Review Article

Galeazzi Fracture
Abstract
Kivanc I. Atesok, MD Jesse B. Jupiter, MD Arnold-Peter C. Weiss, MD

Galeazzi fracture is a fracture of the radial diaphysis with disruption at the distal radioulnar joint (DRUJ). Typically, the mechanism of injury is forceful axial loading and torsion of the forearm. Diagnosis is established on radiographic evaluation. Underdiagnosis is common because disruption of the ligamentous restraints of the DRUJ may be overlooked. Nonsurgical management with anatomic reduction and immobilization in a long-arm cast has been successful in children. In adults, nonsurgical treatment typically fails because of deforming forces acting on the distal radius and DRUJ. Open reduction and internal xation is the preferred surgical option. Anatomic reduction and rigid xation should be followed by intraoperative assessment of the DRUJ. Further intraoperative interventions are based on the reducibility and postreduction stability of the DRUJ. Misdiagnosis or inadequate management of Galeazzi fracture may result in disabling complications, such as DRUJ instability, malunion, limited forearm range of motion, chronic wrist pain, and osteoarthritis.

From the Institute of Medical Science, University of Toronto, Toronto, ON, Canada (Dr. Atesok), the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA (Dr. Jupiter), and the Department of Orthopaedics, Warren Alpert Medical School, Brown University, and Rhode Island Hospital, Providence, RI (Dr. Weiss). J Am Acad Orthop Surg 2011;19: 623-633 Copyright 2011 by the American Academy of Orthopaedic Surgeons.

aleazzi fracture is a distal radial shaft fracture with disruption of the distal radioulnar joint (DRUJ) (Figure 1). First described by Astley Cooper, the fracture was named after Galeazzi following a 1934 publication by that author that described 18 cases.1 This fracture is also referred to as reverse Monteggia, Piedmont, and Darrach-HughstonMilch.1 Galeazzi lesions are frequently underdiagnosed, and the true incidence may vary. Reports indicate an incidence of 3% of all forearm fractures in children and 7% of those in adults.2

Anatomy and Pathophysiology

The radius and ulna are constrained firmly by the interosseous membrane (IOM) and ligamentous structures at the proximal and distal radioulnar

joints. Hence, any disruption (eg, fracture) in the length of the radius can affect either of these joints.3 Cross-sectional properties of cortical bone and bone mineral contents of the radius suggest that the junction of the middle and the distal one third of the radius is at increased risk of fracture.4 Biomechanically, fractures of the middle to distal one third of the radius are more likely to cause disruption of the DRUJ than are fractures more proximal to the radius.5 Rettig and Raskin5 observed that radial shaft fractures located >7.5 cm from the lunate facet of the distal radial articular surface were not typically associated with DRUJ injury. Ring et al6 stated that there may be exceptions to the 7.5 cm rule; the location of the fracture alone may not be sufficient to ascertain whether the DRUJ is stable. The authors found

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Figure 1

Figure 2

Illustration of the supercial and deep attachments of the palmar radioulnar ligament (PRUL) and the dorsal radioulnar ligament (DRUL). Transverse (A) and AP (B) views. (Adapted with permission from Tsai PC, Paksima N: The distal radioulnar joint. Bull NYU Hosp Jt Dis 2009;67[1]:90-96.)

Illustration of a Galeazzi fracture. The arrows indicate the forces acting on the distal radius. (Reproduced with permission from Haugstvedt JR: Dissociations of the radius and ulna: Surgical anatomy and biomechanics, in Berger RA, Weiss AP, eds: Hand Surgery. Philadelphia, PA, Lippincott Williams & Wilkins, 2004, vol 1, pp 615-644.)

DRUJ injury in 4 of 28 patients with fractures of the radius that were more proximally located. DRUJ injury was noted in 5 of 8 patients with fractures to the distal one third of the radial shaft. Hence, distal one third radial shaft fractures are generally associated with DRUJ injury and

tend to have the worst outcomes. The DRUJ is primarily stabilized by the triangular fibrocartilage complex (TFCC).7 Dislocation of the DRUJ requires severe disruption of the TFCC. The base of this softtissue complex attaches to the junction of the lunate fossa and the sigmoid notch of the radius, and the apex of the TFCC attaches to the fovea and ulnar styloid.8 The distal ulna is primarily stabilized by the palmar and dorsal radioulnar ligaments of the TFCC. In the coronal plane, each radioulnar ligament passes ulnarly and is divided into two limbs. The deep limb attaches to the fovea, and the superficial limb attaches to the base and mid portion of the ulnar styloid9 (Figure 2). Conse-

quently, substantial shortening of the fractured radius relative to the ulna results in marked disruption of the TFCC.10 The IOM is a complex ligamentous structure that connects the interosseous borders of the radius and ulna and transfers load from the radius to the ulna. It consists of a central band, a proximal band, membranous portions, and accessory bands. The central band, the strongest portion of the IOM, originates from the proximal one third of the radius and inserts at the distal quarter of the ulna.11 Because the IOM has no attachment to the distal one third of the radius, fractures involving this area may be associated with a higher risk of shortening. McGinley et al12

