Galeazzi Fracture Treatment & Management
- Author: Janos P Ertl, MD; Chief Editor: Harris Gellman, MD more...
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.
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
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.
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. Immediately after surgery, institute occupational therapy for digital and shoulder range of motion.
The overall complication rate in the treatment of Galeazzi fractures approaches 40%. Complications include the following:
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.
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. 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. 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.
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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