Fontana et al.

BMC Musculoskeletal Disorders (2018) 19:312

https://doi.org/10.1186/s12891-018-2232-2

RESEARCH ARTICLE Open Access

Diagnosis and treatment of acute Essex-

Lopresti injury: focus on terminology and
review of literature
Maurizio Fontana1, Marco Cavallo2*, Graziano Bettelli2 and Roberto Rotini2

Abstract
Background: Acute Essex-Lopresti injury is a rare and disabling condition of longitudinal instability of the forearm.
When early diagnosed, patients report better outcomes with higher functional recovery. Aim of this study is to
focus on the different lesion patterns causing forearm instability, reviewing literature and the cases treated by the
Authors and to propose a new terminology for their identification.
Methods: Five patients affected by acute Essex-Lopresti injury have been enrolled for this study. ELI was caused in
two patients by bike fall, two cases by road traffic accident and one patient by fall while walking. A literature search
was performed using Ovid Medline, Ovid Embase, Scopus and Cochrane Library and the Medical Subject Headings
vocabulary. The search was limited to English language literature. 42 articles were evaluated, and finally four papers
were considered for the review.
Results: All patients were operated in acute setting with radial head replacement and different combinations of
interosseous membrane reconstruction and distal radio-ulnar joint stabilization. Patients were followed for a mean
of 15 months: a consistent improvement of clinical results were observed, reporting a mean MEPS of 92 and a
mean MMWS of 90.8. One case complained persistent wrist pain associated to DRUJ discrepancy of 3 mm and
underwent ulnar shortening osteotomy nine months after surgery, with good results.
Discussion: The clinical studies present in literature reported similar results, highlighting as patients properly
diagnosed and treated in acute setting report better results than patients operated after four weeks. In this study,
the definitions of “Acute Engaged” and “Undetected at Imminent Evolution” Essex-Lopresti injury are proposed, in
order to underline the necessity to carefully investigate the anatomical and radiological features in order to perform
an early and proper surgical treatment.
Conclusions: Following the observations, the definitions of “Acute Engaged” and “Undetected at Imminent Evolution”
injuries are proposed to distinguish between evident cases and more insidious settings, with necessity of carefully
investigate the anatomical and radiological features in order to address patients to an early and proper surgical
treatment.
Keywords: Acute Essex-Lopresti injury, Elbow, Wrist, Forearm instability

* Correspondence: marco.cavallo@ior.it
2
Shoulder and Elbow Unit, IRCCS - Istituto Ortopedico Rizzoli, Via G.C. Pupilli
1, Bologna, Italy
Full list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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Fontana et al. BMC Musculoskeletal Disorders (2018) 19:312 Page 2 of 10

Background were considered. A total of 4 articles were finally considered

The forearm can be considered as a single articulating for the review.
unit where the close interdependence of multiple ana- For this study all the thirty-two patients affected by
tomical structures allows forearm rotation, elbow and ELI who came to the Authors' attention between 2010
wrist motion [1, 2]. All of these functions, especially pro- and 2016 have been retrospectively reviewed. Adams et
nation and supination, explain the complex integrated al. considered the acute setting within four weeks from
relationship between the bones and soft tissue along the trauma, [8] and following this indication five patients
entire length of this anatomical district. The forearm have been selected for this study. All patients were
constraints are formed by the Proximal Radio-Ulnar males, with mean age of 40 years. The primary injury
Joint (PRUJ) mainly represented by the Radial Head
(RH), the Interosseous Membrane (IOM) particularly in
its central and stronger part named Central Band or
Interosseous ligament (IOL) [3–5] and Distal Radio-
Ulnar joint (DRUJ) represented by the Triangular Fibro-
cartilage Complex (TFCC) and, when present, by the
Distal Oblique Band (DOB). All these anatomic and
functional structures can be grouped under the name of
the Forearm Unit [6]. In 1951 Peter Essex-Lopresti de-
scribed the proximal migration of the radius following
the surgical excision of comminuted RH fracture [7].
This longitudinal migration of the radius can generate
when a traumatic axial load is transmitted from the wrist
to the elbow, causing the combination of DRUJ disrup-
tion, rupture of the IOM and RH fracture. After
Essex-Lopresti detailed description, this injury pattern
gained the eponym of Essex-Lopresti Injury (ELI) [8].
Like other traumatic patterns, this lesion can be classi-
fied in the group of unstable fractures of the forearm,
characterized by fracture of one or both forearm bones
associated with lesion of some forearm main constraints
(TFCC, IOM and RH). The lack of at least two con-
straints can lead to two different acute patterns: a typical
ELI or a hidden form, difficult to be detected but still
considerably harming the patient’s quality of life [9]. The
development of these conditions depend from the IOM/
TFCC reaction to the energy-related trauma. These
lesions are often misdiagnosed in emergency room and
not properly treated, leading to a Chronic ELI, a disa-
bling condition extremely difficult to treat with positive
outcomes [4, 9–15].
Aim of this work is to focus on the different lesion
patterns causing forearm instability, reviewing literature
and the cases treated by the Authors and to propose a
new terminology for their identification.

