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Galeazzi Fracture Treatment & Management

  • Author: Janos P Ertl, MD; Chief Editor: Harris Gellman, MD  more...
 
Updated: Mar 11, 2016
 

Approach Considerations

Galeazzi fractures are best treated with open reduction of the radius and the distal radioulnar joint (DRUJ). Closed reduction and cast application have led to unsatisfactory results. The term fracture of necessity derives from the observation that the adult Galeazzi fracture is not amenable to treatment by closed means, necessitating surgical stabilization.

Open forearm fractures constitute a surgical emergency. Open wounds may have to be incorporated into the surgical incision. Immediate stabilization of the radial fracture and the DRUJ is recommended.

Galeazzi fractures in skeletally immature patients are typically treated with closed reduction and casting because of the enhanced viscoelastic nature of pediatric bone, as well as the presence of a stout periosteal sleeve.[6, 10, 11]

The only contraindication to surgical intervention is the existence of life-threatening conditions, which take priority. In these situations, definitive surgical management is deferred until the patient is stabilized.

In the future, statically locked intramedullary nailing may prove to be an option for the treatment of Galeazzi fractures, provided that it can neutralize and control the multiple deforming forces associated with these injuries. The indications for intramedullary nailing of forearm fractures have not been clearly defined.

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Surgical Therapy

All adult Galeazzi fractures must be treated with open reduction and internal fixation (ORIF).[12, 13, 14] Anatomic surgical reduction of the radius and the DRUJ provides the best opportunity for healing.

Preparation for surgery

As with any fracture, preoperative planning is necessary. Appropriate radiographs are required, cutout templates are made to simulate reduction, and an implant is chosen. Contralateral extremity radiographs are of benefit as a template.

Preoperative planning includes the following:

  • Operative consent for ORIF and possible bone grafting
  • Radiographs and cutout plan available
  • Small fragment (3.5-mm) fixation system with dynamic compression plates (DCPs) or the newer limited contact dynamic compression plate (LCDCP)
  • Radiolucent hand table
  • C-arm availability
  • Tourniquet

Operative details

Use standard orthopedic preparation and draping of the extremity and iliac crest, as needed, if bone grafting is required. Exsanguinate, and elevate the tourniquet 200-250 mm Hg.

A volar Henry approach is used most often to expose the radius; however, the Thompson approach may be used for proximal radial fractures. The surgeon should use the approach that is most familiar. (See Forearm Fractures.)

The fracture is reduced with the aid of sharp or broad fracture reduction forceps and manual traction. C-arm radiographic visualization can be used to confirm fracture/bone alignment. Apply a 3.5-mm compression plate. Evaluate the fracture and DRUJ for realignment and reduction.

Rotate the forearm, and assess for any DRUJ instability. If the DRUJ is stable, specifically evaluate in supination. If it is reducible and stable in supination, splint in supination for 4 weeks after surgery. If the DRUJ is reducible in supination but unstable, stabilize it in supination by placing two 0.045 Kirschner wires (K-wires) from the ulna into the radius, just proximal to the articular surface. If the DRUJ is unstable and irreducible, perform an open reduction through a dorsal approach, remove soft tissue from it, and stabilize the joint in the above-described manner.

If displaced, ulnar styloid base fractures may represent significant DRUJ instability that necessitates ORIF. This can be accomplished through an approach to the ulna that uses the interval between the flexor carpi ulnaris (FCU) and the extensor carpi ulnaris (ECU). Release the tourniquet, obtain hemostasis prior to closure, and assess vascular fill to the digits.

Although the procedure is controversial, bone graft may be applied to grossly comminuted fractures. Retrospective comparisons of comminuted forearm fractures have given rise to questions about the need for acute bone grafting. The small series published to date appeared to show no differences in healing rates and time to union, suggesting that routine bone grafting is not indicated; however, larger, prospective studies are required. Should the surgeon decide to place supplemental autogenous bone graft, this may be harvested from the olecranon and/or the drill bit on each screw placement.

Check the reduction with radiography. Irrigate and close wounds. Apply a long arm splint with the forearm placed in supination.