Dr. Atesok or an immediate family member serves as a board member, owner, officer, or committee member of the International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine and the Orthopaedic Research Society. Dr. Jupiter or an immediate family member serves as a board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons and the American Shoulder and Elbow Surgeons; serves as a paid consultant to OHK Medical Devices; serves as an unpaid consultant to Synthes and Eidosmed; has stock or stock options held in OHK Medical Devices; and has received research or institutional support from the AO Foundation. Dr. Weiss or an immediate family member serves as a board member, owner, officer, or committee member of the American Society for Surgery of the Hand; has received royalties from DePuy, Extremity Medical, and Medartis; serves as a paid consultant to IlluminOss Medical; and has stock or stock options held in Articulinx, IlluminOss Medical, and OsteoSpring Medical.

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described patterns of IOM disruption in a cadaver study. The authors simulated forearm trauma due to axial loading at different rotational positions and observed that most injuries to the IOM occurred along its distal ulnar insertion. An axial load that is strong enough to fracture the radius and tear the IOM distally may result in dissociation between the radius and the ulna, such as that associated with Galeazzi fractures. In a cadaver study, Schneiderman et al13 reported that the amount of shortening in the fractured radius correlated with the nature of softtissue injury associated with Galeazzi fracture. They noted radial shortening of approximately 5 mm following radial osteotomy. Radial shortening of 5 to 10 mm was achieved with osteotomy of the radius and transection of either the TFCC or IOM. Shortening >10 mm following osteotomy required transection of both the TFCC and IOM. Therefore, radial shaft fractures with shortening >5 mm may indicate injury to either the TFCC or IOM. These cadaver studies were limited by the elimination of muscle strength and variation in the age of the specimens, some of which had decreased bone density and ligamentous consistency that does not reflect the clinical situation.12 To date, no ex vivo studies have successfully reproduced the Galeazzi injury pattern in cadaver models in which axial impact loading was applied to the forearm in different rotational positions.14 Several muscles may exert deforming forces on the distal radius (Figure 3). The pronator quadratus muscle exerts a rotational force on the distal radius that may compromise closed reduction. The brachioradialis muscle pulls the distal fragment of the radius proximally; the abductor pollicis longus and extensor pollicis brevis muscles also can exert deforming
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forces that can shorten the fractured radius.

Figure 3

Mechanism of Injury and Fracture Classication

Forceful axial loading of the forearm with the wrist in extension and maximum pronation is one reported mechanism of injury associated with Galeazzi fracture; however, some authors believe that loading in supination also can cause Galeazzi injury.2,3,5 In addition to falls, other reported mechanisms of injury include motor vehicle accidents, electric shock, and blunt trauma.15,16 Various systems have been used to classify this fracture type. In a study of 41 pediatric patients with Galeazzi fractures, Walsh et al17 observed posterior (dorsal) displacement of the radius fracture in 20 and anterior displacement in 21. This report led to the development of a fracture classification based on displacement of the distal fragment of the fractured radius. Type I fracture (apex volar) is characterized by dorsal displacement of the distal fragment of the radius with anterior (volar) dislocation of the distal ulna. Typically, type I fracture is caused by axial loading with the forearm in supination.18 In a type II fracture (apex dorsal), the distal fragment of the radius is displaced anteriorly with posterior (dorsal) dislocation of the distal ulna. These fractures typically occur as a result of axial loading with the forearm in pronation19,20 (Figure 4). In a retrospective series, 73% of pediatric patients with Galeazzi fractures had type II, which suggests a higher incidence of pronation injuries in the pediatric population.2 In a series of 40 adult patients with Galeazzi fracture-dislocation, Rettig and Raskin5 divided the fracturedislocation patterns into two classes based on the distance of the radial

Illustration of the anatomic structures that have a biomechanical effect on the Galeazzi fracture pattern. The pronator quadratus muscle exerts a rotational force on the distal radius. The interosseous membrane transfers load from the radius to the ulna. The distal fragment of the radius is pulled proximally by the brachioradialis muscle.

