology of the functional

forearm unit

Interosseous
membrane
traumatism

Longitudinal mechanism
Lesions depend of the forearm
rotation

Position

Lesion

Supination
85

Forearm
bones fracture

Supination
45

Radial head
fracture

Supination
15

Complex
radial head
fracture

Neutral
Rotation

Interosseous
Membrane
disruption

Example

Experimentation

McGinley JC et al.
Forearm and Elbow Injury:
The Influence of
Rotational Position JBJS
Am 2003; 85: 2403-2409.

One locker lesion

1P: Radial head fracture, isolated radial head
resection

9/14 Mason I radial head fracture had distal IOM disruption.

Hausmann. J. Trauma 2009; 66:457-461

One locker lesion

1M: Diaphysal fracture of both forearm bones

One locker lesion

1D: Distal radius fracture, ulnar head fracture,
TFCC disruption

Single locker instability ?

A single locker instability is probably not possible
Ulnar head dislocation = associated IOM lesion (Horii,
Watanabe)
One bone forearm fracture are rare: Monteggias,
Galeazzis fractures imply an associated IOM lesion

Two lockers lesion

2 PM: Monteggias fracture

Two lockers lesion

2 MD: Galeazzis

Two lockers lesion

2 MD: Isolated ulnar head dislocation

Two lockers lesion

2 PD: criss-cross injury

Bipolar dislocation with an intact IOM
(Leung 2005)

Three lockers lesion

Essex-Lopresti syndrome (1951)

Already described by Curr & Coe in
1946
Longitudinal (and transverse)
instability

Woman, 19 yrs old

Violent fall or her left forearm
Monteggia + TFCC lesion =
Essex-Lopresti

Natural history of fresh lesions ?

Can recent IOM disruption heal ?
Failla, in fresh injury, describes a widening of the edges (like
in ACL lesions) and a muscular interposition (like in Steners
lesion)

Natural history of fresh lesions ?

Secondary aggravation (or apparition) of EssexLopresti lesions shows:
Some lesions may not heal
Some partial lesions may aggravate
Is there a minimal size of lesion that cannot heal with
progressive aggravation of symptoms ?

Diagnostic of EssexLoprestis lesions

Diagnostic in emergency
Very difficult, no specific signs
Think of it: A lesion of two lockers should make you
suspicious of a possible injury of the third locker

22 yrs old, fall

during sport

27 yrs old, fall

from a ladder,
elbow and wrist
pain

Immediate repair ?
Only some case reported with disappointing results
It seems that the IOM cannot heal or withstand the
mechanical loads

2ary diagnostic

Patient presents with pain associated with

limitation of rotation and signs of instability
(progressive DRUJ dislocation).
Few clinical signs
One needs imaging techniques

Plain X-rays
Same patient
4 weeks
4 months

Indirect signs: Proximal migration of the radius, DRUJ

dislocation

Plain X-rays
Direct signs: Axial
compression tests

Radius Pull Test

Smith, JBJS 2002
A proximal migration of the
radius > 3 mm is associated
with IOM disruption

Mehlhoff: stress X-rays under anesthesia

MRI
PPV : 100% (TP / TP + FP)
NPV : 89% (TN / FN + TN)
Sensibility: 87,5 % (TP / TP + FN)
Specificity: 100 % (FP / FP + TN)

MRI is considered as the gold standard

MRI
Hyposignal T1 & T2 - Fat Saturation +++
However: many artifacts in traumatized patients,
especially if plates and screws have been inserted

Sonography
Static: Some authors consider that sensibility and
specificity is almost 100% !

Longitudinal view

Transverse view, torn

membrane

Transverse view, intact

membrane

Dynamic sonography
Proposed by Soubeyrand
The IOM is divided in three parts
The probe is placed on the
posterior side
One pushes on the anterior
muscles of the forearm

 A slight bulging of the

IOM is visible in normal

subjects
Protrusion of the anterior
muscle is diagnostic of IOM
division
Sensibility/specificity was
100% in proximal and
middle zone

Intact membrane

Rupture with the

hernia sign

Treatment of chronic lesions

Proximal RUJ
Radial head
reconstruction with
allograft (5 cases, short
FU)
Prosthetic replacement
(not with silastic)

Distal RUJ
TFCC reconstruction/repair +++
Ulna shortening +/- ulnar head resection (with
resection distal to the ulnar insertion of the central
band of the IOM)

Treatment directed to forearm bones

Correction of malunion (ulna +++)

One-bone forearm

Interosseous membrane repair ?

Many trials, poorly conclusive
Most transplants try to reproduce the
central band (bone-patellar ligamentbone, tendon graft one or two fascicles,
ligamentoplasties)
Chloros et al. JHS
2008;33A:124-130

The technique we described

Long transplant (semi-tendinosus)
Along the mechanical axis of the forearm

Main problem: DRUJ

Most patients are still unstable at

the DRUJ
Secondary procedures

Conclusion
Pathology of the interosseous membrane cannot be
dissociate from pathology of the forearm
The whole forearm is a functional unit
The three lockers concept helps to better
understand the lesions

Conclusion
Interosseous membrane lesions are always
underestimated
Think of it in recent trauma if other lockers are
damaged +++
Dynamic sonography would probably be helpful
The ideal treatment in front of fresh lesion is still
unknown

Conclusion
In chronic lesions, surgical treatments are still
disappointing
Treat first the bony lesions and the proximal and
distal lockers
We propose a original ligamentoplasty which take
into account the mechanical axis of the forearm

Conclusion
There are probably other unknown lesions of the
IOM: Transverse instability, partial rupture, localized
stiffness,...
That you may discover and explore