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    IOM Cartagena

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    Professeur Christian Dumontier
    The document summarizes the anatomy, physiology, and pathology of the interosseous membrane (IOM) of the forearm. It discusses: 1) The IOM's insertion on both the radius and ulna over 10 cm, with a thickness of 2.18 mm. It is part of the forearm compartment system and transmits axial and transverse loads. 2) Lesions of the IOM can occur from forearm trauma and impact stability. A single locker instability is unlikely, while lesions of two lockers like Monteggia or Galeazzi fractures imply an IOM injury. 3) Essex-Lopresti syndrome involves lesions of the radial head, IOM

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    © All Rights Reserved

    IOM Cartagena

    Uploaded by

    Professeur Christian Dumontier
    5K views77 pages
    The document summarizes the anatomy, physiology, and pathology of the interosseous membrane (IOM) of the forearm. It discusses: 1) The IOM's insertion on both the radius and ulna over 10 cm, with a thickness of 2.18 mm. It is part of the forearm compartment system and transmits axial and transverse loads. 2) Lesions of the IOM can occur from forearm trauma and impact stability. A single locker instability is unlikely, while lesions of two lockers like Monteggia or Galeazzi fractures imply an IOM injury. 3) Essex-Lopresti syndrome involves lesions of the radial head, IOM

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    The document summarizes the anatomy, physiology, and pathology of the interosseous membrane (IOM) of the forearm. It discusses: 1) The IOM's insertion on both the radius and ulna over 10 cm, with a thickness of 2.18 mm. It is part of the forearm compartment system and transmits axial and transverse loads. 2) Lesions of the IOM can occur from forearm trauma and impact stability. A single locker instability is unlikely, while lesions of two lockers like Monteggia or Galeazzi fractures imply an IOM injury. 3) Essex-Lopresti syndrome involves lesions of the radial head, IOM

    Copyright:

    © All Rights Reserved
    5K views77 pages

    IOM Cartagena

    Uploaded by

    Professeur Christian Dumontier
    The document summarizes the anatomy, physiology, and pathology of the interosseous membrane (IOM) of the forearm. It discusses: 1) The IOM's insertion on both the radius and ulna over 10 cm, with a thickness of 2.18 mm. It is part of the forearm compartment system and transmits axial and transverse loads. 2) Lesions of the IOM can occur from forearm trauma and impact stability. A single locker instability is unlikely, while lesions of two lockers like Monteggia or Galeazzi fractures imply an IOM injury. 3) Essex-Lopresti syndrome involves lesions of the radial head, IOM

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    You can see all presentations on

    www.diuchirurgiemain.org

    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

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