shaft fracture from the midarticular surface of the distal radius. Twentytwo fractures were located within 7.5 cm of the midarticular surface of the distal radius; intraoperative DRUJ instability was noted in 12 of these fractures. In contrast, only 1 of 18 fractures located >7.5 cm from the joint surface had DRUJ instability following open reduction and internal fixation (ORIF) of the radius fracture. Macul Beneyto et al21 classified Galeazzi fracture-dislocation based on the location of the radius fracture in a series of 33 patients. In 20 patients (61%), the fracture was located between zero and 10 cm from the styloid process (type I), and in 10 patients (30%), the fracture was located 10 to 15 cm from the styloid

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Figure 4

Figure 5

Illustration of a Galeazzi fracture classication based on the direction of radius displacement. A, Type I fractures (apex volar) occur as a result of axial loading of the forearm in supination, which causes dorsal displacement of the radius and volar dislocation of the distal ulna. B, Type II fractures (apex dorsal) occur as a result of axial loading of the forearm in pronation, which causes anterior displacement of the radius and dorsal dislocation of the distal ulna.

AP (A) and lateral (B) radiographs demonstrating type II Galeazzi fracture. The ulna is dislocated dorsally, and the radius is shortened and displaced anteriorly.

process (type II). Three patients (9%) had type III fractures, which were >15 cm from the styloid process. In this series, the worst results were seen in patients with type I (distal) injuries.

ever, in rare instances, closed reduction is not possible due to soft-tissue interposition, and ORIF may be required.23

Diagnostic Evaluation
Clinical examination usually reveals swelling, deformity, and tenderness of the distal forearm. Forearm rotation and wrist motion are painful and limited as a result of disruption of the DRUJ and fracture of the radius. Injury to the DRUJ is characterized by joint tenderness, and the ulnar head may be prominent dorsally or palmarly. Depending on the severity of the injury, there may be remarkable deformation in the forearm with shortening and angulation of the radius.3 Neurovascular injury is rare.24 Radiographic assessment is performed to confirm the diagnosis of Galeazzi fracture (Figure 5). Separate AP and lateral radiographs of the elbow, forearm, and wrist should be obtained. A displaced, shortened, or

Galeazzi-equivalent Lesion
The Galeazzi-equivalent lesion is a variant of the classic Galeazzi fracture and is seen in skeletally immature children and adolescents. It is characterized by fracture of the radius with fracture through the distal growth plate of the ulna but without disruption of the DRUJ.20 The distal epiphysis separates, but the ligamentous restraints of the DRUJ do not rupture, probably because, in children, the epiphyseal plate is biomechanically weaker than the ligamentous complex that stabilizes the DRUJ.22 Typically, Galeazzi-equivalent lesions are managed nonsurgically with closed reduction and immobilization in an above-elbow cast. How-

angulated radial shaft fracture with incongruity or dislocation of the DRUJ confirms Galeazzi fracture. Radiographs of the contralateral wrist should be obtained for comparison.25 Radiographic evaluation of the DRUJ is crucial for accurate diagnosis. On plain radiographs, findings suggestive of DRUJ injury include fracture of the ulnar styloid base, widening of the DRUJ on the AP view, dislocation or subluxation of the radius relative to the ulna on the true lateral view, shortening of the radius >5 mm relative to the distal ulna, and asymmetry compared with the uninjured contralateral DRUJ.3,7,25 Subtle DRUJ injury may be overlooked. Mikic 26 noted that in 26 of 125 patients (20%), the DRUJ appeared normal on radiographs despite ulnar head subluxation. Axial CT has been recommended for diagnosis of DRUJ disruption when assessment of the integrity of the DRUJ is difficult on plain radiographs; however, CT is not routinely performed.8 The use of MRI in the diagnosis of Galeazzi fractures has not been rigorously studied.7,27

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Figure 6

Treatment algorithm for children and adults with Galeazzi fractures. DRUJ = distal radioulnar joint, K-wire = Kirschner wire, ORIF = open reduction and internal xation, TFCC = triangular brocartilage complex

Management Nonsurgical
Management of Galeazzi injury differs in children and adults (Figure 6). In children, the nonsurgical treatment of choice consists of closed reduction performed under general anesthesia and fluoroscopic guidance, followed by immobilization in an above-elbow cast for 4 to 6 weeks; this option is associated with satisfactory long-term outcomes.2,3 Following closed reduction of the radius fracture, the forearm is immobilized in supination to maintain the reduction of the DRUJ and allow healing of the TFCC.28 Satisfactory outcomes associated with nonsurgical manageOctober 2011, Vol 19, No 10

ment are likely the result of the stability of the reduction. Factors that contribute to this stability include the presence of thick periosteum, superior fracture remodeling capacity, and the increased ligamentous strength and elasticity of the DRUJ. In a review of 41 children with Galeazzi fracture, Walsh et al17 reported that only 2 required ORIF. They recommended closed reduction for fracture management. After ensuring that the DRUJ is reduced, the forearm should be immobilized in supination in a long-arm cast; however, immobilization in a neutral or pronated position can be equally successful. The authors reported worse results in more distally located fractures.