Methods
A literature search was performed using Ovid Medline, Ovid
Embase, Scopus and Cochrane Library and the Medical
Subject Headings vocabulary. The following terms were
combined with ‘AND’ and ‘OR’: ‘essex’; ‘lopresti’; ‘acute’. A
total of 42 articles were The search was limited to English Fig. 1 Clinical case 4, Acute Engaged ELI, pre-operative: elbow. Pre-
operative left elbow X-rays (a, b, c) and 3D reconstruction CT scan
language literature. Papers published before 2018 and clearly
(d) images showing a Mason 3 radial head fracture
reporting clinical results and ELI treatment in acute setting

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Fontana et al. BMC Musculoskeletal Disorders (2018) 19:312 Page 3 of 10

causing ELI was by bike fall in two patients, road traffic

accident in two cases and fall while walking in one case.
Three cases presented an important proximal longitu-
dinal dislocation of the radius, with the proximal radius
engaging into the capitellum (Figs. 1, 2). In one case the
RH fracture showed the involvement of radial neck
(Mason grade 3) without longitudinal radial proximal
dislocation, but in presence of gross instability of elbow
and forearm (Fig. 3). In all the cases the lesion was
caused by high energy upper limb impact trauma (bike
fall, road traffic accident, and so on [16]. Patients’ demo-
graphics and lesion characteristics are reported in
Table 2.
The preliminary evaluation consisted in a clinical
complete examination. In particular the investigation of
the traumatic mechanism reported by the patient arose
the suspect of high energy axial load on the forearm,
with possibility of unstable fracture. The clinical examin-
ation was performed starting from the elbow stability
evaluation (associated lesions of LUCL or MCL),
followed by a check of the radial head (tenderness, pro-
nation supination, Xilo Test). The IOM was checked
with the “C-Fingers comparative test” [17] (Fig. 4): with
this test it is possible to check the tenderness at the level
of CB and DOB. In acute cases a vivid painful reaction is

Fig. 3 Clinical case 2: Acute Undetected at Imminent Evolution ELI

pattern. Pre-operative X-ray of case n. 2: it is evident the radial head
fracture without evident signs of high energy trauma (a, b). The
DRUJ seemed aligned ad regular X-Ray (c). Performing the stress test
under C-arm view the forearm longitudinal instability was detected
(d, e). The treatment consisted in radial head prosthesis positioning
(g), IOM plasty and collateral ligaments reconstruction (f)

Fig. 2 Clinical case 4, pre-operative: wrist. Pre-operative X-rays of the

same patient. The left wrist (a, b) highlighted a DRUJ lesion, more
evident if compared to the right unaffected wrist images (c, d)

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Fontana et al. BMC Musculoskeletal Disorders (2018) 19:312 Page 4 of 10

