CURRENT CONCEPTS

Forearm Instability
Bryan J. Loefer, MD, Jennifer B. Green, MD, David S. Zelouf, MD

CME INFORMATION AND DISCLOSURES

The Review Section of JHS will contain at least 3 clinically relevant articles selected by the Provider Information can be found at http://www.assh.org/Pages/ContactUs.aspx.
editor to be offered for CME in each issue. For CME credit, the participant must read the
Technical Requirements for the Online Examination can be found at http://jhandsurg.
articles in print or online and correctly answer all related questions through an online
org/cme/home.
examination. The questions on the test are designed to make the reader think and will
occasionally require the reader to go back and scrutinize the article for details. Privacy Policy can be found at http://www.assh.org/pages/ASSHPrivacyPolicy.aspx.

The JHS CME Activity fee of $20.00 includes the exam questions/answers only and does not
include access to the JHS articles referenced.
Statement of Need: This CME activity was developed by the JHS review section editors
and review article authors as a convenient education tool to help increase or afrm readers
knowledge. The overall goal of the activity is for participants to evaluate the appropri-
ateness of clinical data and apply it to their practice and the provision of patient care.
Accreditation: The ASSH is accredited by the Accreditation Council for Continuing Medical
Education to provide continuing medical education for physicians.
ASSH Disclosure Policy: As a provider accredited by the ACCME, the ASSH must ensure
balance, independence, objectivity, and scientic rigor in all its activities.
Disclosures for this Article
Editors
Ghazi M. Rayan, MD, has no relevant conicts of interest to disclose.
Authors
All authors of this journal-based CME activity have no relevant conicts of interest to
disclose. In the printed or PDF version of this article, author afliations can be found at the
bottom of the rst page.

AMA PRA Credit Designation: The American Society for Surgery of the Hand designates
this Journal-Based CME activity for a maximum of 2.00 AMA PRA Category 1 Credits.
Physicians should claim only the credit commensurate with the extent of their participation
in the activity.
ASSH Disclaimer: The material presented in this CME activity is made available by the
ASSH for educational purposes only. This material is not intended to represent the only
methods or the best procedures appropriate for the medical situation(s) discussed, but
rather it is intended to present an approach, view, statement, or opinion of the authors that
may be helpful, or of interest, to other practitioners. Examinees agree to participate in this
medical education activity, sponsored by the ASSH, with full knowledge and awareness that
they waive any claim they may have against the ASSH for reliance on any information
presented. The approval of the US Food and Drug Administration is required for procedures
and drugs that are considered experimental. Instrumentation systems discussed or reviewed
during this educational activity may not yet have received FDA approval.
Planners
Ghazi M. Rayan, MD, has no relevant conicts of interest to disclose. The editorial and
education staff involved with this journal-based CME activity has no relevant conicts of
interest to disclose.
Learning Objectives

Elucidate the anatomy and biomechanics of the forearm.

List the stabilizers of the forearm.

Clarify the pathomechanics of forearm instability.

Discuss the clinical presentation and diagnostic tools for forearm instability.

Explain the management of forearm instability.
Deadline: Each examination purchased in 2014 must be completed by January 31, 2015, to
be eligible for CME. A certicate will be issued upon completion of the activity. Estimated
time to complete each months JHS CME activity is up to 2 hours.
Copyright 2014 by the American Society for Surgery of the Hand. All rights reserved.

Forearm instability results from trauma, which disrupts the radial head, the interosseous
membrane, and the triangular brocartilage complex. Inadequate treatment of injuries to these
forearm stabilizers may result in the complex problem of chronic longitudinal forearm insta-
bility. Delayed recognition and/or treatment of injuries producing forearm dissociation has led
to poor patient outcomes, which makes timely recognition of the injury pattern imperative. This
article discusses relevant aspects of forearm anatomy and current concepts in the diagnosis
and treatment options for this complex injury pattern. (J Hand Surg Am. 2014;39(1):156e167.
Copyright
2014 by the American Society for Surgery of the Hand. All rights reserved.)
Key words Essex-Lopresti injury, forearm instability, interosseous membrane, longitudinal
Current Concepts

radioulnar dissociation.

From the Philadelphia Hand Center, King of Prussia, Pennsylvania. Corresponding author: David S. Zelouf, MD, Philadelphia Hand Center, The Merion
Received for publication February 24, 2013; accepted in revised form July 10, 2013. Building, Suite 200, 700 South Henderson Rd., King of Prussia, PA 19406; e-mail:
zeloufhand@gmail.com.
No benets in any form have been received or will be received related directly or indirectly
to the subject of this article. 0363-5023/14/3901-0031$36.00/0
http://dx.doi.org/10.1016/j.jhsa.2013.07.010

156 r
2014 ASSH r Published by Elsevier, Inc. All rights reserved.