In a study of 26 children with Galeazzi fracture, Eberl et al2 treated 22 patients with closed reduction and cast immobilization. The authors stated that proper reduction of the radius with subsequent reduction of the ulna in the DRUJ and cast immobilization provide good to excellent outcomes even if the Galeazzi lesion is primarily underdiagnosed. Long-term instability of the DRUJ after Galeazzi lesions was not observed in our series of pediatric patients. In adults, Galeazzi fractures are extremely unstable, and the results of nonsurgical treatment are uniformly

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unsatisfactory.2,26 A high risk of deformation following nonsurgical management has been linked to various deforming forces, including gravity, which acts through the weight of the hand and causes fracture displacement and subluxation of the DRUJ, as well as the deforming forces associated with the brachioradialis, pronator quadratus, and thumb abductors and extensors.3,8,21,29 In a study of 40 adult patients with Galeazzi fractures, Reckling29 reported that none of the 11 patients treated nonsurgically with closed reduction and immobilization in a plaster cast had a good result. Four of these patients had fair results, and seven had poor results. The authors stated that all of these patients had restriction of pronation and supination due to malunion of the radial fracture, and all had some deformity and discomfort in the distal radioulnar joint. Mikic 26 studied 125 patients (14 children, 86 adults) with classic Galeazzi fractures. In 46 (12 children, 34 adults), the authors performed closed reduction with immobilization in a plaster cast. The results of nonsurgical treatment were excellent in 75% of children and poor in 80% of adults.

Surgical
In children, surgical treatment is indicated in rare cases in which initial closed reduction of the radius and DRUJ is not possible or when anatomic alignment achieved with closed reduction is lost. A variety of surgical techniques can be used to manage pediatric Galeazzi injuries, including open reduction without internal fixation; open reduction with Kirschner wire (K-wire) fixation, intramedullary nailing or dorsal plate fixation of the radius; and open reduction with radioulnar transfixation.2,21,26 Differences in outcome

between these techniques have not been well studied due to the relatively small number of cases managed surgically. Nevertheless, plate fixation of the radius may be advisable if open reduction is inevitable. Depending on the age of the child and size of the bone, a 3.5- or 2.7-mm dynamic compression plate (DCP) or a one-third tubular plate can be used. In adults, ORIF is considered the standard of care for most patients with Galeazzi fracture.2,3,5,11,21,29,30 Because this fracture requires surgical treatment to obtain satisfactory results, it is known as the fracture of necessity.31 Anatomic reduction and stable fixation of the radius fracture with intraoperative assessment and repair of associated soft-tissue damage in the DRUJ is essential to achieve favorable outcomes. Plate fixation is the preferred method of osteosynthesis for radius fracture and is best performed with a DCP applied through an anterior approach.5,15,29,30 Restoration of the radial bow at the time of open reduction is important in reconstituting the normal architecture of the forearm and the DRUJ.32 Care must be taken to contour the plate accurately to restore the normal sagittal bow and eliminate subluxation of the DRUJ.33 Insufficient evidence exists to support the use of locked plates for fixation of radius fracture in patients with Galeazzi injury. Reports indicate that compression plates may provide better torsional stability than locked plates with unicortical screws.34 Decreased torsional stability appears to be a potential disadvantage of locked plating in patients with Galeazzi fractures, in whom torsional forces should be minimized postoperatively. Moreover, bending a locked plate to preserve the radial bow may deform the locking system. In general, lateral (radial) plating

of the radius is not the preferred fixation method in patients with Galeazzi fracture. This approach can be technically challenging because it requires elevation of the brachioradialis muscle and extensor tendon as well as additional dissection and mobilization of the radial sensory nerve.35 Furthermore, ex vivo biomechanical studies have not demonstrated superior outcomes associated with lateral plating compared with anterior plating.35 Alternative fixation methods, such as percutaneous intramedullary Kirschner or Rush pinning, have been reported. However, these stabilization methods are less effective than plate fixation in controlling rotation and shortening of the radius.3,26 No studies have compared plate fixation with other fixation methods in patients with Galeazzi injury. Anatomic reduction and stable fixation of the radius is essential to achieve a concentric and stable reduction of the DRUJ. Hence, it is critical to assess the DRUJ intraoperatively following reduction and fixation of the radius.30 After anatomic reduction has been performed and the plate has been applied, AP and true lateral radiographs of the DRUJ are obtained. Radiographs must be obtained without undue force to minimize the possibility of forcing the DRUJ into a reduced position despite soft-tissue or bone interposition.5 Once the DRUJ has been reduced, stability is tested clinically with the forearm in supination and throughout forearm rotation. The DRUJ is defined as unstable in the setting of gross AP translation of the radioulnar joint with displacement of the ulnar head out of the sigmoid notch. The amount of joint relaxation may vary in patients under anesthesia; thus, the contralateral DRUJ is used for comparison.3,5 At this stage, the DRUJ can be confirmed as either re-

