eMedicine Specialties > Orthopedic Surgery > Hand & Upper Extremity

Galeazzi Fracture: Treatment

Author: Janos P Ertl, MD, Clinical Assistant Professor, Department of Orthopedic Surgery, University of California at Davis; Director of Amputee Clinic, Chief of Orthopedic Trauma, Kaiser Hospital
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Updated: Dec 4, 2007

Treatment

Surgical Therapy

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

Preoperative Details

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 is as follows:

• 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

Intraoperative 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 also the eMedicine article 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 reducible and stable in supination, splint in supination for 4 weeks after surgery.
  • If the DRUJ is reducible in supination but unstable, stabilize the DRUJ in supination by placing 2 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 the DRUJ, and stabilize the DRUJ in the above-described manner.
• If displaced, ulnar styloid base fractures may represent significant DRUJ instability that requires ORIF. This can be accomplished through an approach to the ulna, using 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. As a result of retrospective comparison of comminuted forearm fractures, questions have arisen concerning the need for acute bone grafting. No differences appeared to be present in healing rates and time to union in the small series studies that have been conducted, 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 radiograph.
• Irrigate and close wounds.
• Apply a long arm splint with the forearm placed in supination.

Postoperative Details

Postoperative details are as follows:

• Elevate the upper extremity.
• Apply ice to the operative site as needed.
• Check neurologic and vascular status. Specifically, evaluate for function of the 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.
• Immediately after surgery, institute occupational therapy for digital and shoulder range of motion.

Follow-up

Follow-up care is as follows:

• 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 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.

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

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.³

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.⁴ 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 FPL, and the median nerve. It is important to achieve an adequate assessment of the DRUJ preoperatively, intraoperatively, and postoperatively. A CT scan may be necessary to confirm DRUJ reduction.

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