 FOREARM INSTABILITY
I
NSTABILITY OF the forearm results from traumatic
disruption of the primary and secondary stabi-
lizers of the radius and ulna. Left untreated,
forearm instability leads to forearm and wrist pain,
limited forearm motion, and deformity at the wrist.
Knowledge of the normal anatomy and biomechanics
of the forearm is critical to fully understand the
complexity of forearm instability and its treatment
options.
Curr and Coe1 provided the rst documentation of
an acute forearm instability injury pattern in 1946.
However, in 1951, Essex-Lopresti2 further described
an injury pattern of radial head fracture, rupture of the
interosseous membrane (IOM), and distal radioulnar
joint (DRUJ) disruption resulting from a traumatic
axial load transmitted from the wrist to the elbow.
Because of his detailed description, the injury pattern
was assigned the eponym Essex-Lopresti injury.2 In
1992, Trousdale et al3 described the chronic sequelae
of proximal migration of the radius and longitudinal
radioulnar dissociation that occur after this injury
pattern. Since that time, considerable research has
been performed to describe the anatomy and biome-
chanics of the forearm axis as well as injury patterns
that disrupt its stability. This novel research has led to
a greater understanding of these injury patterns and
additional treatment options for this complex prob-
lem. Trousdale et al3 reported that only 25% of pa-
tients with longitudinal radioulnar dissociation were
fully diagnosed upon initial presentation, and only
20% of patients with delayed diagnosis and subse-
quent treatment had positive outcomes. This study
demonstrates the importance of early recognition of
the injury patterns associated with forearm instability
as well as the need for appropriate initial treatment to
improve the likelihood of positive results.
An intact radial head, IOM, and triangular bro-
cartilage complex (TFCC) all contribute to axial
stability of the forearm axis. A severe axial
compression force through the forearm may injure 1
or more of these stabilizers. Some injuries result in
isolated radial head or neck fractures without
disruption of axial forearm stability, whereas others
result in a spectrum of severity that may involve a
radial head or neck fracture, or both, along with
concomitant injuries to the IOM and TFCC. With
disruption of these stabilizers and inadequate treat-
ment, longitudinal radioulnar dissociation typically
occurs, resulting in proximal migration of the radius,
altered loading patterns through the forearm and
wrist, and forearm instability. Forearm destabiliza-
tion, if recognized acutely, requires immediate sur-
gical intervention with repair or replacement of the
J Hand Surg Am.
157
radial head. In addition, treatment of concomitant
IOM and TFCC injuries should be considered. If the
forearm instability pattern is unrecognized, chronic
insufciency of the IOM with resultant symptoms at
the elbow and wrist can be expected.4
The purpose of this article is to review the anatomy
and biomechanics of the forearm stabilizers, to
discuss early recognition of forearm instability pat-
terns, and to review the treatment options for acute
and chronic cases of forearm instability.
ANATOMY AND BIOMECHANICS OF FOREARM
STABILIZERS
The forearm unit consists of the radius and ulna,
which are bound proximally by the proximal radio-
ulnar joint (PRUJ), centrally by the IOM, and
distally by the DRUJ. The primary functions of the
forearm unit are (1) to provide stability and maintain
anatomical relationships of the radius and ulna, thus
allowing for optimal pronosupination, (2) to facili-
tate load transfer from the radius to the ulna as force
is transmitted from the wrist to the elbow, and (3) to
serve as an attachment site for muscles responsible
for forearm, wrist, and nger motion. Axial stability
of the forearm is attributed primarily to the radial
head and secondarily to the IOM and TFCC.5 The
radial head is the primary stabilizer of the forearm
because the articulation between the radial head and
the capitellum prevents proximal migration of the
radius.6 The PRUJ is the site where the radial head
articulates with the lesser sigmoid notch of the ulna,
and the annular ligament maintains the radial head in
this position. The radial collateral ligament and
accessory radial collateral ligament also contribute to
stabilizing the radial head in its anatomical position.
The IOM provides a central connection between
the radius and the ulna, and recent research has
elucidated its importance in forearm stability. The
anatomy of the IOM allows multiple functions,
including load transfer from the radius to the ulna as
well as maintenance of longitudinal and transverse
forearm stability. In addition, it provides support
during forearm rotation, serves as an origin for the
wrist exors and extensors, and separates the volar
Current Concepts
and dorsal compartments of the forearm.
Noda et al7 recently described a total of 5 distinct
components to the IOM ligaments over 3 portions
of the forearm. The proximal membranous portion
travels in a distal direction and consists of the
proximal oblique and dorsal accessory cords. The
middle ligamentous complex supplies the majority of
the stiffness to the IOM and comprises the central
r Vol. 39, January 2014
 158 FOREARM INSTABILITY
FIGURE 1: Gross dissection depicts the anatomy of the interosseous membrane as described by Noda et al.7 The distal oblique bundle is
identied by the asterisk. AB, accessory band; CB, central band; DOAC, dorsal oblique accessory cord; POC, proximal oblique cord.
band and accessory band. The central band is a very
stout and consistent structure, which originates on
the radius and is oriented distally an average of 21
to the longitudinal axis of the ulna toward its inser-
tion on the ulna8 (Fig. 1). The distal membranous
portion of the IOM is the distal oblique bundle, which
exhibits a more oblique trajectory. These segments of
the IOM help to transfer longitudinal loads between
the radius and the ulna.9 When ulnar variance is
neutral, the radiocarpal joint absorbs 80% of the axial
load transmitted through the wrist, and the remaining
20% is transmitted to the ulna.10 The IOM transfers
load from the radius to the ulna as the force travels
through the forearm, so that, at the elbow, the radio-
capitellar joint is subjected to 60% of the original axial
load and the ulnohumeral joint the remaining 40%.11
The IOM also functions as a longitudinal and a
transverse stabilizer of the forearm. After radial head
resection (the primary longitudinal stabilizer of the
forearm), the central band segment of the IOM was
found to contribute 71% to the overall mechanical
stiffness of the forearm.12 Hotchkiss et al12 noted
that, after resection of the radial head, the IOM
transmits 90% of the axial load through the forearm,
thus resisting proximal migration of the radius. The
proximal membranous portion of the IOM contributes
to the stability of the PRUJ, and the distal segment of
the IOM provides stability to the DRUJ, particularly
in the 40% of individuals who have a distal oblique
bundle.13e15 In addition to longitudinal forearm sta-
bility, the distal IOM also resists volar and dorsal
Current Concepts
translation of the distal radius at the DRUJ.16 Wata-
nabe et al16 have demonstrated that both TFCC and
IOM disruption are required for DRUJ dislocation to
occur. The function of the IOM to provide transverse
stability was explored by Pfaefe et al,17 who iden-
tied transverse force vectors within the IOM that
help to pull the radius and ulna together, thus pre-
venting radioulnar splaying.
The DRUJ links the radius and the ulna in the
distal forearm. It consists of soft tissue stabilizers
J Hand Surg Am.
including the TFCC, the distal IOM, and the pronator
quadratus as well as the bony articulation between the
radius and the ulna at the sigmoid notch. Of these
structures, the TFCC, which includes the dorsal and
palmar radioulnar ligaments as well as the ulnocarpal
ligaments, is the primary stabilizer of the DRUJ.18
Consequently, the TFCC is a secondary stabilizer of
the forearm unit, and it is responsible for 8% of the
mechanical stiffness of the forearm.12
MECHANISM OF INJURY
Trauma that completely disrupts the forearm unit
produces acute longitudinal forearm instability. An
Essex-Lopresti injury pattern typically occurs when a
fall from a height onto the outstretched hand imparts
an axial force that causes a radial head fracture, IOM
disruption, and TFCC tear. Galeazzi fractures (radial
shaft fracture with associated DRUJ dislocation),
Monteggia fractures (ulnar shaft fracture with asso-
ciated PRUJ dislocation), and isolated DRUJ dislo-
cations are other examples of transverse forearm
instability patterns. In contrast to Essex-Lopresti le-
sions, these injury patterns typically spare the central
band of the IOM, and they are also easier to recognize
based on injury radiographs. Essex-Lopresti injuries,
however, are often more difcult to fully appreciate
