JBJS | Magnetic Resonance Imaging of the Interosseous Membrane of the Forearm

The Journal of Bone & Joint Surgery, Volume 83, Issue 2

Articles | February 01, 2001

Magnetic Resonance Imaging of the Interosseous Membrane of the Forearm

David W. Starch, MD; Eugene J. Dabezies, MD

Investigation performed at Texas Tech University Health Sciences Center, Lubbock, Texas
David W. Starch, MD Eugene J. Dabezies, MD Texas Tech University Health Sciences Center, 3601 4th Street, Lubbock, TX 79430. E-mail address for D. Starch: dstarch@bcm.tmc.edu.
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

The Journal of Bone & Joint Surgery. 2001; 83:235-235

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Abstract

Background: Diagnosis of damage to the interosseous membrane of the forearm after trauma is difficult. Patients with a proximal radial fracture and associated damage to the interosseous membrane may have wrist pain in association with subluxation or dislocation of the distal radioulnar joint. Accurate identification of injury to the interosseous membrane may allow better planning of surgical treatment.

Methods: T1 and T2-weighted magnetic resonance images that were made in the axial, sagittal, and coronal planes were used to evaluate the interosseous membrane in the forearms of cadavera, volunteers, and patients. The images were evaluated subjectively by two orthopaedic surgeons and a musculoskeletal radiologist.

Results: The interosseous membrane was most consistently visualized on the axial images. Axial T2-weighted images showed the interosseous membrane clearly. The addition of fat-suppression techniques allowed abnormalities to be identified more accurately. Fast-spin-echo techniques were used to obtain data quickly and accurately.

Conclusions: The intact and disrupted interosseous membrane can be evaluated with use of magnetic resonance imaging. Axial T2-weighted fast-spin-echo images with fat suppression in the middle one-third of the forearm provide the most accurate information.

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

The importance of the interosseous membrane in controlling proximal and distal migration of the radius and ulna has been demonstrated in studies of forearm injuries associated with radial head injury. Hotchkiss et al. showed that the central one-third of the interosseous membrane was responsible for 71% of the longitudinal stiffness of the forearm after removal of the radial head¹. Patients who have a radial head fracture with disruption of the distal radioulnar joint and acute proximal migration of the radius, the so-called Essex-Lopresti lesion, consistently report wrist symptoms following isolated excision of the comminuted radial head^2-5. Problems associated with late proximal migration of the radius also have been reported when the forearm is stabilized initially with a prosthetic radial head or with cross-pinning of the radius and ulna^2,3,5. These problems are thought to develop secondary to disruption of the interosseous membrane at the time of the injury^2,3,6. The need for more definitive information with which to guide the acute treatment of injuries involving the interosseous membrane was the stimulus for our investigation.

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Fig. 1:: Axial T1-weighted magnetic resonance image of the forearm of a volunteer. The interosseous membrane is intact.

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Fig. 2:: Axial T2-weighted fast-spin-echo magnetic resonance image of the forearm of a volunteer. The interosseous membrane is intact.

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Fig. 3:: Axial T2-weighted fast-spin-echo magnetic resonance image of the forearm of a patient, showing increased signal intensity in the volar musculature. The interosseous membrane is intact.

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Fig. 4-A:: Figs. 4-A and 4-B Axial T2-weighted fast-spin-echo magnetic resonance images of the forearm of the patient who had an Essex-Lopresti lesion. Increased signal intensity is visible in the area of the interosseous membrane. There is disruption of the interosseous membrane near its radial attachment.

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Fig. 4-B:: Figs. 4-A and 4-B Axial T2-weighted fast-spin-echo magnetic resonance images of the forearm of the patient who had an Essex-Lopresti lesion. Increased signal intensity is visible in the area of the interosseous membrane. There is disruption of the interosseous membrane near its radial attachment.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

A magnetic resonance imaging machine (Signa Horizon-LX; GE Medical Systems, Milwaukee, Wisconsin) with echo speed gradients to 1.5 T was used to evaluate the forearms of cadavera, volunteers, and patients during the period from January through May 1998. A flex coil was utilized for imaging of the extremities. Fast-spin-echo techniques were used to obtain the images more quickly. The forearms of the cadavera and volunteers were held in supination as this position has been shown to increase tension in the interosseous membrane⁷. The injured patients were encouraged to hold the forearm in this position as tolerated. Full extension of the elbow with the arm by the side or extended above the head was the desired position for evaluation of the patients and volunteers.

Axial, sagittal, and coronal images were used to evaluate eight forearms from fresh cadavera as well as four forearms of uninjured volunteers. T1 and T2-weighted images, with and without utilization of fat-suppression techniques for the T2-weighted images, were made in the three planes. After these initial evaluations, four of the cadaveric forearms underwent limited dissection with a scalpel to disrupt the central one-third of the interosseous membrane. The images were then repeated in the three planes with use of the previously described techniques.

Axial T2-weighted fast-spin-echo images with fat suppression were used to evaluate the forearms of five patients who had forearm trauma and an associated fracture of the radial head. One of these patients had clinical and radiographic findings that were consistent with disruption of the distal radioulnar joint. Four of the five patients were able to tolerate nearly full extension of the elbow, without joint aspiration or lidocaine injection, with the arm by the side or extended above the head. The other patient could not tolerate extension of the elbow beyond 70 degrees even after the administration of pain medication; therefore, the forearm was positioned across the chest and the patient attempted to hold her breath during periods of imaging.

Results

Introduction | Materials and Methods | Results | Discussion | References

All images were evaluated by two orthopaedic surgeons (D.W.S. and E.J.D.) and a musculoskeletal radiologist. The interosseous membrane was consistently identified on the axial images. The thicker, ligamentous portion could be differentiated from the thinner, membranous portions in cuts from the middle one-third of the forearm. The interosseous membrane was not clearly defined on the coronal and sagittal images.