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Postoperative Care

Postoperatively, elevate the upper extremity. Apply ice to the operative site as needed. Check neurologic and vascular status. Specifically, evaluate for function of the anterior interosseous nerve (AIN) and for the presence of compartment syndrome. Immobilize the forearm in supination for 4 weeks, with removal of any percutaneous pins at 4 weeks.[15]  Immediately after surgery, institute occupational therapy for digital and shoulder range of motion.

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Complications

The overall complication rate in the treatment of Galeazzi fractures approaches 40%. Complications include the following:

  • Nonunion
  • Malunion
  • Infection
  • Refracture following plate removal
  • Posterior interosseous nerve (PIN) injury
  • Instability of the DRUJ

Nonunion and malunion are primarily associated with closed reduction, plaster immobilization, intramedullary nails, and inadequate plate fixation.

Radial nerve injury is reportedly the most common nerve injury to occur during either the volar or dorsal forearm approach to a Galeazzi fracture. The radial sensory nerve is reported to be the most frequently injured branch, with damage occurring in association with the Henry (volar) approach. The PIN, another branch of the radial nerve, also is vulnerable (during the dorsal Thompson approach), especially when there is a failure to identify the PIN at the time of dissection.

Plate removal is not without risk and should be undertaken cautiously. A second approach to the forearm may put the PIN at risk at a site that has already been surgically treated. Refracture of the radius is another possibility with plate removal. The patient should be advised of potential complications prior to pursuing hardware removal.

The occurrence of tardy ulnar tunnel syndrome has been reported in the closed treatment of a Galeazzi fracture; this resulted from a malunion and the compression of a stretched vascular branch situated over the ulnar head.[16]

Instability of the DRUJ may occur because of a failure to recognize the injury, a failure to reduce the dislocation intraoperatively, nonanatomic radial reduction, or interposed soft-tissue that blocks reduction. Most often, the ECU is the interposed structure.[17] Other soft-tissue structures that have been implicated in the blockage of reduction include the extensor digitorum communis (EDC), the extensor digiti minimi (EDM), the flexor pollicis longus (FPL), and the median nerve. It is important to achieve an adequate assessment of the DRUJ preoperatively, intraoperatively, and postoperatively. Computed tomography (CT) may be necessary to confirm DRUJ reduction.

A case of late extensor pollicis longus (EPL) tendon rupture after plate fixation of a Galeazzi fracture dislocation has been reported.[18]  Delayed, complete rupture of the flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) tendons in zone V 18 years after conservative treatment of Galeazzi fracture-dislocation with volar dislocation of the ulna from the DRUJ has been described.[19]

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Long-Term Monitoring

At 7 and 14 days after surgery, the wound is examined. Remove the sutures 10-14 days after surgery, obtain radiographs at each visit, and replace the splint with an above-elbow cast brace in supination.

At 4 weeks, obtain radiographs to recheck alignment and reduction of the radius and the DRUJ, remove pins if present, recheck radiographs to confirm maintenance of reduction, and replace the cast brace in supination.

At 6 weeks, remove the cast, obtain radiographs, and initiate physical therapy for elbow, wrist, and digital motion. Application of a functional forearm brace is appropriate at this time.

Reexamine radiographs at 6-week intervals until healing is apparent.

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Contributor Information and Disclosures
Author

Janos P Ertl, MD Assistant Professor, Department of Orthopedic Surgery, Indiana University School of Medicine; Chief of Orthopedic Surgery, Wishard Hospital; Chief, Sports Medicine and Arthroscopy, Indiana University School of Medicine

Janos P Ertl, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Hungarian Medical Association of America, Sierra Sacramento Valley Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

William J Brackett, MD Research Assistant, Department of Orthopedic Surgery, Indiana University School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Michael Yaszemski, MD, PhD Associate Professor, Departments of Orthopedic Surgery and Bioengineering, Mayo Foundation, Mayo Medical School

Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine, Clinical Professor, Surgery, Nova Southeastern School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, Arkansas Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

Peter M Murray, MD Professor and Chair, Department of Orthopedic Surgery, Mayo Clinic College of Medicine; Director of Education, Mayo Foundation for Medical Education and Research, Jacksonville; Consultant, Department of Orthopedic Surgery, Mayo Clinic, Jacksonville; Consulting Staff, Nemours Children's Clinic and Wolfson's Children's Hospital

Peter M Murray, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Reconstructive Microsurgery, Orthopaedic Research Society, Society of Military Orthopaedic Surgeons, American Association for Hand Surgery, American Society for Surgery of the Hand, Florida Medical Association

Disclosure: Nothing to disclose.