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ducible and stable, reducible and unstable, or irreducible. No further surgical intervention is needed when the DRUJ is reduced and confirmed as stable. If the DRUJ remains unstable, the TFCC can be explored and repaired, and the DRUJ can be temporarily transfixed with K-wires (Figure 7). TFCC injury in patients with Galeazzi fracture is typically repaired through an open dorsal approach, which allows visualization of the TFCC injury and open repair via drill holes or suture anchor technique.36 TFCC avulsion from the ulnar styloid base in the absence of ulnar styloid fracture is the typical pathology; however, theoretically, radial-sided TFCC injury can occur. Although arthroscopy can be a useful adjunct for evaluation and treatment of acute TFCC injury, its use in Galeazzi fractures has not been substantiated.37 Ideally, the DRUJ is transfixed with two 1.6-mm K-wires that are placed transversely proximal to the sigmoid notch with the forearm in supination. The K-wires are inserted percutaneously from ulnar to radial and should protrude somewhat from the radial side of the radius to make retrieval easier if they break. The K-wires are left in place for 4 to 6 weeks to protect the repaired TFCC and postoperative congruency of the DRUJ.3,5 The ulnar styloid contributes vitally to the stability of the DRUJ at the attachment of the TFCC. Therefore, in the patient with ulnar styloid fracture, ORIF should be performed using a cannulated lag screw, pins, or tension band technique depending on the size of the fragment (Figure 8). If the DRUJ is clinically stable following internal fixation of the ulnar styloid, the forearm can be immobilized in supination without further intervention38 (Figure 9). Satisfactory results have been reported in adults with reducible but
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unstable DRUJs who underwent temporary pinning of the DRUJ in supination for 4 to 6 weeks following ORIF of the radius fracture without exploration or repair of the TFCC.5,26 No studies demonstrate superior results with TFCC repair compared with pinning the DRUJ in supination alone in patients with unstable Galeazzi injury. In rare cases, the DRUJ may be irreducible; this is most commonly caused by the interposition of soft tissues, in particular the extensor carpi ulnaris tendon.23,31 Entrapment of fracture fragments avulsed from the distal articular surface or from the fovea of the ulna can prevent reduction of the DRUJ, as well.39,40 In these cases, the interposition must be surgically extricated to reduce the DRUJ. Further management is determined based on the stability of the DRUJ.

Figure 7

Surgical Outcomes
Rettig and Raskin5 evaluated 40 patients (average age, 35 years) with Galeazzi fracture. All patients underwent ORIF with a volar DCP. Following fixation of the radius fracture, the authors identified persistent gross instability of the DRUJ in 13 patients. In 10 of these patients, the DRUJ was reduced and stabilized in supination using two transversely placed percutaneous K-wires. The DRUJ was irreducible in the remaining three patients due to interposition of the TFCC, which was avulsed from its insertion on the base of the ulnar styloid. These patients underwent open reduction and repair of the TFCC through a dorsal approach followed by transfixation of the DRUJ with K-wires. At an average follow-up of 38 months, 38 patients (95%) had excellent results and 2 (5%) had poor results. The authors stated that

Postoperative AP radiograph demonstrating xation of the radius with a dynamic compression plate in a patient with a Galeazzi fracture. The distal radioulnar joint is transxed in supination with two parallel Kirschner wires.

open anatomic reduction and stable fixation of the fractured radius often completely corrects the pathologic condition. Instability of the DRUJ can be encountered, however, even after rigid stabilization of the fracture. After ORIF of the radial shaft fracture, we recommend evaluating the stability of the DRUJ for all Galeazzi fracture-dislocations.5 In a study of 36 patients with isolated radial shaft fractures, Ring et al6 identified 9 patients with Galeazzi injuries and treated them with ORIF using compression plates. In five patients, temporary pinning or immobi-

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Figure 8

dysfunction at final (mean, 43 months).