in the acute setting, but they may lead to longitudinal
forearm instability.
PATHOMECHANICS OF INSTABILITY
Forearm instability most frequently occurs following
a traumatic axial load through the forearm and an
obvious radial head fracture. This radial head frac-
ture may or may not be associated with complete
disruption of the IOM and TFCC. Treatment options
for radial head fractures include open reduction and
internal xation, excision of the radial head, or radial
head replacement. Radial head excision in the setting
of a compromised IOM and TFCC can lead to lon-
gitudinal radioulnar dissociation due to loss of the
primary and secondary forearm stabilizers. Proximal
r Vol. 39, January 2014
 FOREARM INSTABILITY
radial migration and relative ulnar lengthening pre-
dictably occur, leading to ulnar abutment at the wrist
and radiocapitellar impingement.
Excision of the radial head without disruption of
any other forearm stabilizers can result in up to 7 mm
of proximal migration of the radius with axial
loading of the forearm.6 There is little change in the
distance that the radius migrates proximally if either
the IOM or the TFCC remains intact because the
intact soft tissue stabilizers resist this proximal
migration. However, if the radial head is excised, and
both the TFCC and the central portion of the IOM
are injured, further proximal migration of the radius
occurs and a complete Essex-Lopresti results.6
Proximal migration occurs when the radial head is
excised and the IOM is disrupted because load
cannot be transmitted from the radius to the ulna
through the damaged IOM. Tomaino et al19 as well
as Birkbeck et al9 demonstrated that, with an intact
radial head and a sectioned IOM, load transmission
from the radius to the ulna no longer occurred, and
the entire load was transmitted along the radius from
the radiocarpal joint directly to the radiocapitellar
joint. This increased force through the radiocapitellar
joint results in abnormal wear patterns, which can
subsequently lead to radiocapitellar arthritis, elbow
pain, and decreased motion. When the radial head
has been excised and the IOM is compromised, all
the force is transferred directly from the radiocarpal
joint through the radius to the proximal radial stump/
capitellar joint. This load transmission combined
with the proximal pull of the wrist and nger exor
and extensor tendons, along with the biceps on the
radius, generates an axial load along the forearm.
These forces lead to proximal radial migration,
radiocapitellar impingement, and relative ulnar
lengthening along with associated elbow and wrist
symptoms.20 For every 1 mm of proximal radial
migration, a 10% increase in load across the distal
ulna occurs.21 This increased load across the ulno-
carpal joint can lead to symptoms of ulnocarpal
abutment, including limited forearm rotation, wrist
pain, and DRUJ instability.
Longitudinal radioulnar dissociation can occur as
an acute process with radial head fracture and com-
plete disruption of the IOM and TFCC, but more
commonly, the radial head fracture is associated with
an incomplete injury to the IOM. If radial head
excision is performed in this setting, the remaining
bers of the IOM central band are forced to resist
longitudinal forearm forces and prevent proximal
migration of the radius. As shown by Skahen et al22
and Hotchkiss et al,12 once the radial head is excised,
J Hand Surg Am.
159
the central band of the IOM becomes responsible for
71% of the longitudinal stiffness of the forearm. This
increase in stress across the IOM may lead to atten-
uation of remaining intact IOM bers8,22 and even-
tual longitudinal forearm instability.
DIAGNOSIS
History and physical examination ndings
The rst step in establishing the diagnosis of longi-
tudinal radioulnar dissociation is achieved by
obtaining a detailed history and performing a proper
physical examination. Patients typically describe a
fall on an outstretched hand with the elbow extended,
sustaining an acute axial load injury. In the acute
setting, pain at the elbow is often due to a radial head
fracture, and elbow and forearm motion may be
limited secondary to a joint effusion and/or a dis-
placed radial head fracture. Tenderness to palpation at
the mid-dorsal forearm, the DRUJ, and/or the fovea
heightens suspicion for longitudinal radioulnar
dissociation. The DRUJ should also be evaluated for
instability in full supination, neutral rotation, and full
pronation. The clinician should be aware, however,
that these additional physical examination ndings
may be negative in the acute setting even when an
Essex-Lopresti injury has occurred.
In subacute and chronic cases, patients may present
with a history of a previous radial head fracture and
subsequent excision. Chronic wrist pain often de-
velops along with limited wrist and forearm motion,
and weakness of grip. A prominent distal ulna is also
evident owing to proximal migration of the radius.
Imagingradiographs
For an acute injury, radiographs of the elbow and the
wrist are necessary for evaluation. Anteroposterior,
lateral, and oblique views of the elbow reveal the
degree of displacement and comminution of a radial
head fracture. Neutral rotation posteroanterior and
lateral views of the wrist joint may demonstrate
widening of the DRUJ or positive ulnar variance. If
static posteroanterior and lateral wrist views are
normal, a grip-loaded pronation posteroanterior view
is helpful to demonstrate dynamic ulnar-positive
Current Concepts
variance. Radiographs of the contralateral uninjured
wrist joint are obtained for comparison. Essex-Lopresti
lesions may not be evident on these initial radio-
graphs.23,24 but repeat radiographs may detect the
injury pattern. An additional set of radiographs should
be performed if a patients follow-up examination is
concerning for longitudinal radioulnar dissociation.25
For delayed presentation or chronic wrist pain
associated with a previous radial head fracture, the
r Vol. 39, January 2014
 160 FOREARM INSTABILITY
same sets of radiographs are obtained. The x-rays
should be scrutinized for positive ulnar variance and
cystic or sclerotic changes in the proximal ulnar aspect
of the lunate and/or radial aspect of the triquetrum
secondary to ulnar impaction. When available, these
images may be compared with those obtained at the
time of injury. Wrist magnetic resonance imaging
(MRI) can also be useful to further assess for evidence
of ulnar impaction and TFCC tearing.
Advanced imagingMRI and ultrasound
A thorough history, physical examination, and
appropriate radiographic studies are not always diag-
nostic of acute Essex-Lopresti lesions. The concern
for underrecognition of this injury pattern has led to
considerable research to improve diagnosis of longi-
tudinal radioulnar dissociations. Multiple studies have
examined the utility of MRI and ultrasound to
improve the diagnosis of IOM disruptions and TFCC
injuries associated with radial head fractures.
MRI and ultrasound have emerged as useful tools
for the evaluation of ruptures of the IOM. In a study
evaluating the effectiveness of MRI in diagnosing
IOM injuries in cadavers and patients, Starch
and Dabenzies26 illustrated excellent results using
T2-weighted fast spin-echo fat-suppressed images.
Fester et al27 used a cadaver model to establish the
sensitivity and specicity of MRI to diagnose central
band transections of the IOM. The mean sensitivity
was 93%, specicity was 100%, and the overall ac-
curacy of using MRI to diagnose an IOM central third
disruption was 96%. They also conrmed that the
central band disruption was most easily identied
as wavy, bowed, and discontinuous ligament bers
seen on T2-weighted axial cuts. McGinley et al28
compared use of MRI versus laser micrometry for
evaluation of the IOM anatomy and found that there
was no signicant difference between the two
methods of evaluation (P .75). In another study,
McGinley et al29 evaluated MRI as a tool for accurate
diagnosis of traumatic IOM injuries induced in a
cadaver model. In this study, diagnosis by MRI had a
sensitivity of 88% and a specicity of 100%. These
Current Concepts
authors also reported that, in this model, most tears
occurred along the ulnar insertion of the IOM and not
in its midsubstance.
Ultrasound has also been found to be an effective
modality to evaluate IOM integrity. This method is
less expensive than MRI, can usually be performed
relatively quickly, and allows for a dynamic evalua-
tion of the IOM. When an ultrasonographer with
experience in evaluating IOM injuries is available,
ultrasound can be a very efcient tool to aid in the
J Hand Surg Am.
diagnosis of forearm instability. Jaakkola et al30 used
a cadaver model to conrm the clinical research of
Failla et al,4 demonstrating that the intact IOM ap-
pears as a hyperechoic continuous structure, which is
easily distinguished from surrounding musculature.
In contrast, a disrupted IOM is identied as a
discontinuation of this hyperechoic line, particularly
on axial views. Jaakkola et al30 established 96% ac-
curacy for detecting a damaged IOM by ultrasound.
