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The three lockers

concept
Pr Christian Dumontier, MD, PhD
Pr Marc Soubeyrand, MD, PhD

Presentation and references can be seen on


www.diuchirurgiemain.org
The forearm is by sure very
useful ! you need one

Hey! Im trying to
pass the potatoes!
.Remember, my
forearms are just as
useless as yours!
And it can be so useful
that it can compensate
for severe loss of
function of the hand

Amaranth S et al. Krukenberg operation: The "lobster claw" for traumatic amputation of the left
hand. 2014
This is because the forearm is
a joint (an association of joints)

That allows two different


bones (radius and ulna)
to move one aroud the
other
The forearm biomechanics
is about pronosupination

A joint: The association of three


(four) joints

A mouvement: rotation of the


forearm

An axis: starting at the radial head


and ending at the ulnar head

Motors: muscles for pronation


and supination
PRUJ and DRUJ are well-know
synovial joints

Proximal Proximal
For teaching purposes, ulna radius

CG. HAGERT used to


removed the middle Distal radius Distal ulna
forearm to explain
forearm rotation around
the two trochoid joints
The forearm should be regarded as the
third joint: The middle radioulnar joint

Forearm rotation is not possible is


the third joint is not functional +++
LaStayo PC, Lee MJ (2006) The forearm complex: anatomy, biomechanics and clinical
considerations. J Hand Ther 19:137144
As any joint, it has bony structures
Whose shape and alignment
are important for motion
Ulnar shaft, almost linear
Radial shaft has two
curvatures (supinator
proximal, pronator distal)

Failure to restore the normal


radial bow to within 4% to 5%
of the contralateral forearm has
been associated with greater
than 20% loss of forearm
rotation.

Schemitsch EH, Richards RR. The effect of malunion on functional outcome after plate fixation of fractures
of both bones of the forearm in adults. J Bone Joint Surg 1992;74A:10681078.
and ligaments

The Interosseous membrane : thickness


2,18 mm Assemblage
nucleus
Two type of fibers according to their
direction forming a criss-cross system

Most of them originates from the


assemblage nucleus 8 cm from
elbow joint
Poitevin LA (2001) Anatomy and biomechanics of the interosseous membrane: its importance in the
longitudinal stability of the forearm. Hand Clin 17:97110
The forearm joint is in close relationship
with the PRUJ
The oblique ligament or Weitbrechts ligament
extends from the ulna below the radial notch
and ends at the radius below the biceps
tuberosity. It becomes taut when the radius is
in supination.
The forearm joint is in close relationship
with the DRUJ

The distal oblique bundle (DOB) inserts on


the inferior rim of the sigmoid notch of the
radius and fibres blend into the capsular
tissue of the DRUJ.
The forearm joint is in close relationship
with the DRUJ

The DOB, when present,


seems to be important
isometric stabilizer of the
DRUJ and second after the
TFCC for DRUJ stability.

Moritomo H (2012) The distal interosseous membrane: current concepts in wrist anatomy
and biomechanics. J Hand Surg Am 37(7):15011507
The three lockers concept
Fragonard: the locker
Paris, the Louvre

Each joint participate to the pronosupination and


constitute a locker
Each locker can be absent, unstable or locked (stiff)
Proximal locker = PRUJ
Proximal radioulnar
Locking
synostosis

Absent Radial head resection

Unstable Radial head dislocation


Distal locker = DRUJ

Locking DRUJ stiffness

Absent Ulnar head resection

Isolated ulnar head


Unstable
dislocation
Middle locker
Synostosis, forearm
Locking bone malunion or IOM
retraction

Absent
?
IOM lesion or dyaphysal
Unstable
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


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 and usually
non-displaced: Monteggias, Galeazzis fractures
imply an associated IOM lesion
However

If an absent locker can be compensate


for longitudinal stability
Transverse instability may represent a
problem like in Monteggias or
Galeazzis fractures when instability
persists after bone fixation
Consequences in clinical
practice
An absent locker can be compensate by
the other two

Radial head resection


Ulnar head resection
Isolated section of the IOM
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)
Consequences

Absence of two lockers cannot be compensate by the


last one

Radial head resection + IOM Lesion =


persistent instability
TFCC disruption + IOM lesion = persistent
instability
Three lockers lesion

Essex-Lopresti syndrome (1951)


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

The whole forearm is a functional unit


The forearm joint, the three lockers concept, is
one way to realize that all structures in the forearm
contribute to the prono-supination movement.
If bony injuries are well-known, soft-tissues lesions are
most difficult to diagnose and treat. However they
should not be under-estimated
Thank you for your attention