References
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  4. Moore TM, Klein JP, Patzakis MJ. Results of compression-plating of closed Galeazzi fractures. J Bone Joint Surg Am. 1985 Sep. 67(7):1015-21. [Medline].

  5. Reckling FW. Unstable fracture-dislocations of the forearm (Monteggia and Galeazzi lesions). J Bone Joint Surg Am. 1982 Jul. 64(6):857-63. [Medline].

  6. Eberl R, Singer G, Schalamon J, Petnehazy T, Hoellwarth ME. Galeazzi lesions in children and adolescents: treatment and outcome. Clin Orthop Relat Res. 2008 Jul. 466(7):1705-9. [Medline]. [Full Text].

  7. Ploegmakers JJ, The B, Brutty M, Ackland TR, Wang AW. The effect of a Galeazzi fracture on the strength of pronation and supination two years after surgical treatment. Bone Joint J. 2013 Nov. 95-B(11):1508-13. [Medline].

  8. Ilyas AM, Thoder JJ. Intramedullary fixation of displaced distal radius fractures: a preliminary report. J Hand Surg Am. 2008 Dec. 33(10):1706-15. [Medline].

  9. Galanopoulos I, Fogg Q, Ashwood N, Fu K. A widely displaced Galeazzi-equivalent lesion with median nerve compromise. BMJ Case Rep. 2012 Aug 18. 2012:[Medline].

  10. Kontakis GM, Pasku D, Pagkalos J, Katonis PG. The natural history of a mistreated ipsilateral Galeazzi and Monteggia lesion: report of a case 39 years post-injury. Acta Orthop Belg. 2008 Aug. 74(4):546-9. [Medline].

  11. Mitsui Y, Yagi M, Gotoh M, Inoue H, Nagata K. Irreducible Galeazzi-equivalent fracture in a child: an unusual case. J Orthop Trauma. 2009 Jan. 23(1):76-9. [Medline].

  12. Giannoulis FS, Sotereanos DG. Galeazzi fractures and dislocations. Hand Clin. 2007 May. 23(2):153-63, v. [Medline].

  13. Lendemans S, Taeger G, Nast-Kolb D. [Dislocation fractures of the forearm. Galeazzi, Monteggia, and Essex-Lopresti injuries]. Unfallchirurg. 2008 Dec. 111(12):1005-14; quiz 1015-6. [Medline].

  14. Macintyre NR, Ilyas AM, Jupiter JB. Treatment of forearm fractures. Acta Chir Orthop Traumatol Cech. 2009 Feb. 76(1):7-14. [Medline].

  15. Park MJ, Pappas N, Steinberg DR, Bozentka DJ. Immobilization in supination versus neutral following surgical treatment of Galeazzi fracture-dislocations in adults: case series. J Hand Surg Am. 2012 Mar. 37(3):528-31. [Medline].

  16. Saitoh S, Seki H, Murakami N. Tardy ulnar tunnel syndrome caused by Galeazzi fracture-dislocation: a neuropathy with a new pathomechanism. J Orthop Trauma. 2000 Jan. 14(1):66-70. [Medline].

  17. Alexander AH, Lichtman DM. Irreducible distal radioulnar joint occurring in a Galeazzi fracture - case report. J Hand Surg [Am]. 1981 May. 6(3):258-61. [Medline].

  18. Sabat D, Dabas V, Dhal A. Late extensor pollicis longus rupture following plate fixation in Galeazzi fracture dislocation. Indian J Orthop. 2014 Jul. 48 (4):426-8. [Medline].

  19. Nagy MT, Ghosh S, Shah B, Sankar T. Delayed rupture of flexor tendons in zone V complicated by neuritis 18 years following Galeazzi fracture-dislocation. BMJ Case Rep. 2014 Apr 16. 2014:[Medline].

 
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Anteroposterior radiograph demonstrates classic Galeazzi fracture: short oblique or transverse fracture of radius with associated dislocation of distal ulna. Dislocation results from disruption of distal radioulnar joint (DRUJ). Note prominence of distal ulna (ulna positive variance).
 
 
 
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