indicative of an IOM laceration. In chronic patients a

reduced resistance of one or more segments compared
to the counterlateral forearm is suspect for partial or
complete IOM tear. The DRUJ was evaluated by the
mean of the Tilt test: at the wrist the physician tests the
DRUJ with dorsal and volar comparative translation of
the ulna in neutral, supination and pronation. Then the
potential longitudinal forearm instability was investi-
gated with a comparative wrist X ray, with the detection
of a distal radius proximal migration comparing to the
counterlateral wrist. An elbow CT scan was performed
in all cases to better assess the pathoanathomy of the
RH fracture.
Surgery has been performed at a mean of 13 days after
trauma. Before the surgical procedure the ELI was
confirmed under anesthesia, performing some specific
tests to better assess the elbow stability: the ultrasono-
graphic evaluation of the so called “Muscular Hernia
Sign” [18] and the axial stress test [19]. A distal radial
migration of 3 mm or greater was considered indicative
of longitudinal instability [20].
After the confirmation of acute presence of Essex
Lopresti syndrome, the surgery was performed with a preli-
minar positioning of an infraclavear catheter for continuous
post operative analgesia. Patients were placed in supine
Fig. 4 C-Fingers comparative test. Clinical image of the C-Fingers position with a pneumatic tourniquet at the limb’s root.
comparative test: the arm lies on a table, with elbow flexed at 90°
The surgical repair was performed in three steps. Since
and forearm vertical to the floor plane. With the thumb opposite to
other fingers (forming the shape of a “C” letter) the surgeon ELI is a non frequent lesion, not all the three steps were
squeezes the forearm space and pushes alternatively in dorsal and performed in all cases, reflecting the progressive and
palmar direction to feel the muscular-IOM resistance in pronation recent development of knowledge in this pathology.
and supination; the test must be comparative and is generally The first step, performed in all cases, consisted in the
hindered by muscular hypertrophy and edema
positioning of the radial head prosthesis. Using the
Kocher interval the implanted prosthesis was unipolar in

Fig. 5 Surgical images of the procedure, clinical case 3. The radial head prosthesis was firstly positioned (a), followed by TFCC reconstruction and
DRUJ pinning (b). At the level of the maximum radial bow, passing between flexor and extensor muscles, the radial origin of the pronator teres
was recognized and isolated (c). At intermediate forearm rotation two 1.5 mmm drill were performed (d)

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Fontana et al. BMC Musculoskeletal Disorders (2018) 19:312 Page 5 of 10

three cases and bipolar in two cases, all non cemented performed. In Patients n.3 and 4 underwent radial head
with press fit insertion in the radial canal (Fig. 5a). replacement, TFCC reconstruction, DRUJ pinning and
In patient n.1, only radial head replacement was IOM reconstruction. Patient n.5 underwent radial head
performed. Patient n.2 was initially underestimated: in prosthesis, TFCC reconstruction and DRUJ pinning.
emergency room it was classified as isolated Mason 3 ra- In cases when TFCC reconstruction and DRUJ pin-
dial head fracture and addressed for surgery. It was only ning were performed a dorsal access to the DRUJ was
under anesthesia and under C-arm view that forearm used. The TFCC was re-inserted with a high resistance 0
longitudinal instability was detected. The muscular wire to the ulnar stiloid process with a trans osseous
hernia sign was negative, Axial test positive with a stable stitch, and the DRUJ was then reduced and fixed by two
DRUJ. The radial head prosthesis was positioned, then extra articular Kirschener wires. (Fig. 5b). When a IOM
IOM and lateral collateral ligaments reconstruction were reconstruction was performed (patients n.2,3 and 4) it
was used a technique similar to Soubeyrand procedure

Fig. 6 Surgical images of the procedure clinical case 3. With the

help of a smooth tool the path for the stabilizer device was
performed, dorsally crossing the forearm bones under the muscular Fig. 7 Post operative X-rays, clinical case 3. Post operative X-rays
extensor compartment (a). The stabilizer device was then put in show the reduced and stabilized DRUJ (a, b) and the radial head
position with the help of a knee ligament passer (b) and finally prosthesis (c). It is possible to see the radial and ulnar tunnels of the
tensioned (c) two bundles of the newly reconstructed IOM (a)

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Table 1 Studies in literature reporting cases of acute Essex-Lopresti injuries

Author N. of patients mean follow up, MEPS at MMWS at mean DRUJ Described
operated within months follow up follow up at final FU results
4 weeks
Grassmann 12 59 86.7 88.4 not reported
et al. [24]
Trousdale 5 54 91 80 + 2.5 mm ulna
et al. [15]
Edwards 5 18 not reported not reported + 2 mm ulna 3 excellent,
and Jupiter 1 good, 1
[10] poor
Schnetzke 16 63.6 91.3 81.3 + 2 mm ulna
et al. [14]

