Galeazzi Fracture 

Updated: Jun 01, 2018
Author: Janos P Ertl, MD; Chief Editor: Harris Gellman, MD 

Overview

Background

The Galeazzi fracture-dislocation is an injury pattern involving isolated fractures of the junction of the distal third and middle third of the radius with associated subluxation or dislocation of the distal radioulnar joint (DRUJ); the injury disrupts the forearm axis joint.[1, 2]  (See also Forearm Fractures in Emergency Medicine and Distal Fractures of the Radius.)

The Galeazzi fracture injury pattern was first described by Cooper in 1842, 92 years before Galeazzi reported his results. Ricardo Galeazzi (1866-1952), an Italian surgeon at the Instituto de Rachitici in Milan, was known for his extensive work experience on congenital dislocation of the hip. In 1934, he reported on his experience with 18 fractures with the above-described pattern as a compliment to the Monteggia lesion. Such fractures have since become synonymous with his name.

In 1941, Campbell termed the Galeazzi fracture the "fracture of necessity," because it necessitates surgical treatment; in adults, nonsurgical treatment of the injury results in persistent or recurrent dislocations of the distal ulna. Although researchers have been unable to reproduce the mechanism of injury in a laboratory setting, Hughston outlined the definitive management of these fractures in 1957.[3]

Pathophysiology

The deforming forces in a Galeazzi fracture include those of the brachioradialis, pronator quadratus, and thumb extensors, as well as the weight of the hand. The deforming muscular and soft-tissue injuries that are associated with this fracture cannot be controlled with plaster immobilization.

Etiology

The etiology of the Galeazzi fracture is thought to be a fall that causes an axial load to be placed on a hyperpronated forearm.

Epidemiology

Galeazzi fractures account for 3-7% of all forearm fractures. They are seen most often in males. Although Galeazzi fracture patterns are reportedly uncommon, they are estimated to account for 7% of all forearm fractures in adults.

Prognosis

Successful treatment of Galeazzi fractures depends on the reduction of the radius and DRUJ and the restoration of the forearm axis. Hughston outlined the difficulties and complications of nonoperative treatment in 1957.[3] An unsatisfactory result—caused by a loss of reduction that, in turn, led to malunion—was identified in 92% of patients (35 of 38) treated with closed reduction and cast immobilization.

Hughston's study attributed loss of reduction to the deforming force of the brachioradialis, the pull of the pronator quadratus (leading to rotation of the distal radial fragment towards the ulna), and the weight of the hand as a deforming force (leading to dorsal angulation of the radius and subluxation of the DRUJ). These deforming forces cannot be controlled with plaster immobilization; operative management is required.

The incidence of nonunion of Galeazzi fractures is very low. The rate of union following the open reduction of forearm fractures has been reported to approach 98%.[4]

Reckling and Moore separately reported satisfactory results with compression plating and immobilization in supination.[5, 6]

Eberl et al retrospectively reported on Galeazzi lesions over a 3-year period in 26 patients.[7] Casting after fracture reduction was possible in 22, of whom 13 were treated with immobilization in a below-elbow cast and nine were treated with an above-elbow cast. Four patients were treated operatively. Results were excellent in 23 cases and good in three. The authors noted that in all cases of distal forearm fractures, a possible Galeazzi lesion should be considered but that proper reduction of the radius with concomitant reduction of the DRUJ and cast immobilization provides good-to-excellent outcome even if the Galeazzi lesion is not recognized primarily.

Ploegmakers et al retrospectively reviewed Galeazzi fractures to determine their effect on the strength of pronation and supination at a mean of 2 years after surgery.[8] They found that the mean absolute loss of strength of supination in the injured arm compared with the noninjured arm throughout all ranges of forearm rotation was 16.1 kg, corresponding to a relative loss of 12.5%. For the strength of pronation, the mean loss was 19.1 kg, corresponding to a relative loss of 27.2%.

Loss of strength of supination following a Galeazzi fracture correlated with poor quickDASH (Disabilities of the Arm, Shoulder, and Hand) and PRWE (Patient-Rated Wrist Evaluation) scores.[8] Loss of strength of pronation (27.2%), and of supination (12.5%) in particular, after a Galeazzi fracture is associated with worse clinical scores, highlighting the importance of supination of the forearm in function of the upper limb.