follow-up

Postoperative Immobilization
It is widely accepted that stable reduction of Galeazzi fracture in children can be best accomplished with immobilization of the forearm in supination in an above-elbow cast for 4 to 6 weeks following nonsurgical treatment with closed reduction.2,3,17 Some physicians immobilize the forearm in supination for type II (pronation) injuries and in pronation for type I (supination) injuries; others occasionally immobilize the forearm in a neutral position. No studies have proved that positioning the forearm either according to fracture type or degree of supination affects outcome.15,17 In children, immobilization in an above-elbow cast is preferred postoperatively to control forearm rotation and maintain DRUJ reduction. In adults, postoperative immobilization in an above-elbow cast with the forearm in supination is preferred, particularly if the DRUJ is unstable or irreducible following plate fixation of the radius.5,21,29 This position decreases the rotational forces around the DRUJ, allows for healing of the ligamentous restraints, minimizes the risk of breakage or displacement of the pins, and protects the repaired TFCC.3,5 The literature also includes unusual case reports in which DRUJ stability was achieved with immobilization in an aboveelbow cast with the forearm in full pronation following plate fixation of radius fracture in adult patients with type I Galeazzi fracture (ie, supination injury with anterior dislocation of the ulna).20 If the DRUJ is reduced and stable throughout full forearm rotation following plate fixation of the radius, a protective splint can be

Illustration of open reduction and internal xation of an ulnar styloid fracture using a cannulated lag screw (A), pins (B), and tension band technique (C). In cannulated screw xation, the wire is withdrawn following placement of the screw. (Adapted with permission from Katolik LI, Trumble T: Distal radioulnar joint dysfunction. Journal of the American Society for Surgery of the Hand 2005;5[1]:8-29.)

Figure 9

A, AP radiograph demonstrating fracture of the radius (red arrow) with disruption of the distal radioulnar joint (DRUJ) (circle) and fracture at the base of the ulnar styloid (white arrow). B, Lateral radiograph demonstrating dorsal dislocation of the ulnar head with volar displacement of the fractured radial fragment. Postoperative AP (C) and lateral (D) radiographs demonstrating volar plate xation of the radial fracture. The DRUJ was stabilized following tension band wiring of the ulnar styloid. (Reproduced with permission from Schoonhoven JV, Lanz U: Acute injuries of the distal ulna, in Berger RA, Weiss AP, eds: Hand Surgery. Philadelphia, PA, Lippincott Williams & Wilkins, 2004, pp 297-320.)

lization of the DRUJ (4 to 6 weeks) was performed to address the DRUJ injury. Four patients had a displaced

fracture at the base of the ulnar styloid and underwent ORIF. There were no signs or symptoms of DRUJ

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Figure 10

A 44-year-old man presented with severe pain and limited right forearm and wrist range of motion after 4 months of nonsurgical treatment. A, AP radiograph demonstrating a malunited radius fracture (arrow) in the right forearm and resultant shortening of the radius and incongruence of the distal radioulnar joint (DRUJ) (dashed lines). The uninjured left forearm is shown for comparison. B, Lateral radiograph demonstrating the malunited radius fracture (red arrow) and dorsal displacement of the distal ulna (white arrows) in relation to the posterior surface of the radius (dashed line). AP (C) and lateral (D) radiographs of the right forearm obtained after realignment, xation with a dynamic compression plate, and cancellous bone grafting. Radial length and DRUJ anatomy were restored. The patient regained full supination (E) and pronation (F) within 3 months postoperatively.

applied and early forearm motion can be permitted.38

Complications and Prognosis

Complications are similar to those associated with the other forearm fractures and include nerve compression, tendon entrapment, nonunion, delayed union, malunion, and infection.3,23,24,41 The most devastating complication of this fracture type is malunion of the radius with chronic subluxation and instability of the DRUJ as a result of misdiagnosis or inappropriate treatment. Patients with a malunited Galeazzi fracture
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may report persistent pain in the DRUJ due to instability, limited forearm rotation, and loss of grip strength. With late presentation, it may be possible to perform an osteotomy of the radius with plating and bone graft to restore length and improve congruency of the DRUJ3 (Figure 10). In chronic cases in which DRUJ congruity is not attainable, salvage options are indicated.42 Salvage techniques include the Darrach procedure, hemiresection arthroplasty, the Sauve-Kapandji procedure, and implant arthroplasty.36,43,44 The goal of these procedures is to decrease pain and increase range of motion and

forearm and wrist function; they do not restore normal anatomy. Hence, some compromise of function and incomplete pain relief often occur.36

Summary
The Galeazzi fracture is an inherently unstable injury involving disruption of the DRUJ and deforming muscle forces acting on the distal radius. Addressing the DRUJ, which may be irreducible or unstable even with anatomic reduction and fixation of the radius fracture, is of particular importance. Appropriate management of this fracture differs in children and adults. In children,

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nonsurgical management with closed reduction and immobilization in an above-elbow cast with the forearm in supination is the treatment of choice. In adults, surgical management with open reduction and plate fixation of the radius and intraoperative assessment of the DRUJ is preferred. Unrecognized Galeazzi fractures or incomplete reduction and stabilization of this complex injury are associated with a high incidence of complications, such as chronic DRUJ pain and limitation of forearm and wrist motion.