Soubeyrand et al31 used dynamic ultrasonography to
determine IOM disruption by identifying the
muscular hernia sign. This sign was visible by
ultrasound when a load was placed from anterior to
posterior across the forearm, which demonstrated
herniation of the forearm musculature through the
damaged IOM. Fester et al27 used a cadaver model to
evaluate the effectiveness of ultrasound as a diag-
nostic tool for IOM disruptions. These researchers
established an overall sensitivity of 100%, specicity
of 89%, and an overall accuracy rate of 94%. In their
comparison between ultrasound and MRI evaluation
of IOM disruptions, they found no statistical differ-
ence between accuracy of MRI and that of ultra-
sound. When a forearm instability pattern is
suspected and radiographs are nondiagnostic, MRI or
ultrasound may be very useful in making the early
diagnosis of longitudinal radioulnar dissociation.24
Intraoperative examination
When performing surgery on the injured radial head
and/or neck, the forearm and ulnar wrist may be
further examined during surgery to assess for signs of
IOM and TFCC disruption. Longitudinal forearm
instability can be assessed using the radius pull
test.32 When determining whether a fractured radial
head should be excised or replaced, this test for
forearm stability can assist in the decision-making
process. Smith et al32 described this test using cadaver
models with excision of the radial head followed by
sequential sectioning of the IOM and the TFCC.
Longitudinal traction on the radius with greater than 3
mm of proximal radial migration indicated disruption
of the IOM and impaired longitudinal stability of the
forearm. Proximal radial migration greater than 6 mm
was associated with damage to both the TFCC and the
IOM, resulting in gross forearm instability and,
therefore, a contraindication for a radial head excision
without replacement.
Recently, an intraoperative radius joystick test
has been described and tested in cadavers to improve
the diagnosis of IOM disruption in a simulated
Essex-Lopresti injury pattern.33 Lateral traction is
applied to the radial neck while the forearm is
r Vol. 39, January 2014
 FOREARM INSTABILITY
maximally pronated. The examiner looks for lateral
displacement of the proximal radius, thus indicating an
IOM disruption. The test was 100% sensitive for
detecting an IOM injury, and the positive predictive
value was 90%. A study of this test in vivo has not yet
been reported.
A limitation of these tests, however, is that,
although they do measure the ability of the forearm to
withstand an axial load acutely, they are unable to
detect whether incomplete injury to the IOM has
occurred. Incomplete IOM injuries coupled with radial
head excision may lead to late attenuation of the
remaining IOM bers and resultant forearm instability.
TREATMENT OPTIONS
After establishing the diagnosis of longitudinal fore-
arm dissociation, a number of potential treatment
options are available to reestablish forearm stability
and maximize functional outcomes. These can be
divided into options for acute injuries versus chronic
forearm instability. In both settings, treatment options
should be considered to address the injuries to the
elbow, forearm, and wrist.
Acute injury treatment options
Acute injuries require attention to the fractured radial
head as well as the injured IOM and TFCC. If an
isolated radial head fracture is present and the in-
tegrities of the TFCC and the IOM are maintained,
then the radial head should be repaired if there are 3
or fewer articular fragments.34 If the radial head
fracture pattern precludes open reduction and internal
xation and there is no preoperative or intraoperative
evidence of longitudinal instability or valgus insta-
bility of the elbow, excision without replacement
is reasonable.35 However, if there is any concern
for forearm instability, the radial head should be
replaced to reestablish the integrity of the primary
longitudinal forearm stabilizer and prevent proximal
migration of the radius. We generally perform radial
head replacement as opposed to excision, particularly
in young, active individuals, although long-term
outcome studies for this treatment are not yet available.
When performing radial head replacement,
metallic radial head implants are most commonly
used. Silicone radial head arthroplasty is no longer
recommended primarily owing to its poor loading
characteristics with implant breakdown and resultant
silicone synovitis.36,37 More recently, pyrocarbon
radial head implants have been introduced owing to
theoretical advantages of favorable wear properties,
decreased damage to adjacent cartilage, and an elastic
modulus that is close to cortical bone.38,39 These
J Hand Surg Am.
161
theoretical advantages have not yet been evaluated
with long-term follow-up studies.
Knight et al40 used metallic radial head implants in
comminuted radial head fractures and demonstrated
reliable re-creation of stability and prevention of
proximal radial migration with follow-up of 5 years.
Short-term clinical results are favorable, but long-
term outcomes for isolated metallic radial head
replacements are lacking at this time.41 Also, the long-
term effects of the metal-cartilage articulation at the
radial head replacementecapitellar joint are unknown.
For a full-blown Essex-Lopresti injury, treatment
with a radial head replacement alone may lead to
radiocapitellar based pain and/or prosthesis subluxa-
tion owing to the neglected IOM and TFCC
injuries. Increased radiocapitellar loads from decient
longitudinal forearm stabilization may lead to early
capitellar wear and lateral elbow pain.42,43 Radio-
capitellar arthroplasty is an alternate treatment option
with the potential to avoid possible sequelae from this
metal-cartilage interface, but only limited follow-up
data are currently available. In addition, radio-
capitellar arthroplasty may have a potential role in
cases in which the articular surface of the capitellum
is damaged or painful radiocapitellar arthritis after
radial head replacement occurs.
Other potential options to prevent radiocapitellar
wear include performing acute repair, augmenta-
tion, or reconstruction of the IOM in addition to
radial head replacement. Pfaefe et al44 demon-
strated that treatment of the IOM central band injury
decreased radial head prosthesis to capitellum
loads. Another reason to consider acute treatment of
the IOM injury is that it is unclear whether the IOM
is even capable of healing. Gong et al45 reported on
a case of Essex-Lopresti injury treated by radial
head replacement, DRUJ pinning, and 8 weeks of
immobilization in which the patient subsequently
developed lateral elbow pain and ulnar-sided wrist
pain due to incompetence of the IOM and associ-
ated longitudinal forearm instability. It has been
hypothesized that the forearm musculature herniates
through the defect created by the IOM disruption
and thus prevents healing between the radius and
Current Concepts
the ulna.
Exploration and repair of the central band of the
IOM is 1 option, but anecdotally, the tissue is difcult
to directly repair. Augmentation of the central band
by proximal release of the pronator teres and rerout-
ing it dorsal to the IOM and distally along the same
orientation as the central band has also been
described.46 A proposed advantages of this technique
is the use of readily accessible autograft with the
r Vol. 39, January 2014
 162 FOREARM INSTABILITY
capacity to permanently heal along the same vector as
the central band. The need for acute reconstruction of
the IOM is debatable. Sellman et al47 found that
replacing the radial head with a metallic implant, in a
cadaveric model of radial head fracture with soft
tissue disruption, resulted in restoration of forearm
stiffness to 89% of normal. When a metallic radial
head implant was combined with an IOM recon-
struction, forearm stiffness increased to 145% of
normal. Although this cadaveric study suggests that
there may be a biomechanical advantage to per-
forming acute central band reconstruction, there is
limited published literature at this time to support
early reconstruction.
At the wrist, repair of the TFCC should be
considered. Radial head xation or replacement along
with TFCC repair may be sufcient to maintain the
relationship between the radius and the ulna, thereby
preventing subsequent forearm instability. Radial
head excision combined with closed reduction and
pin xation of the DRUJ alone is not recommended,
given the limited potential for IOM healing and
concerns for proximal migration of the radius
following pin removal.45 Overall, the goal of treat-
ment for acute injuries is to establish forearm stability
in the acute period to prevent the issues related to
chronic forearm instability.
Chronic injury treatment options
Historically, outcomes after treatment of chronic
longitudinal forearm instability have been poor.
However, with increased understanding of the me-
chanics of this challenging problem and more recent
study of IOM reconstruction techniques, outcomes
