Acta Orthopaedica 2011; 82 (3): 356–359 357 Figure 1. An Essex-Lopresti lesion was diagnosed in this patient’s radiographs, which demonstrated greater than 2 mm of shortening of the ipsilateral radius when compared to the contralateral side. on a subgroup of these patients who presented with a closed proximal radial fracture and ipsilateral wrist pain. No meth- ods of assessment or intervention were changed at the time of the study, so this was considered to be an audit and it did not require ethical approval according to local guidelines. Radiographic assessment used standard anteroposterior (AP) and lateral radiographs of the elbow. Initial elbow radiographs were used to classify the proximal radial fracture using the modified Mason (Broberg and Morrey 1987) classification system. If the patient had wrist pain or tenderness, neutral PA and lateral radiographs of the affected wrist were performed to screen for the presence of any distal radial-ulnar joint abnormality. Radiographs of the unaffected contralateral wrist were performed for comparison. If there was 2 mm or more of ipsilateral radial shortening compared to the contralateral side, this was considered to be suggestive of an Essex-Lopresti type lesion (Figure 1). 2 trauma-trained fellows independently assessed and classified each injury, and any discrepancies were resolved by discussion with the senior authors. All diag- noses were made within 2 weeks of injury. The final treatment decision for individual patients was determined independently by their supervising consultants, all of whom were experienced orthopedic trauma surgeons. Nonoperative management involved a standardized proto- col of a collar and cuff for 1 week, followed by supervised physiotherapy. Physiotherapy included standard mobilization and strengthening exercises of the affected elbow and wrist as symptomatology allowed. Operative management could use either open reduction and internal fixation or radial head replacement, depending on the degree of comminution to the radial head. Follow-up Patients were scheduled for review at 2 and 6 weeks, at 3 and 6 months, and 1 year after injury. Demographic data were recorded at the initial visit and results of physical examina- tion, treatment, and complications were recorded at each sub- sequent visit. Both clinical and radiographic follow-up were carried out by the senior authors in all cases. At each visit, a full functional assessment was completed by a single dedicated research physiotherapist who was not involved in patient man- agement. The range of motion was measured using a standard full-circle goniometer. Flexion, extension, supination, and pronation in the affected elbow were measured in triplicate and the mean was recorded to minimize intra-observer bias. The Mayo elbow score (MES) and the short musculoskeletal function assessment (SMFA) questionnaire were completed by all patients at each visit (Morrey et al. 1993, Swiontkowski et al. 1999). Statistics SPSS software version 17.0 was used for statistical analysis. The Mann-Whitney U-test was used to analyze non-paramet- ric continuous data. The Kruskal-Wallis one-way analysis of variance test was used to analyze data for several groups. Sig- nificance was determined as a p-value of < 0.05 in all analy- ses, with 95% confidence intervals (CIs) set. The kappa value was used to determine the inter-observer reliability of diagnosing an Essex-Lopresti type injury as 2 mm or more of ipsilateral radial shortening compared to the contralateral side, with an associated grading assigned as follows: slight agreement (0.00–0.20), fair agreement (0.21– 0.40), moderate agreement (0.41–0.60), substantial agreement (0.61–0.80), and very good agreement (≥ 0.81) (Landis and Koch 1977). The 95% CI for the kappa value was calculated using the standard formula, which was kappa value ± 1.96 × the standard error (0.026). Results 60 patients were noted to have ipsilateral wrist pain at the ini- tial assessment of 237 proximal radial fractures. Radial short- ening of ≥ 2 mm (mean 2.5 (2–4) mm) was seen in 22 patients (9%; CI: 6–14) with a mean age of 48 (19–79) years, 16 of whom were females. There were 2 disagreements regard- ing the diagnosis of radial shortening between the 2 trauma- trained fellows, giving a kappa value of 0.96 (CI: 0.9–1), with the strength of agreement considered to be very good. The most frequent mechanism of injury was a fall from standing height (45%) followed by sports-related injuries (27%). There was no association between the mechanism of injury and the degree of radial shortening (p = 0.2). The left elbow was affected in 14 patients and the dominant side in 9 patients. There were 10 radial head fractures and 12 radial neck fractures. Using the Mason classification, there were 13