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Galeazzi # dislocation
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Galeazzi # dislocation

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  • 1. INTRODUCTION & HISTORY - Combination of radial shaft # and dislocation of DRUJ – ist time by sir astley cooper in 1852 - 110 yrs later richardo galeazzi of italy – potentially unstable & loss of reduction occurs in plaster. - Described his own method of reduction – traction of the thumb in line with radius , forearm in supination & then radial deviation of hand to reduce DRUJ sublaxtion or dislocation
  • 2.  Jack hughston in 1956 during meeting of american academy of orthopaedic surgeons – stunned everyone when he recorded 92% failure in closed reduction  Campbell – need for OR & rigid IF - FRACTURE OF NECESSITY - STEWART – associate of campbell – fixation should be rigid in the form of plate than nailing , bone graft - esp in comminuted # radius , intraoperative assessment of DRUJ , discouraged excision of lower end of ulna
  • 3.  DEFINITION fractures of shaft of radius anywhere between radial tuberosity & a point 2 – 4 cms proximal to the wrist, associated with subluxation or dislocation of distal end of ulna
  • 4. - CLASSIFICATION : two types - Type 1 : # in distal 1/3 rd within in 7.5 cms from distal articular surface - Type 2 : middle 1/3 rd of radius > 7.5 cms from distal articular surface
  • 5. -- depending on fracture pattern - type 1 : # running distally & radially from above downwards , 75% cases , highly unstable . - type 2 : # running distally & medially from above downwards , 25 % cases , relatively stable
  • 6.  STATISTICS - 30 – 50 % galeazzi # are associated with multiple injuries - Incidence – 7 % of skeletal injury to forearm - More common in middle aged - Rarely below < 10 yrs & > 80 yrs - 70 % cases – high velocity injuries - Males four times prone to females - 10 – 20 % - open - 60 % : transverse , 30 % short oblique , 10 % comminuted
  • 7.  MECHANISM OF INJURY axial loading and hyperpronation of wrist during fall on a outstretched hand - Fracture generally occurs at ht. of maximal radial bowing , once fracture occurs, associated hyperpronation causes disruption of DRUJ , if force continues ulna breaks - Direct injury to radius – very uncommon
  • 8. - # made more unstable by 5 factors - Pronator quadratus , - Outporing muscles of thumb : Abductor pollicis longus & ext. pollicis brevis - Brachioradialis - Wt. of hand - Interosseous membrane - DISPLACEMENTS - In majority –RADIUS : medial , volar & proximal - Dorsal & radial – rare - Ulna – distal & dorsal very rarely – volar
  • 9.  20 % of DRUJ subluxation – occult in nature  Hence all single bone fracture radius are considered as galeazzi , unless proved otherwise  Fortunately most subluxation /dislocations are simple ( reduced spontaneously after radial fixation )  Sometimes – irreducible / recurrent MOST OFTEN - EXT CARPI ULNARIS tendon is trapped # and dislocation : complimentary greater the fracture displacement , more severe is dislocation
  • 10.  Radial shortening if > 5mm – always associated with tear of TFCC  If > 10 mm – generally associated with tear of interosseous membrane also  GALEAZZI EQUIVALENT LESIONS can occur in children & elderly IN CHILDREN : radial # 6 – 8 cms proximal to wrist associated with distal ulnar epiphyseal injury epiphyseal plate weaker than TFCC, hence no subluxation / dislocation better prognosis , emenable for conservative treatment
  • 11.  IN ELDERLY radial shaft # 6 – 8 cms proximal to wrist associated with ulnar fracture 2 cm proximal to wrist weaker osteoporotic ulna than TFCC Ulnar # always caused after disruption of DRUJ difficult to treat poor prognosis unless DRUJ is properly reduced after fixation of both radius & ulna
  • 12.  DIAGNOSIS radius fractures between insertion of pronator teres & pronator quadratus usually at jn. of middle 1/3rd & lower 1/3rd Good quality x- ray needed - concave deformity of radius - radial shortening - dorsal prominence of ulnar head - postero-lateral angulation