[21] (Figs. 5, 6, 7): at the level of the maximum radial Elbow Performance Score [22] and the Modified Mayo
bow and at the opposite part of inner ridge detected Wrist Score [23]. An X ray investigation has been per-
under C-arm, a five centimetres incision was performed. formed in all cases at final follow up.
Passing between flexor and extensor muscles, the radial
origin of the pronator teres was recognized. Keeping the Results
forearm in neutral pronation and supination position, Only few reports are present in literature about acute
two 1.5 mm drill holes were performed. Other two ELI (Table 1): Grassmann et al. [24] identified 12 acute
1.5 mm drill holes were performed at the level of the ELI in a group of 295 patients affected by RH fracture.
distal ulnar neck, with a 20 degrees axis respect to An evident radio-ulnar X-ray discrepancy was found in
longitudinal forearm axis. As stabilizer device a cadaveric only five patients, and a partial or complete IOM rup-
tendon allograft was used in one case (n.4) and a synthetic ture was diagnosed by MRI in all 12 cases. The authors
band (Ultratape, Smith & Nephew,UK) in two cases reported good mid-term results. Trousdale [15] reported
(patient n.2 and 3). The stabilizer device was then passed, a case series of 20 ELI, identifying 5 cases of acute
dorsally crossing the forearm bones under the muscular forms: these cases, properly treated, reported good out-
extensor compartment, with the help of a plastic knee come in 4 cases, while the other 15, initially misdiag-
ligament passer. Under C-arm view the device was then nosed and treated with RH resection, developed severe
stretched; pronation supination and radial head pistoning pain at distal DRUJ, with good results even after treat-
were checked and definitively fixed. Due to LUCL lace- ment only in 3 cases. In 1987 Edwards and Jupiter [10]
ration observed, all patients underwent a final LUCL prox- reported on 7 patients, 4 operated within one month,
imal reinsertion and in one case a MCL was proximally with excellent results obtained only in the three cases.
reinserted with metallic anchors. The only poor result was experienced by the patient
All the patients underwent a post operative cast who underwent a RH excision. Duckworth [25] retro-
immobilization for 48 h, followed by progressive passive spectively reviewed 60 patients affected by RH fracture,
and active elbow and wrist mobilization. Progressive identifying 22 patients with radio-ulnar discrepancy. The
muscular reinforcement protocol was permitted starting good short term results (6 months) even after conserva-
one month after surgery. The DRUJ K wires were surgi- tive management are to be considered non indicative,
cally removed after 40 days. since usually patients experience a later worsening and
All patients of this study have been clinically evaluated no indication is reported about IOM assessment. The
at a mean of 17 months of follow up using the Mayo most representative case series have been reported by

Table 2 Patients’ demographics and lesion characteristics

Patient n. Name age sex Injury type Mason DRUJ discrepancy M hernia Axial Essex-Lopresti Injury Type
grade mm sign test
1 PA 41 M road traffic accident 3 3 + + Acute engaged
2 RM 46 M bike fall 3 0 – + Undetected at Imminent Evolution
3 FDR 33 M fall while walking 3 7 + + Acute engaged
4 CM 42 M road traffic accident 4 9 + + Acute engaged
5 GS 40 M bike fall 4 6 + + Acute engaged

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Fontana et al. BMC Musculoskeletal Disorders (2018) 19:312 Page 7 of 10

Table 3 Patients intra operative and clinical data set

Patient n. RH prosthesis IOM IOM plasty TFCC Reoperation FInal Follow MEPS at MMWS DRUJ at
plasty material reinsertion Up time follow up final FU
1 yes no no Ulnar shortening 16 83 88 + 2 mm ulna
at 9 months
2 yes yes Ultratape no no 15 95 95 + 0 mm
3 yes yes Ultratape yes no 15 92 94 +3 mm ulna
4 yes yes Allograft yes no 25 100 85 + 2 mm ulna
5 yes no yes no 14 90 92 + 0 mm