are more optimistic. As with acute Essex-Lopresti
injuries, treatment at the elbow, forearm, and wrist
should be considered. Treatment efforts are aimed at
reestablishing the integrity of the forearm stabilizers
and leveling the DRUJ to eliminate ulnar-sided wrist
symptoms resulting from positive ulnar variance.
Ultimately, the goal is to re-create a more normal
association between the radius and ulna and to
eliminate the longitudinal instability.42 Reestablish-
Current Concepts
ing the relative length of the radius and ulna is
imperative when attempting to re-create forearm
stability in the setting of a chronic injury. An ulnar-
shortening osteotomy is often recommended to
establish neutral or slightly negative ulnar vari-
ance.48,49 Proximal migration of the radius can be
addressed by simultaneous replacement of the radial
head to partially restore radial length and limit the
potential for the radius to further migrate proxi-
mally. Currently, metallic implants are preferred for
J Hand Surg Am.
implantation because these restore forearm stiffness47
and prevent further migration.40 However, the long-
term effects of radial head metallic implant articu-
lating with the native capitellum are unknown, and
these effects may be magnied when longitudinal
forearm stability is partially dependent upon radio-
capitellar abutment.
IOM reconstruction
Restoring soft tissue stability is the other major
component to be addressed when treating chronic
radioulnar dissociation injuries. An ulnar-shortening
osteotomy levels the DRUJ and can also signicantly
increase DRUJ stability. Osteotomies performed
proximal to the distal IOM attachment increase DRUJ
stability compared with more distal osteotomies,
particularly when a distal oblique bundle is present.14
In addition, a TFCC repair may be considered to
further increase DRUJ stability. Recent studies have
examined the ability of various techniques of IOM
reconstruction to improve forearm soft tissue stabil-
ity. The goal of reconstruction is to re-create the
vector of the IOMs central band to restore longitu-
dinal stability and proper force transmission along the
forearm. The native central band originates in the
proximal half of the radius at approximately 60% of
the distance from the radial styloid to the radial head.
It extends distally at a 21 angle to the longitudinal
axis before inserting at the junction of the middle and
distal one third of the ulna. Reconstructions are
designed to reproduce this origin and insertion in the
same orientation as the central band.
Reconstruction of the IOM with various tendon
grafts has been described with the aim of reestab-
lishing forearm longitudinal stability and re-creating
more normal loading patterns. Tendon grafts such
as pronator teres,46 exor carpi radialis (FCR),8
semitendinosis,50 palmaris longus,51 Achilles,19 and
boneepatellar ligamentebone (BLB) constructs52
have been used in both cadaver models and in vivo
with varying results. More recently, IOM recon-
struction with synthetic grafts and/or endobuttons has
been described as well.53,54 Multiple biomechanical
studies have been performed in cadaver models to
establish which constructs most closely replicate the
native IOM and resultant longitudinal stability of the
forearm. Skahen et al8 demonstrated that FCR
reconstruction of the IOM is insufcient to re-create
forearm stability after a radial head excision, although
it did prevent complete migration of the radius
onto the capitellum. In another cadaveric study,
Stabile et al55 compared the relative stiffness of
various reconstructive grafts and an intact IOM by
r Vol. 39, January 2014
 FOREARM INSTABILITY
applying a physiological traumatic load. The authors
found that all of the graft constructs were signi-
cantly weaker than the native IOM (P < .05), with
the BLB construct being 3 times weaker, the FCR
tendon 7 times weaker, and the Achilles tendon 8
times weaker. They also demonstrated that the BLB
graft was signicantly more stiff than the FCR and
Achilles tendon grafts (P < .05). Tejwani et al51
compared the biomechanical properties of palmaris
longus and FCR tendons, and BLB grafts used to
reconstruct the IOM in cadaveric specimens. Fore-
arms were subjected to axial loads to determine
which graft was superior in preventing proximal
radial migration. The authors reported that, although
none of the grafts was as effective as the native IOM,
the BLB graft had the greatest cross-sectional area
and most effectively prevented proximal migration.
In addition, it exhibited less permanent graft elon-
gation after 10 cycles of loading. In another biome-
chanical cadaver study, Pfaefe et al56 evaluated load
transfer and proximal radius migration in forearms
with native IOM, reconstructed IOM using a single
FCR tendon, and IOM reconstruction using a double-
stranded FCR graft. These authors concluded that
double-stranded FCR graft reconstruction of the IOM
normalized both longitudinal and transverse forearm
forces similar to an intact IOM. Tejwani et al57 re-
ported that, when the IOM was reconstructed in
conjunction with placement of a metallic radial head
implant, force across the distal ulna was maintained
at levels similar to those of an intact forearm. Chloros
et al46 described a procedure in which the pronator
teres is rerouted to reconstruct the central band of
the IOM while simultaneously replacing the radial
head. If indicated, ulnar-shortening and TFCC repair
was also recommended. Although clinical data are
unavailable, these studies support the concept that
radial head replacement in conjunction with IOM
reconstruction may be benecial in reestablishing
forearm biomechanics.
Marcotte and Osterman52 reported positive func-
tional results after IOM reconstruction using a BLB
construct (Figs. 2 and 3). In a preliminary clinical
series of 16 patients treated for chronic forearm insta-
bility, all patients had an ulnar-shortening osteotomy
for a joint-leveling procedure with simultaneous
bone-patellar tendon-bone autograft reconstruction of
the IOM. No patient received a radial head replace-
ment. After an average of 78 months of follow-up, 15
of 16 patients had improved wrist pain, and grip
strength improved from 59% to 86% of that of the
unaffected upper extremity. Ten of 14 patients who
were working before the surgery returned to their
J Hand Surg Am.
163
regular employment, and another 3 of the 14 returned
to work with job modications. Complications in-
cluded anterior knee pain (4), ulna nonunion (1), and
extensor tendon adhesions (1). No patient required
further surgery to address forearm instability. This
procedure is currently being performed using BLB
allograft rather than autograft, thus eliminating donor-
site morbidity at the knee with no reported difference in
outcomes.49
Creation of 1-bone forearm
Although it is hoped that current treatment options
for chronic longitudinal forearm instability will pro-
duce successful results, the long-term outcomes of
IOM reconstruction with these techniques is currently
unknown. The ultimate salvage procedure to treat
longitudinal radioulnar dissociation is creation of a
radioulnar synostosis, or 1-bone forearm, to elim-
inate forearm instability. Despite complete loss of
forearm rotation with successful creation of a 1-bone
forearm, some positive long-term functional out-
comes have been reported. Allende and Allende58
reported that 7 of 7 patients who were treated with a
1-bone forearm for post-traumatic instability had
stable and pain-free forearms at follow-up of 9 years.
All patients were satised with the position, function,
and cosmesis of the reconstructed forearm. Peterson
et al59 demonstrated less predictable results for their
patients who had a radioulnar synostosis. Of 19 pa-
tients who had creation of a 1-bone forearm owing to
traumatic instability, tumor resection, or congenital
deformity, 69% had excellent or good results, 26%
had fair results, and 5% had poor results at 42 months
after surgery. Their primary union rate was 68% and
the complication rate was 53%, with complications
occurring more frequently in patients who had radi-
oulnar instability secondary to trauma. Most recently,
Jacoby et al60 reported a 38% nonunion rate and a
40% rate of painful proximal radius impingement
for 10 patients undergoing primary 1-bone forearm
surgery for chronic post-traumatic forearm or DRUJ
instability. At a median follow-up of 10 years, the
median pain and satisfaction scores were both 7
(out of a maximum of 10), with 10 indicating most
Current Concepts
severe pain and highest satisfaction, respectively. The
median Quick Disabilities of the Arm, Shoulder, and
Hand questionnaire score was 77. These authors
recommend 1-bone forearm surgery only as a last
resort for the chronically painful and unstable fore-
arm owing to this high rate of complications and poor
functional outcomes.
In conclusion, forearm instability is an extremely
complex problem that must be recognized and
r Vol. 39, January 2014
 164 FOREARM INSTABILITY
Current Concepts

