Galeazzi Fracture Overview and Case Example

1. Trauma Presentation: Galleazzi Fracture
Orthopaedic Surgery

2. HPI
• CC: Right forearm pain and deformity
• Elderly female who fell onto an outstretched
right arm
• Immediate pain and visible deformity

3. ADDITIONAL HISTORY
PMH
Asthma, migraine,
GERD, HTN
PSH
Partial hysterectomy
cholecystectomy
Soc
No EtOH, smoking, drugs
Meds
Tramadol, pregabalin, prilosec
Allergies
tetracycline

4. PHYSICAL EXAM
Gen:
• in no acute distress
MSK:
• RUE:
– No lacerations/abrasions
– Gross deformity of forearm (radial deviation of right
wrist)
– Compartments soft
– Sensation and motor function intact
– 2+ radial pulse

5. RADIOGRAPHS

6. GALEAZZI FRACTURE-DISLOCATION
• Defined as a fracture of the radial diaphysis
(typically distal 1/3) with a dislocation of the
DRUJ
• First described in 1822 by Sir Astley Cooper
• Further described by Galeazzi in 1934
• Frequently underdiagnosed
• Most likely to occur within 7.5cm of
midarticular surface of distal radius (Rettig and
Raskin)

7. MECHANISM
• Forceful axial loading of the forearm
with wrist extended and maximally
pronated
• Some authors believe loading in
supination can also result in the
injury
• Falls, MVC, electric shock, blunt
trauma

8. ANATOMY: OSSEOUS
• Major radial bow: from the biceps
tuberosity to the ulnar aspect of the
articular surface
– Essential for proper forearm
rotation

9. ANATOMY: SOFT TISSUE
• Interosseous membrane
– Complex ligamentous structure that
firmly attaches the radius and ulna
– Transfers load from radius to ulna
– Terminates proximal to the distal 1/3
radial diaphysis
• Higher risk of shortening

10. ANATOMY: SOFT TISSUE
• Triangular Fibrocartilage Complex (TFCC)
– Primary stabilizer of the DRUJ
– Base attaches to the junction of the
lunate fossa and the sigmoid notch
– Apex attaches to the fovea and ulnar
styloid
– Primary stabilizers of distal ulna: dorsal
and palmar radioulnar ligaments

12. PATHOPHYSIOLOGY
• Radius fractures 2/2 axial load
• The radius shortens, significant force is
pulled through the distal ulna via the TFCC
• The TFCC fails in its substance or through
avulsion of the ulnar styloid
• Without this ligamentous constraint, the
DRUJ is destabilized and the distal ulna
dislocates

13. DEFORMING FORCES
• Shortening:
– Brachioradialis
– Abductor pollicis longus
– Extensor pollicis brevis
– Extensor digiti minimi
• Rotational
– Pronator quadratus

14. IMAGING
• Radiographs of the elbow, wrist, and forearm
– AP
– True lateral
• Findings suggestive of DRUJ instability:
– Ulnar styloid fracture
– DRUJ widening (AP)
– Dislocation/subluxation of ulna relative to
radius (lateral)
– Radial shortening >5mm

15. CLASSIFICATION
Walsh:
• Type I: Dorsal displacement of the distal radius
with volar displacement of the ulna
• Type II: Volar displacement of the distal radius
with dorsal displacement of the ulna
• an

16. CLASSIFICATION
Rettig and Raskin:
• Type I: within 7.5cm of wrist joint
• Type II: >7.5cm from wrist joint
• an

17. CLASSIFICATION
AO/OTA:

18. ASSESSMENT
59 YO female with right distal 1/3 radial
diaphyseal fracture with associated DRUJ
dislocation
– Walsh type II
– Rettig and Raskin type I
– AO/OTA 22A2.3

19. MANAGEMENT
Nonoperative
• Not indicated
• Fracture of necessity
• Historically, nonoperative treatment with closed
reduction and casting yielded poor outcomes
Operative
• ORIF radius
– Plate osteosynthesis
– Rush rod
– Percutaneous K-wire fixation
• +/- ORIF ulnar styloid, open reduction of DRUJ, closed
reduction and pinning of DRUJ

20. LITERATURE REVIEW
1985

21. SUMMARY
• Largest study of compression plating at that
time (n=55)
• Both dorsal and volar techniques used
– Superior results with dorsal, although volar
technically easier (mechanical limitation to
pronation)
• Functional outcomes excellent/good in 97% of
patients
• Radiographic healing in 97% patients

22. LITERATURE REVIEW
2011

23. MATERIALS AND METHODS
• Purpose: to determine if fracture location has
an effect on DRUJ stability
• Retrospective
• 95 patients with Galeazzi fx
• Mean f/u: 6.8 months

24. RESULTS AND CONCLUSION
• Results:
– 40/90 pts had residual DRUJ instability after
rigid fixation of radius
• 37 w/in 10cm of radial styloid
• 2 10-15cm
• 1 >15cm
• Conclusion:
– Proximity to radial styloid is predictive of DRUJ instability
requiring fixation after rigid radius fixation

25. LITERATURE REVIEW
2016

26. MATERIALS AND METHODS
• Retrospective cohort study
• 66 patients
• Galeazzi fracture diagnosed intraoperatively
via DRUJ instability testing

27. RESULTS AND CONCLUSION
• 39% of fractures with residual DRUJ instability
located w/in 7.5cm of wrist joint (Rettig and
Raskin type I)
• 31% with shortening >5mm
• Conclusion: Radiographic guidelines for prediction of
Galeazzi lesion are only moderately accurate.
Intraoperative evaluation of the DRUJ should remain
the gold-standard

28. DISCUSSION

29. OPERATION IN BRIEF
• Volar approach of Henry
• Fracture reduced via longitudinal traction
• Reduction held with K-wire
• Dynamic compression plate applied
• Reduction judged anatomic
• DRUJ was found to be reduced after reduction
of radius
• Instability noted with both pronation and
supination, so K-wired placed across the DRUJ

30. INTRAOPERATIVE IMAGES

31. IMMEDIATE POST-OP

32. POST-OPERATIVE COURSE
2 weeks:
• Incision c/d/i
• Pain controlled
• Long arm cast placed

33. 2 WEEKS

34. 6 WEEKS
• Incision healed
• Cast removed
• Pin removed
• OT for ROM and strengthening begun

35. 6 WEEKS

36. 3 MONTHS
• Minimal pain
• Hypersensitivity at dorsum of wrist
• Limited flexion index finger

37. 6 MONTHS
• Increased from prior visit forearm pain
• Hypersensitivity at dorsum of wrist
• Limited flexion index finger

38. 6 MONTHS

39. 10 MONTHS
• Continued pain in forearm
• ROM full
• Sent to hand specialist for second opinion
– Forearm tenosynovitis
– Plan medimix for pain
– f/u PRN