Schnetzke in 2017 [14]: outcome of 16 acute and 15 late also in the two patients reported by Helmerhorst et al. [28].
ELI were compared. Acute ELI, treated with DRUJ pin- Usually a correct diagnose is performed in chronic setting,
ning and no IOM reconstruction) showed better clinical when the symptoms of a longitudinal instability became
and radiological results, with lower rate of reoperations. evident but unfortunately with poor outcome [14]. The
The authors highlighted how seven patients had a proxi- clinic extrinsication of one of these two conditions depends
malization of more than 2 mm at final follow up, associ-
ated with worst outcome: the authors conclude that this
observation supports the idea that IOM is not able to
heal, and once disrupted the muscle herniation through
the laceration prevent its healing [24, 26].
Case n.1 during the post operative rehabilitation protocol
complained the onset of persistent wrist pain associated to
DRUJ discrepancy of 3 mm (MEPS score 72, MMWS 75),
which led to ulnar shortening osteotomy 9 months after
the first surgery, with good results at final follow up (MEPS
83, MMWS 88) (as reported in Table 3).
The complete data set is reported in Tables 2 and 3.

Discussion
In 2007 Marc Soubeyrand proposed the “Three Forearm
Constraints” concept [27]. The Forearm Unit has to be
considered like an association of three main constraints:
the PRUJ, the IOM and the DRUJ. Each constraint is essen-
tial for stability and movements of the forearm. In case of
single constraint damage (distal radius fracture, simple RH
fracture, and so on) a pronation-supination decrease oc-
curs, without causing instability (Stage 1). In case of two
constraints damage (Stage 2) a partial transversal instability
may occur (Criss-Cross lesion, Galeazzi lesion, Monteggia
lesions). The disruption of three constraints (Stage 3)
causes a longitudinal-transversal instability (Acute). Stage 2
and 3 patterns present an intrinsic instability, and may be
grouped under the “Unstable Fractures of the Forearm”
definition. In this different conditions, the lack of at least
two of the three constraints (TFCC, IOM and RH) can lead
to two different patterns. The first is an acute and evident
longitudinal instability of the forearm, defined by the au-
Fig. 8 1 year X-rays, clinical case 3. Follow up X-rays at 1 year of
thors “Acute Engaged Essex-Lopresti Injury”. The second follow up, showing the radial head prosthesis in situ and the whole
has already been identified by different Authors [7, 9, 10, forearm (a). The lateral view shows no dorsal dislocation of the distal
15] but still not pointed as specific clinical entity: it shows a ulna (b). At the DRUJ a slight recurrence of the ulnar plus is evident
more obscure clinical pattern, easy to misdiagnose but still (c), even if non symptomatic. Nevertheless the improvement pre-
operative wrist x-ray (d) is evident. e Image shows the opposite side
causing instability, defined by Authors “Undetected at
normal wrist
Imminent Evolution Acute Essex-Lopresti Injury”, observed

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Fontana et al. BMC Musculoskeletal Disorders (2018) 19:312 Page 8 of 10

on the IOM answer to the trauma. In the first case, an im- shortening ulnar osteotomy to treat the persistent wrist pain.
mediate proximal translation greater than 5 mm associated It was noticeable that in this case after the RH replacement
with impacted RH fracture into Capitulum Humeri is sig- a proximal radial migration was barely evident with a DRUJ
nificative for acute high-henergy complete irreparable IOM discrepancy of 3 mm, and the treatment seemed to be
and TFCC laceration. Aim of this work was to examine the sufficient with the experience maturated at that time. A
different lesion patterns that may cause forearm instability, possible explanation is due to a partial IOM/TFCC tear
focusing on cases treated by the authors and the few litera- caused by the high-energy trauma, that became complete
ture reports, in order to better define the different entities. after repetitive tractions by Biceps Brachii. This condition
Among the cases enrolled for this paper, the Authors progressively evolves into a proximal radial migration
observed four cases presenting characteristics of Acute causing DRUJ instability-discomfort and grip weakness.
Engaged ELI. Unfortunately not all patients received the These observations lead to the confirmation that there
same treatment: due to the rarity of this condition the is an elevated possibility to misdiagnose these non evi-
knowledge development on anatomopathology and treat- dent acute Essex-Lopresti, that in a first step may be
ment is still ongoing, so it is only in the recent years that it considered and treated as simple RH fracture but shortly
has been properly understood, diagnosed and treated. It is express the typical symptoms of a forearm instability.
very important to pinpoint how most of the authors indicate Basing on several observation of similar cases, in 2006 in
that this lesion seems to occur more often than realized up fact Junghbluth et al. introduced the term “missed”
to now, reporting values of around 38% of correct diagnoses Essex-Lopresti [12], characterized by a painful but
performed in excellence centers [8]. Similarly to other series correctly positioned radial head prosthesis in a context
reported in literature, the cases treated with RH implant, of longitudinal instability of the forearm due to IOM
IOM reconstruction and TFCC fixation and pinning re- laceration. Patient n.3 (Figs. 2, 5, 6, 7, 8, 9) experienced a
ported higher scores and better functional outcomes, progressive worsening of DRUJ discrepancy at follow up
whereas the patient who underwent the isolated radial compared to post operative control: this may be ex-
head replacement reported worst outcomes, requiring a plained with a slight tension loosening of the IOM and