FIGURE 2: A chronic presentation of Essex-Lopresti injury. A Lateral radiograph of an elbow demonstrates radial head replacement for
comminuted radial head fracture performed 6 months before referral. The patient initially sustained a fall from a height resulting in a
high-energy axial load through the forearm and complained of worsening wrist and forearm pain with grip weakness. B Grip-loaded
posteroanterior view of the wrist demonstrated accentuation of the ulnar-positive variance diagnostic of longitudinal forearm instability.
C Forearm radiographs 6 months after ulnar shortening osteotomy and central band reconstruction with bone-ligament-bone allograft.
(Radiographs courtesy of A. Lee Osterman, MD.)

J Hand Surg Am. r Vol. 39, January 2014

 FOREARM INSTABILITY 165

Current Concepts

FIGURE 3: Complex elbow instability with delayed recognition of longitudinal forearm instability. A The patient presented 8 months
after undergoing radial head replacement and lateral ulnar collateral ligament (LUCL) repair at an outside institution with a chronically
unstable ulnohumeral joint, radiocapitellar abutment, and grossly positive ulnar variance. B After radial head prosthesis removal, LUCL
reconstruction, and a temporary elbow external xator, the ulnohumeral congruity was restored. C In a staged fashion, an ulnar
shortening osteotomy and bone-ligament-bone reconstruction of the interosseous membranes central band was performed. Forearm
posteroanterior radiograph 4 months after reconstruction demonstrates restoration of slight ulnar-negative variance and early integration
of the graft. (Radiographs courtesy of A. Lee Osterman, MD.)

