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Radius Axial Interosseous Load (RAIL) Test for Essex Lopresti Injuries
Zachary Lum, DO; Eric G. Huish, DO; Marc A. Trzeciak, DO
Valley Orthopedic Surgery Residency, Modesto, CA
Introduction: When approaching radial head and neck fractures, the decision for ORIF, resection, or arthroplasty is often performed intraoperatively. Factors that contribute include ligamentous and bony stability, cartilage injury, mechanical alignment as well as patient factors. Recent data has suggested conventional methods may not be sufficiently sensitive in detecting Essex Lopresti injuries. Here we describe an intraoperative technique that could objectively assess proximal radio-ulnar stability with subsequent disruption of the ligamentous structures.
Technique: - Surgeon performs approach of choice to expose radial head and neck, then excise radial head if irrepairable
- Bring arm into 90 deg flexion, place 20lb axial force through palm into radius in pronation and supination
- If proximal migration more than 4mm is palpated and visually confirmed, radial head replacement may be necessary
Methods: - Radial heads were resected on 8 fresh frozen cadavers
- Consecutive measurements of radial head resection, interosseous membrane (IOM) and distal radioulnar joint (DRUJ) resection were performed, and radiocapitellar distance was measured
Results: - After initial resection, intact ligaments measured 10.75mm & 10.375mm of RC distance in supination & pronation, respectively
- After IOM resection, there was 6.69mm & 7.63mm RC distance, a 2.8-4.0mm proximal migration of the radial head, p < 0.0001 pronation, p = 0.00005 supination
- After DRUJ & IOM resection, there was 4.5mm & 4.18mm RC distance >6mm proximal migration, p=0.003 in supination & pronation
Discussion - Our study suggests that progressive disruption of the interosseous membrane and DRUJ may result in a predictable radiocapitellar measurement with our RAIL test
- This test may aid the surgeon in deciding competence of the interosseous membrane and DRUJ
- Prior tests attempt to evaluate radius distraction when proximal radial migration is the major complication of Essex-Lopresti injuries
- Prior tests also require use of instruments and an intact radial neck cortex
- The interosseous membrane is most taut in the ends of rotation, thus it is best to test in these positions
- The RAIL test is a quick and easy test that can be performed intraoperatively to help determine interosseous membrane stability
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