Fig. 9 Clinical follow up, clinical case 3. Follow up clinical aspect at 1 year of follow up, showing a good movement of the elbow (a-d) and the
wrist (e, f)

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Fontana et al. BMC Musculoskeletal Disorders (2018) 19:312 Page 9 of 10

DRUJ reconstruction. At the final follow up this condi- Abbreviations

tion was non-symptomatic, supporting the idea that if DOB: Distal Oblique Band; DRUJ: Distal Radio-Ulnar joint; ELI: Essex-Lopresti
Injury; IOL: Interosseous ligament; IOM: Interosseous Membrane;
left untreated the clinical results were prone to deterior- PRUJ: Proximal Radio-Ulnar Joint; RH: Radial Head; TFCC: Triangular
ate even more at follow up, as observed in case n.1. Fibrocartilage Complex
These results are consistent with the few reports
Availability of data and materials
available in literature (Table 1), with comparable values The datasets used and/or analysed during the current study are available
of MEPS, MMWS and DRUJ discrepancy at follow up. from the corresponding author on reasonable request.
The higher clinical results have been obtained in cases
when the IOM have been reconstructed, highlighting the Authors’ contributions
MF and RR performed the surgeries, performed the pre operative and post
importance of this anatomical structure. operative clinical examination of the patients and analyzed and interpreted
For these reasons it is mandatory to perform an accurate the patient data regarding the forearm instability. MC and GB performed the
clinical examination to the patient in acute setting, tagging literature review, collected images, functional scores and were the major
contributors in writing the manuscript. All authors read and approved the
these cases as Undetected at Imminent Evolution ELI and final manuscript.
addressing them to a proper and complete treatment. The
diagnosis of the acute engaged pattern of ELI is easier to Ethics approval and consent to participate
The work presented in this paper obtained the IRB approval of our
recognize. On the other side, a radial translation inferior to Institution (Comitato etico dell’ IRCCS Istituto Ortopedico Rizzoli, prot.gen.
5 mm associated with Mason 3 radial head fracture, forearm 0011803), and all patients enrolled signed the informed consent.
or wrist painful and positive radiological Axial Test is to be
Consent for publication
considered indicative for an acute IOM laceration, even if
Written informed consent for publication of their clinical details and/or
not as evident as the acute engaged pattern presentation. clinical images was obtained from the patient/parent/guardian/ relative of
Therefore, the diagnosis of Acute Undetected at imminent the patient. A copy of the consent form is available for review by the Editor
of this journal.
evolution ELI is difficult, because a proximal radial transla-
tion inferior to 3 mm does not lead to an immediate longi- Competing interests
tudinal instability [29]. Imaging does not give an effective The authors declare that they have no competing interests.
contribution, so the clinical investigation part and the phys-
ical examination are fundamental for the correct diagnosis. Publisher’s Note
The main limitation of this study is represented by the low Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
number of cases, mainly because ELI is an uncommon
condition. This led to a consequent limitation, that is the Author details
1
different surgical procedure performed and the different Orthopaedic Department, Infermi Hospital, Viale Stradone 9, 48018 Faenza,
Italy. 2Shoulder and Elbow Unit, IRCCS - Istituto Ortopedico Rizzoli, Via G.C.
approach to ELI. At the same time this reflects the develop- Pupilli 1, Bologna, Italy.
ment in the knowledge of this disease over the last years.
Received: 28 March 2018 Accepted: 15 August 2018
Conclusions
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