J Hand Surg Am. r Vol. 39, January 2014

 166 FOREARM INSTABILITY
addressed acutely to optimize results. Recent basic
science research has illustrated the normal anatomy
and the biomechanics required to maintain forearm
stability. Injury to the primary longitudinal forearm
stabilizer (the radial head) and the secondary stabi-
lizers (the IOM and TFCC) must be recognized and
treated appropriately to prevent the long-term sequelae
of persistent radioulnar dissociation. Based on an
improved understanding of forearm anatomy and
instability patterns, the treatment options for reestab-
lishing forearm stability continue to evolve; however,
long-term outcomes with these techniques have not yet
been reported.
REFERENCES
1. Curr JF, Coe WA. Dislocation of the inferior radio-ulnar joint. Br J
Surg. 1946;34:74e77.
2. Essex-Lopresti P. Fractures of the radial head with distal radio-ulnar
dislocation: report of two cases. J Bone Joint Surg Br. 1951;33(2):
244e247.
3. Trousdale RT, Amadio PC, Cooney WP, Morrey BF. Radio-ulnar
dissociation. A review of twenty cases. J Bone Joint Surg Am.
1992;74(10):1486e1497.
4. Failla JM, Jacobson J, van Holsbeeck M. Ultrasound diagnosis and
surgical pathology of the torn interosseous membrane in forearm
fractures/dislocations. J Hand Surg Am. 1999;24(2):257e266.
5. Morrey BF, Chao EY, Hui FC. Biomechanical study of the elbow
following excision of the radial head. J Bone Joint Surg Am.
1979;61(1):63e68.
6. Rabinowitz RS, Light TR, Havey RM, et al. The role of the inter-
osseous membrane and triangular brocartilage complex in forearm
stability. J Hand Surg Am. 1994;19(3):385e393.
7. Noda K, Goto A, Murase T, Sugamoto K, Yoshikawa H,
Moritomo H. Interosseous membrane of the forearm: an anatomical
study of ligament attachment locations. J Hand Surg Am. 2009;34(3):
415e422.
8. Skahen JR III, Palmer AK, Werner FW, Fortino MD. Reconstruction
of the interosseous membrane of the forearm in cadavers. J Hand
Surg Am. 1997;22(6):986e994.
9. Birkbeck DP, Failla JM, Hoshaw SJ, Fyhrie DP, Schafer M. The
interosseous membrane affects load distribution in the forearm.
J Hand Surg Am. 1997;22(6):975e980.
10. Palmer AK, Werner FW. Biomechanics of the distal radioulnar joint.
Clin Orthop Relat Res. 1984;187:26e35.
11. Halls AA, Travill A. Transmission of pressures across the elbow
joint. Anat Rec. 1964;150:243e247.
12. Hotchkiss RN, An KN, Sowa DT, Basta S, Weiland AJ. An anatomic
and mechanical study of the interosseous membrane of the forearm:
pathomechanics of proximal migration of the radius. J Hand Surg
Am. 1989;14(2 Pt 1):256e261.
Current Concepts
13. Gofton WT, Gordon KD, Dunning CE, Johnson JA, King GJ. Soft-
tissue stabilizers of the distal radioulnar joint: an in vitro kinematic
study. J Hand Surg Am. 2004;29(3):423e431.
14. Arimitsu S, Moritomo H, Kitamura T, et al. The stabilizing effect of
the distal interosseous membrane on the distal radioulnar joint in an
ulnar shortening procedure: a biomechanical study. J Bone Joint Surg
Am. 2011;93(21):2022e2030.
15. Poitevin LA. Anatomy and biomechanics of the interosseous mem-
brane: its importance in the longitudinal stability of the forearm.
Hand Clin. 2001;17(1):97e110, vii.
16. Watanabe H, Berger RA, Berglund LJ, Zobitz ME, An KN.
Contribution of the interosseous membrane to distal radioulnar joint
constraint. J Hand Surg Am. 2005;30(6):1164e1171.
J Hand Surg Am.
17. Pfaefe HJ, Fischer KJ, Manson TT, Tomaino MM, Woo SL,
Herndon JH. Role of the forearm interosseous ligament: is it more
than just longitudinal load transfer? J Hand Surg Am. 2000;25(4):
683e688.
18. Lawler E, Adams BD. Reconstruction for DRUJ instability. Hand
(N Y). 2007;2(3):123e126.
19. Tomaino MM, Pfaefe J, Stabile K, Li ZM. Reconstruction of the
interosseous ligament of the forearm reduces load on the radial head
in cadavers. J Hand Surg Br. 2003;28(3):267e270.
20. Hotchkiss RN. Injuries to the interosseous ligament of the forearm.
Hand Clin. 1994;10(3):391e398.
21. Shepard MF, Markolf KL, Dunbar AM. Effects of radial head
excision and distal radial shortening on load-sharing in cadaver
forearms. J Bone Joint Surg Am. 2001;83(1):92e100.
22. Skahen JR III, Palmer AK, Werner FW, Fortino MD. The inteross-
eous membrane of the forearm: anatomy and function. J Hand Surg
Am. 1997;22(6):981e985.
23. Sowa DT, Hotchkiss RN, Weiland AJ. Symptomatic proximal
translation of the radius following radial head resection. Clin Orthop
Relat Res. 1995;317:106e113.
24. Rodriguez-Martin J, Pretell-Mazzini J, Vidal-Bujanda C. Unusual
pattern of Essex-Lopresti injury with negative plain radiographs of
the wrist: a case report and literature review. Hand Surg. 2010;15(1):
41e45.
25. Helmerhorst GT, Ring D. Subtle Essex-Lopresti lesions: report of 2
cases. J Hand Surg Am. 2009;34(3):436e438.
26. Starch DW, Dabezies EJ. Magnetic resonance imaging of the inter-
osseous membrane of the forearm. J Bone Joint Surg Am.
2001;83(2):235e238.
27. Fester EW, Murray PM, Sanders TG, Ingari JV, Leyendecker J,
Leis HL. The efcacy of magnetic resonance imaging and ultrasound
in detecting disruptions of the forearm interosseous membrane: a
cadaver study. J Hand Surg Am. 2002;27(3):418e424.
28. McGinley JC, Roach N, Gaughan JP, Kozin SH. Forearm inteross-
eous membrane imaging and anatomy. Skeletal Radiol. 2004;33(10):
561e568.
29. McGinley JC, Roach N, Hopgood BC, Limmer K, Kozin SH.
Forearm interosseous membrane trauma: MRI diagnostic criteria and
injury patterns. Skeletal Radiol. 2006;35(5):275e281.
30. Jaakkola JI, Riggans DH, Lourie GM, Lang CJ, Elhassan BT,
Rosenthal SJ. Ultrasonography for the evaluation of forearm inter-
osseous membrane disruption in a cadaver model. J Hand Surg Am.
2001;26(6):1053e1057.
31. Soubeyrand M, Lafont C, Oberlin C, France W, Maulat I,
Degeorges R. The muscular hernia sign: an original ultrasono-
graphic sign to detect lesions of the forearms interosseous mem-
brane. Surg Radiol Anat. 2006;28(4):372e378.
32. Smith AM, Urbanosky LR, Castle JA, Rushing JT, Ruch DS. Radius
pull test: predictor of longitudinal forearm instability. J Bone Joint
Surg Am. 2002;84(11):1970e1976.
33. Soubeyrand M, Ciais G, Wassermann V, et al. The intra-operative
radius joystick test to diagnose complete disruption of the inter-
osseous membrane. J Bone Joint Surg Br. 2011;93(10):
1389e1394.