Ilyas et al, in a study of 10 patients with AO type A and C distal radius fractures who underwent fracture fixation, found that intramedullary nailing for displaced distal radius fractures could result in good functional outcome but had a high incidence of complications.[9] The authors did not identify any long-term soft tissue problems but noted that intramedullary nails should be limited to extra-articular and simple intra-articular distal radius fractures.

In this study, all cases maintained reduction between postoperative and final radiographs, except for two cases of AO type A3 fractures with a loss of volar tilt greater than 5º.[9] Grip strength relative to the uninjured limb was 91%. According to the DASH questionnaire, eight results were excellent, one good, and one poor. There were two cases of transient superficial radial sensory neuritis and three cases of screw penetration into the DRUJ. There were no cases of infection, tendon injury, or hardware failure or removal.

 

Presentation

History and Physical Examination

Pain and soft-tissue swelling are present at the distal-third radial fracture site and at the wrist joint. This injury is confirmed on radiographic evaluation (see Workup).

Forearm trauma may be associated with compartment syndrome. (See Chronic Exertional Compartment Syndrome for further treatment information.)

Anterior interosseous nerve (AIN) palsy may also be present, but it is often overlooked because there is no sensory component to this finding. A purely motor nerve, the AIN is a division of the median nerve. Injury to the AIN can cause paralysis of the flexor pollicis longus (FPL) and flexor digitorum profundus (FDP) to the index finger, resulting in loss of the pinch mechanism between the thumb and the index finger.[10]

 

Workup

Imaging Studies

The diagnosis of a Galeazzi fracture is confirmed on radiographic examination. Standard anteroposterior (AP) and true lateral forearm views are obtained, which must include an AP or a posteroanterior (PA) view, as well as a lateral view, of the wrist, along with AP and lateral views of the elbow. (See the image below.) Radiographs of the contralateral extremity can be obtained for comparison.

Anteroposterior radiograph demonstrates classic Ga 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).

Plain radiographic findings suggestive of injury to the distal radioulnar joint (DRUJ) are as follows:

  • Fracture at the ulnar styloid base
  • Widening of the DRUJ space on an AP radiograph
  • Dislocation of the radius relative to the ulna on a true lateral radiograph, which is obtained with the shoulder abducted 90°
  • Shortening of the radius by more than 5 mm relative to the distal ulna

Assessment of DRUJ integrity is often difficult with plain radiography alone. Bilateral axial computed tomography (CT) of the forearm is the preferred imaging study for diagnosing DRUJ disruption.

A study by Tsismenakis et al found that the radiographic guidelines in general use were only moderately accurate in predicting DRUJ instability and that treatment was best determined on the basis of intraoperative assessment of the DRUJ after radial fixation.[11]

 

Treatment

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.[7, 12, 13]

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.

Surgical Therapy

All adult Galeazzi fractures must be treated with open reduction and internal fixation (ORIF).[14, 15, 16] 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 DCP (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.[17] 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 before 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. Several small series 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. If the decision is made to place supplemental autogenous bone graft, this may be harvested from the olecranon 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.

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.[18]  Immediately after surgery, institute occupational therapy for digital and shoulder range of motion.

Complications

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

  • Nonunion
  • Malunion
  • Infection
  • Refracture following plate removal
  • Radial sensory nerve and posterior interosseous nerve (PIN) injury
  • Instability of the DRUJ

Nonunion and malunion are primarily associated with closed reduction, plaster immobilization, intramedullary nailing, 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 the PIN has not been identified at the time of dissection.

Ulnar nerve injury, though rare, has been reported.[19]  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.[20]

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.

Instability of the DRUJ may occur for the following reasons:

  • Failure to recognize the injury
  • Failure to reduce the dislocation intraoperatively
  • Nonanatomic radial reduction
  • Interposed soft tissue that blocks reduction - Most often, the ECU is the interposed structure [21] ; 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.[22]  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.[23]

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.