Axial T1-weighted images of the uninjured forearms of cadavera and volunteers showed the interosseous membrane as a dark line with crisp detail (Fig. 1Fig. 1). The simulated injuries in the four cadaveric specimens that had undergone limited dissection were also clearly visualized. Axial T2-weighted images demonstrated the intact and disrupted interosseous membranes clearly as well. The use of fat suppression more clearly delineated the areas of edema and injury in the trauma patients. Uninjured muscle tissue in the forearms of volunteers and patients demonstrated low signal intensity (Fig. 2Fig. 2), whereas areas of injury and edema were reflected by increased signal intensity.

Patient Evaluation

The magnetic resonance images for the patient who had held the forearm across the chest during periods of imaging could not be analyzed because of motion artifact. The images for three of the remaining four patients demonstrated increased signal intensity in the volar musculature but no evidence of an injury of the interosseous membrane (Fig. 3Fig. 3). The last patient, who had clinical findings that were consistent with an Essex-Lopresti lesion, had a comminuted radial head fracture with an associated fracture of the proximal one-third of the ulna. The images for this patient showed increased signal intensity, representing edema and hemorrhage, in the area of the interosseous membrane (Fig. 4-AFig. 4-A). There also was evidence of disruption of the ligamentous portion in the middle one-third of the forearm as indicated by discontinuity of the low-intensity signal (Fig. 4-BFig. 4-B). This patient was managed with replacement of the radial head with a polyethylene-and-metal prosthesis as well as plate fixation of the proximal ulnar fracture and eventually required a midshaft radioulnar arthrodesis because of pain and instability at the radiocapitellar joint. We were therefore unable to perform a follow-up investigation to assess the interosseous membrane.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

The interosseous membrane of the forearm has been shown to be an important structure to consider in cases of forearm trauma. Hotchkiss reported that magnetic resonance imaging could be used to demonstrate disruption of the interosseous membrane in patients with a forearm injury but commented that his experience was too limited to assess the full utility of the method³. Despite recent advances in the understanding of forearm injuries, we are not aware of any reports in the English-language literature that have demonstrated the most effective use of magnetic resonance imaging in the evaluation of the interosseous membrane after trauma. Other investigators have reported on the use of magnetic resonance imaging to assess the upper extremity in cadavera and uninjured volunteers^7-10. Nakamura et al. used three-dimensional magnetic resonance imaging to investigate the biomechanics of the interosseous membrane¹⁰.

We evaluated the forearms of cadavera, volunteers, and patients in order to identify the best magnetic resonance imaging technique for the evaluation of damage to the interosseous membrane. We found that axial images were much better than coronal and sagittal images for visualization of this structure. Both T1 and T2-weighted axial images demonstrated the intact and disrupted interosseous membrane well. Soft-tissue injury and edema were more easily identified as areas of increased signal intensity on T2-weighted images. The use of fat suppression decreased undesirable tissue signals. Fast-spin-echo techniques yielded clearer images by limiting distortion and allowed the images to be produced more quickly.

The wrist pain that can develop following injury to the interosseous membrane of the forearm in patients with an associated radial head fracture is often unanticipated. Excision of a comminuted radial head in a patient who has associated instability of the distal radioulnar joint may result in proximal migration of the radius. Several treatment options are available in this situation, including reconstruction of the interosseous membrane³. None of the options has yet proved to be the treatment of choice. The need for more definitive information with which to guide the treatment of these complex injuries was the impetus for our study. We found that axial T2-weighted fast-spin-echo images with fat suppression provided the best information.

References

Introduction | Materials and Methods | Results | Discussion | References

Hotchkiss RN; An KN; Sowa DT; Basta S; and 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): 256-61, 14(2 Pt 1)256 1989

Edwards GS Jr, and Jupiter JB.: Radial head fractures with acute distal radioulnar dislocation. Essex-Lopresti revisited. Clin Orthop,1988.234: 61-9, 23461 1988 [PubMed]

Hotchkiss RN: Injuries to the interosseous ligament of the forearm. Hand Clin,1994.10: 391-8, 10391 1994 [PubMed]

Morrey BF; Chao EY; and Hui FC: Biomechanical study of the elbow following excision of the radial head. J Bone Joint Surg Am,1979.61: 63-8, 6163 1979 [PubMed]

Trousdale RT; Amadio PC; Cooney WP; and Morrey BF: Radio-ulnar dissociation. A review of twenty cases. J Bone Joint Surg Am,1992.74: 1486-97, 741486 1992 [PubMed]

Knight DJ; Rymaszewski LH; Amis AA; and Miller JH: Primary replacement of the fractured radial head with a metal prosthesis. J Bone Joint Surg Br,1993.75: 572-6, 75572 1993 [PubMed]

Nakamura T; Yabe Y; and Horiuchi Y: In vivo MR studies of dynamic changes in the interosseous membrane of the forearm during rotation. J Hand Surg [Br],1999.24: 245-8, 24245 1999 [PubMed]

Herzog RJ: Magnetic resonance imaging of the elbow. Magn Reson Q,1993.9: 188-210, 9188 1993 [PubMed]

Hodler J; Cotton A; Trudell D; and Resnick D: Magnetic resonance imaging of the forearm. Invest Radiology,1988.33: 6-11, 336 1988

Nakamura T; Yabe Y; Horiuchi Y; and Yamazaki N: Three-dimensional magnetic resonance imaging of the interosseous membrane of forearm: a new method using fuzzy reasoning. Magn Reson Imaging,1999.17: 463-70, 17463 1999 [PubMed]

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