34. Ring D, Quintero J, Jupiter JB. Open reduction and internal xation
of fractures of the radial head. J Bone Joint Surg Am. 2002;84(10):
1811e1815.
35. Herbertsson P, Josefsson PO, Hasserius R, Besjakov J, Nyqvist F,
Karlsson MK. Fractures of the radial head and neck treated with
radial head excision. J Bone Joint Surg Am. 2004;86(9):1925e1930.
36. Morrey BF, Askew L, Chao EY. Silastic prosthetic replacement for
the radial head. J Bone Joint Surg Am. 1981;63(3):454e458.
37. Vanderwilde RS, Morrey BF, Melberg MW, Vinh TN. Inammatory
arthritis after failure of silicone rubber replacement of the radial head.
J Bone Joint Surg Br. 1994;76(1):78e81.
38. Lamas C, Castellanos J, Proubasta I, Dominguez E. Comminuted
radial head fractures treated with pyrocarbon prosthetic replacement.
Hand (N Y). 2011;6(1):27e33.
r Vol. 39, January 2014
 FOREARM INSTABILITY
39. Ricon FJ, Sanchez P, Lajara F, Galan A, Lozano JA, Guerado E.
Result of a pyrocarbon prosthesis after comminuted and unrecon-
structable radial head fractures. J Shoulder Elbow Surg. 2012;21(1):
82e91.
40. Knight DJ, Rymaszewski LA, Amis AA, Miller JH. Primary
replacement of the fractured radial head with a metal prosthesis.
J Bone Joint Surg Br. 1993;75(4):572e576.
41. Moro JK, Werier J, MacDermid JC, Patterson SD, King GJ.
Arthroplasty with a metal radial head for unreconstructible
fractures of the radial head. J Bone Joint Surg Am. 2001;83(8):
1201e1211.
42. Jungbluth P, Frangen TM, Arens S, Muhr G, Kalicke T. The undi-
agnosed Essex-Lopresti injury. J Bone Joint Surg Br. 2006;88(12):
1629e1633.
43. Jungbluth P, Frangen TM, Muhr G, Kalicke T. A primarily over-
looked and incorrectly treated Essex-Lopresti injury: what can this
lead to? Arch Orthop Trauma Surg. 2008;128(1):89e95.
44. Pfaefe HJ, Stabile KJ, Li ZM, Tomaino MM. Reconstruction of
the interosseous ligament unloads metallic radial head arthroplasty
and the distal ulna in cadavers. J Hand Surg Am. 2006;31(2):
269e278.
45. Gong HS, Chung MS, Oh JH, Lee YH, Kim SH, Baek GH. Failure of
the interosseous membrane to heal with immobilization, pinning of
the distal radioulnar joint, and bipolar radial head replacement in a
case of Essex-Lopresti injury: case report. J Hand Surg Am.
2010;35(6):976e980.
46. Chloros GD, Wiesler ER, Stabile KJ, Papadonikolakis A, Ruch DS,
Kuzma GR. Reconstruction of essex-lopresti injury of the forearm:
technical note. J Hand Surg Am. 2008;33(1):124e130.
47. Sellman DC, Seitz WH Jr, Postak PD, Greenwald AS. Reconstructive
strategies for radioulnar dissociation: a biomechanical study.
J Orthop Trauma. 1995;9(6):516e522.
48. Duckworth AD, Clement ND, Aitken SA, Ring D, McQueen MM.
Essex-Lopresti lesion associated with an impacted radial neck frac-
ture: interest of ulnar shortening in the secondary management of
sequelae. J Shoulder Elbow Surg. 2011;20(6):e19e24.
JOURNAL CME QUESTIONS
Forearm Instability
Axial stability of the forearm is attributed to:
a. Primarily the interosseous membrane (IOM) and
secondarily the radial head and the triangular
brocartilage complex (TFCC)
b. Primarily the TFCC and secondarily the IOM
and radial head
c. Primarily the radial head and secondarily the
IOM and TFCC
d. The IOM and radial collateral ligament of the
elbow
e. The radial collateral and accessory collateral
ligaments of the elbow
To take the online test and receive CME credit, go to http://www.jhandsurg.org/CME/home.
J Hand Surg Am.
167
49. Adams JE, Osterman MN, Osterman AL. Interosseous membrane
reconstruction for forearm longitudinal instability. Tech Hand Up
Extrem Surg. 2010;14(4):222e225.
50. Soubeyrand M, Oberlin C, Dumontier C, Belkheyar Z, Lafont C,
Degeorges R. Ligamentoplasty of the forearm interosseous mem-
brane using the semitendinosus tendon: anatomical study and surgical
procedure. Surg Radiol Anat. 2006;28(3):300e307.
51. Tejwani SG, Markolf KL, Benhaim P. Reconstruction of the inter-
osseous membrane of the forearm with a graft substitute: a cadaveric
study. J Hand Surg Am. 2005;30(2):326e334.
52. Marcotte AL, Osterman AL. Longitudinal radioulnar dissociation:
identication and treatment of acute and chronic injuries. Hand Clin.
2007;23(2):195e208, vi.
53. Sabo MT, Watts AC. Reconstructing the interosseous membrane: a
technique using synthetic graft and endobuttons. Tech Hand Up
Extrem Surg. 2012;16(4):187e193.
54. Jones CM, Kam CC, Ouellette EA, Milne EL, Kaimrajh D, Latta LL.
Comparison of 2 forearm reconstructions for longitudinal radioulnar
dissociation: a cadaver study. J Hand Surg Am. 2012;37(4):741e747.
55. Stabile KJ, Pfaefe J, Saris I, Li ZM, Tomaino MM. Structural
properties of reconstruction constructs for the interosseous ligament
of the forearm. J Hand Surg Am. 2005;30(2):312e318.
56. Pfaefe HJ, Stabile KJ, Li ZM, Tomaino MM. Reconstruction of the
interosseous ligament restores normal forearm compressive load
transfer in cadavers. J Hand Surg Am. 2005;30(2):319e325.
57. Tejwani SG, Markolf KL, Benhaim P. Graft reconstruction of the
interosseous membrane in conjunction with metallic radial head
replacement: a cadaveric study. J Hand Surg Am. 2005;30(2):335e342.
58. Allende C, Allende BT. Posttraumatic one-bone forearm reconstruction.
A report of seven cases. J Bone Joint Surg Am. 2004;86(2):364e369.
59. Peterson CA, Maki S, Wood MB. Clinical results of the one-bone
forearm. J Hand Surg Am. 1995;20(4):609e618.
60. Jacoby SM, Bachoura A, Diprinzio EV, Culp RW, Osterman AL.
Complications following one-bone forearm surgery for posttraumatic
forearm and distal radioulnar joint instability. J Hand Surg Am.
2013;38(5):976e982.
Which of the following statements is most relevant
regarding the diagnosis or treatment of
longitudinal forearm instability?
a. Magnetic resonance imaging and ultrasound are
not useful in making an early diagnosis of longi-
tudinal radioulnar dissociation
b. Longitudinal radial traction resulting in proximal
radial migration of 3 mm is indicative of intact IOM
c. The radius pull test does not determine if the
radial head should be replaced
d. Proximal radial migration of 6 mm after removal
of the radial head is indicative of damage to both
Current Concepts
the TFCC and IOM
e. The radius joystick test is performed by lateral
traction on the radial head with the forearm
maximally supinated
r Vol. 39, January 2014