6.

Ring D, Rhim R, Carpenter C, Jupiter JB: Isolated radial shaft fractures are more common than Galeazzi fractures. J Hand Surg Am 2006;31(1):17-21. Tsai PC, Paksima N: The distal radioulnar joint. Bull NYU Hosp Jt Dis 2009;67(1):90-96. Nicolaidis SC, Hildreth DH, Lichtman DM: Acute injuries of the distal radioulnar joint. Hand Clin 2000;16(3): 449-459. Adams BD: Distal radioulnar joint instability, in Berger RA, Weiss AP, eds: Hand Surgery. Philadelphia, PA, Lippincott Williams & Wilkins, 2004, pp 337-354. Moore TM, Lester DK, Sarmiento A: The stabilizing effect of soft-tissue constraints in artificial Galeazzi fractures. Clin Orthop Relat Res 1985; (194):189-194. LaStayo PC, Lee MJ: The forearm complex: Anatomy, biomechanics and clinical considerations. J Hand Ther 2006;19(2):137-144. McGinley JC, Roach N, Hopgood BC, Limmer K, Kozin SH: Forearm interosseous membrane trauma: MRI diagnostic criteria and injury patterns. Skeletal Radiol 2006;35(5):275-281. Schneiderman G, Meldrum RD, Bloebaum RD, Tarr R, Sarmiento A: The interosseous membrane of the forearm: Structure and its role in Galeazzi fractures. J Trauma 1993;35(6):879-885. McGinley JC, Hopgood BC, Gaughan JP, Sadeghipour K, Kozin SH: Forearm and elbow injury: The influence of rotational position. J Bone Joint Surg Am 2003;85(12):2403-2409. Moore TM, Klein JP, Patzakis MJ, Harvey JP Jr: Results of compressionplating of closed Galeazzi fractures. J Bone Joint Surg Am 1985;67(7):10151021. Hostetler MA, Davis CO: Galeazzi fracture resulting from electrical shock. Pediatr Emerg Care 2000;16(4):258259. Walsh HP, McLaren CA, Owen R: Galeazzi fractures in children. J Bone Joint Surg Br 1987;69(5):730-733. Rose-Innes AP: Anterior dislocation of the ulna at the inferior radio-ulnar joint: Case report, with a discussion of the anatomy of rotation of the forearm. J Bone Joint Surg Br 1960;42:515-521. Egol KA, Koval KJ, Zuckerman JD: Pediatric forearm, in Egol KA, Koval KJ, Zuckerman JD, eds: Handbook of Fractures, ed 4. Philadelphia, PA, Lippincott Williams & Wilkins, 2010, pp 645-659.

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Shiboi R, Kobayashi M, Watanabe Y, Matsushita T: Elbow dislocation combined with ipsilateral Galeazzi fracture. J Orthop Sci 2005;10(5):540542. Macul Beneyto F, Arandes Ren JM, Ferreres Claramunt A, Ramn Soler R: Treatment of Galeazzi fracturedislocations. J Trauma 1994;36(3):352355. Imatani J, Hashizume H, Nishida K, Morito Y, Inoue H: The Galeazziequivalent lesion in children revisited. J Hand Surg Br 1996;21(4):455-457. Mitsui Y, Yagi M, Gotoh M, Inoue H, Nagata K: Irreducible Galeazziequivalent fracture in a child: An unusual case. J Orthop Trauma 2009; 23(1):76-79. Magill P, Harrington P: Complex volar dislocation of the distal radioulnar joint in a Galeazzi variant associated with interposition of the ulnar neurovascular bundle. European Journal of Orthopaedic Surgery & Traumatology 2009;19:265-267. Perron AD, Hersh RE, Brady WJ, Keats TE: Orthopedic pitfalls in the ED: Galeazzi and Monteggia fracturedislocation. Am J Emerg Med 2001; 19(3):225-228. Mikic ZD: Galeazzi fracture dislocations. J Bone Joint Surg Am 1975; 57(8):1071-1080. Ahn AK, Chang D, Plate AM: Triangular fibrocartilage complex tears: A review. Bull NYU Hosp Jt Dis 2006;64(3-4):114118. Rodrguez-Merchn EC: Pediatric fractures of the forearm. Clin Orthop Relat Res 2005;(432):65-72. Reckling FW: Unstable fracturedislocations of the forearm (Monteggia and Galeazzi lesions). J Bone Joint Surg Am 1982;64(6):857-863. Macintyre NR, Ilyas AM, Jupiter JB: Treatment of forearm fractures. Acta Chir Orthop Traumatol Cech 2009; 76(1):7-14. Borens O, Chehab EL, Roberts MM, Helfet DL, Levine DS: Bilateral Galeazzi fracture-dislocations. Am J Orthop (Belle Mead NJ) 2006;35(8):369-372. Schemitsch EH, Richards RR: The effect of malunion on functional outcome after plate fixation of fractures of both bones of the forearm in adults. J Bone Joint Surg Am 1992;74(7):1068-1078. Gosselin RA, Contreras DM, Delgado E, Paiement GD: Anterior dislocation of the distal end of the ulna after use of a compression plate for the treatment of a Galeazzi fracture: A case report. J Bone Joint Surg Am 1993;75(4):593-596.