  • 13.  Features s/o injury to DRUJ - # styloid process of ulna - widening of lower end of radius and ulna in AP view – meaning diastasis - dorsal displacement of distal ulna - shortening of radius > 5 mm relaitive to distal ulna ASSOCIATED INJURIES - carpal injuries - metacarpal injuries - # both bones of forearm doesn’t rule out galeazzi # because 20 % may be associated with ulnar #
  • 14.  Assessment of DRUJ integrity is often difficult using plain radiography alone  BILATERAL AXIAL FOREARM C.T SCAN is imaging of choice  TREATMENT : CONSERVATIVE : only in children with galeazzi classic or equivalent forearm is immobilised in above elbow cast with SUPINATION for 4 – 6 wks - cast may be extended distally as thumb spica – enhances immobilisation - Volar ulnar head – in PRONATION
  • 15.  CONSERVATIVE – in very old osteoporotic bone of galeazzi equivalent lesion  SURGICAL timing : as early as possible ( most complications are related to timing of surgery ) - A.O 3.5 mm plate – implant of choice - 6 – 7 holed - preferred - primary bone graft – generally not needed ( probably indicated in comminuted fracture ) - Radial fracture : approached anteriorly / posteriorly
  • 16.  ANTERIOR APPROACH - advantages : easier & familiar esp for distal radius better soft tissue coverage over implant useful when DRUJ needs exploration through separate dorsoulnar incision - disadvantages : iatrogenic injury to superficial br. of radial N. lower ¼ plate has to be accurately bent may restrict movement of wrist more then posterior approach
  • 17.  POSTERIOR APPROACH - advantages : it is the tension side , hence ideal helps surgeon to identify & isolate PIN in proximal third fractures - Disadvantages : doesn’t provide good soft tissue coverage to distal ½ of radius difficult to explore DRUJ can precipitate chronic tenosynovitis
  • 18. HENCE VOLAR APPROACH FOR DISTAL RADIUS & DORSAL APPROACH FOR PROXIMAL RADIUS - Once radius fixed rigidly - DRUJ is assessed both clinically & radiologically - Rotate forearm and assess DRUJ instability ( esp in supination ) - Reducible & stable – splint in supination * 4 wks - Reducible & unstable – two K wires ( in supination ) ulna to radius , just proximal to articular surface - Irreducible & recurrent – open reduction ( dorsal approach ) remove interposing soft tissue & stabilise as above
  • 19.  EXTENSOR CARPI ULNARIS – mc interposing soft tissue  Dorsal DRUJ disruption – needs supination  Volar DRUJ disruption - needs pronation  If K wire used to transfix – immobilise by cast than slab to prevent K wire breakage in situ  Primary excision of ulnar head – not advised  If TFCC torn – repaired or reconstructed  Primary stabilisers of DRUJ : TFCC  Secondary stabilisers : pronator quadratus & interosseous membrane
  • 20.  TFCC ( TRIANGULAR FIBRO- CARTILAGENOUS COMPLEX ) - functions : share the load to about 20 – 30 % produced by axial compression stability of DRUJ distal connection suspends ulnar side of carpus with ulna – needed for adequate grip
  • 21.  Parts of TFCC - articular disc also called TFCC proper - volar & dorsal radioulnar ligament - ulno carpal ligament - thick firous sheath to ext. carpi ulnaris - ulnar collateral ligament
  • 22.  COMPLICATIONS  Loss of grip strength  Loss of range of motion  Dalayed or nonunion  Nerve injuries – ulnar N . - superficial br. Of radial N. ( IATROGENIC ) -- extensor tenosynovitis due to dorsal plate -- reflex sympathetic dystrophy – rare
  • 23.  Essex – lopresti injury rare complex injury of forearm – described as radio - ulnar dissociation . fall on outstretched hand , fracture of head of radius and disruption of both the interosseous membrane and DRUJ leading to proximal migration of radius often missed , because of attention directed to radial head fracture
  • 24. THANK YOU

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