21.

8.

22.

9.

23.

10.

24.

References
11.

Evidence-based Medicine: Levels of evidence are described in the table of contents. In this article, references 2, 6, 15, 17, 21, 26, 29, 32, and 44 are level IV studies. References 1, 3, 5, 7, 8, 11, 25, 27, 28, 30, 36, 37, 42, and 43 are level V expert opinion. References 16, 18, 20, 22-24, 31, 33, and 39-41 are case reports. References 4, 10, 12-14, 34, and 35 are biomechanical or cadaver studies. References printed in bold type are those published within the past 5 years.

12.

25.

13.

26.

27.

14.

28.

15. 1. Sebastin SJ, Chung KC: A historical report on Riccardo Galeazzi and the management of Galeazzi fractures. J Hand Surg Am 2010;35(11):18701877. Eberl R, Singer G, Schalamon J, Petnehazy T, Hoellwarth ME: Galeazzi lesions in children and adolescents: Treatment and outcome. Clin Orthop Relat Res 2008;466(7):1705-1709. Giannoulis FS, Sotereanos DG: Galeazzi fractures and dislocations. Hand Clin 2007;23(2):153-163, v. Hsu ES, Patwardhan AG, Meade KP, Light TR, Martin WR: Cross-sectional geometrical properties and bone mineral contents of the human radius and ulna. J Biomech 1993;26(11):1307-1318. Rettig ME, Raskin KB: Galeazzi fracture-dislocation: A new treatmentoriented classification. J Hand Surg Am 2001;26(2):228-235.

29.

30.

16.

2.

31.

17.

3.

18.

32.

4.

19.

33.

5.

632

Journal of the American Academy of Orthopaedic Surgeons

Kivanc I. Atesok, MD, et al

34. Roberts JW, Grindel SI, Rebholz B, Wang M: Biomechanical evaluation of locking plate radial shaft fixation: Unicortical locking fixation versus mixed bicortical and unicortical fixation in a sawbone model. J Hand Surg Am 2007; 32(7):971-975. Eglseder WA, Jasper LE, Davis CW, Belkoff SM: A biomechanical evaluation of lateral plating of distal radial shaft fractures. J Hand Surg Am 2003;28(6): 959-963. Katolik LI, Trumble T: Distal radioulnar joint dysfunction. Journal of the American Society for Surgery of the Hand 2005;5(1):8-29. Carlsen BT, Dennison DG, Moran SL: Acute dislocations of the distal radioulnar joint and distal ulna fractures. Hand Clin 2010;26(4):503-516. 38. Jupiter JB, Kellam JF: Diaphyseal fractures of the forearm, in Browner BD, Jupiter JB, Levine AM, Trafton PG, Krettek C, eds: Skeletal Trauma. Philadelphia, PA, Saunders Elsevier, 2009, pp 1478-1481. Kikuchi Y, Nakamura T: Irreducible Galeazzi fracture-dislocation due to an avulsion fracture of the fovea of the ulna. J Hand Surg Br 1999;24(3):379381. Gunes T, Erdem M, Sen C: Irreducible Galeazzi fracture-dislocation due to intra-articular fracture of the distal ulna. J Hand Surg Eur Vol 2007;32(2):185187. 41. Fujiwara M: Galeazzi fracture nonunion treated with a free vascularized corticoperiosteal graft. J Reconstr Microsurg 2006;22(5):357-362. Mulford JS, Axelrod TS: Traumatic injuries of the distal radioulnar joint. Hand Clin 2010;26(1):155-163. Szabo RM: Distal radioulnar joint instability. J Bone Joint Surg Am 2006; 88(4):884-894. Chu PJ, Lee HM, Hung ST, Shih JT: Stabilization of the proximal ulnar stump after the Darrach or SauvKapandji procedure by using the extensor carpi ulnaris tendon. Hand (N Y) 2008;3(4):346-351.

42.

35.

43.

39.

44.

36.

40.

37.

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