Recognition of a Galeazzi pattern of injury is essential, as failure to recognize the distal radioulnar joint (DRUJ) injury can lead to permanent impairment.
The primary goal of management is to obtain anatomic restoration of the radius and subsequent alignment/stability of the DRUJ.
Surgical reduction is indicated except in patients with comorbidities/conditions that preclude surgery.
After open reduction and internal fixation of the radius in an anatomical position, stability of the DRUJ must be assessed through a full range of pronosupination.
Treatment of the DRUJ is based on the extent of persistent instability and the arc of motion in which it occurs. Immobilization in a reduced position is preferred when instability persists only in one extreme of rotational motion (i.e., immobilization in supination when unstable only in full pronation).
Cases of persistent instability that cannot be easily maintained or irreducible dislocations are best treated with reduction and ulnoradial Kirschner wire transfixation of the DRUJ, with consideration of repair of the ulnar styloid/triangular fibrocartilage complex (TFCC) to increase stability. Before this line of treatment is considered, it is assumed that the radius has been reduced anatomically.
A 47-year-old, right hand dominant male accountant suffered an isolated injury to his right upper extremity after biking on his morning commute. He presented to the emergency department with a displaced distal third radial shaft fracture and dislocation of the distal radioulnar joint ( Fig. 1 ). What is the most effective approach to management of this acute Galeazzi fracture dislocation?
Importance of the Problem
Recognition of the Galeazzi fracture pattern is critical to successful management of these injuries. While the majority of radial shaft fractures are isolated and do not have associated instability, the DRUJ must be scrutinized for subluxation or dislocation, especially those occurring at the junction of the middle and distal third of the radius. Most true Galeazzi injuries will result in frank dislocation of the DRUJ, however, the ulnar head may demonstrate more subtle subluxation in about 20% of cases making diagnosis more difficult. While Galeazzi fracture-dislocations comprise ≤ 7% of adult forearm fractures, misidentification and inadequately treated injuries may result in ongoing DRUJ instability, restricted forearm rotational range of motion, and persistent ulnar sided wrist pain. Patients may experience limited function as well as reduced strength as a result. Additionally, the results of acute operative treatment are superior to that of nonoperative management or delayed reconstruction, particularly with regards to reduction and stability of the DRUJ.
In adult patients with acute Galeazzi fracture-dislocations, what is the most effective approach to management in order to restore stability and full range of motion to the distal radioulnar joint?
After anatomic reduction of the radius with rigid fixation, assessment of stability of the DRUJ should be performed through a full range of pronosupination. When the DRUJ may be safely reduced and easily maintained, immobilization in a stable position is recommended. For injuries where the reduction is difficult to maintain, or stable only through a short arc of motion, pin fixation of the DRUJ is indicated. Open reduction is performed when the joint is unable to be reduced by closed means.
Finding the Evidence
We conducted a search of the Cochrane library, Medline and Embase via OVID, and the Cumulative Index of Nursing and Allied Health Literature (CINAHL). The search terms included using “Galeazzi” as a keyword and combining “radius” and “radius fracture” with “wrist injuries,” “joint dislocations,” “ulna,” “ulna fractures.” We excluded papers not published or translated into English. The reference list of included articles were also reviewed to identify additional papers not included in our initial search.
Quality of the Evidence
No Level I, II, or III evidence exists regarding adult Galeazzi fracture-dislocation management. The best available evidence included in this review are Level IV:
13 Case Series, 2 Small Retrospective Cohort Studies and 1 Systematic Review (of case reports).
We included comparative studies and any series reporting results in 10 or more adult patients. Sixteen studies were identified for inclusion (total 573 patients, range 10–95). Thirteen studies were case series (Level IV) of which a total of 448 patients were treated operatively and 108 patients were initially treated nonoperatively. Two of the studies included were retrospective cohort studies (Level IV) with a total of 17 patients with Galeazzi injuries. There was also one systematic review of case reports (Level IV) describing irreducible DRUJ dislocations.
Closed reduction alone consistently results in poor outcomes as demonstrated by early case series. Ninety-two percent of nonoperative patients (38/41) in Hughston’s case series demonstrated persistent DRUJ instability, nonunion, shortening or angulation. Similarly, Mikic showed an 80% failure rate with nonoperative management. Wong reported only 3 of 34 patients were able to maintain successful radial alignment and DRUJ stability after closed reduction, and 0 of 4 patients were successfully treated by immobilization without reduction. Similarly, Reckling and Cordell only achieved fair or poor results ( N = 8) with reduction and immobilization. They noted that while all 8 of their nonoperative patients went on to achieve radial union, all had persistent ulnar head dislocation. In fact, multiple studies report early conversion from nonoperative to operative management for persistent ulnar head dislocation and/or radial malreduction ( N = 39). In those patients who did not receive surgery, persistent ulnar head dislocation was often associated with severe limitations in prosupination, ultimately requiring salvage procedures (most commonly Darrach/ulnar head resection). Hughston’s early study recognized this issue with radial malreduction and advocated for early ulnar head resection, however, subsequent authors recommend such salvage procedures to be reserved for delayed presentations of refractory DRUJ instability.
The main consensus following review of the available evidence is that open reduction and rigid internal fixation of the radial shaft fracture is necessary.
In his landmark paper, Mikic described satisfactory results with both flexible intramedullary (Rush) rod and plate fixation. He went on to acknowledge that Rush rod fixation is most applicable in simple 2-part fractures and that plate fixation more readily provided rigid fixation in complex cases. This combined with modern AO principles and inferior clinical results with Rush rod/intramedullary fixation reported by Reckling and Cordell (1 of 3 “poor”), Macule Beneyto (3 of 3 “poor”) and Hughston (2 of 4 “unsatisfactory”) has led to plate fixation being the accepted standard of care for modern treatment.
Furthermore, plate and screw fixation has resulted in the most consistent satisfactory results in the literature. Mohan and colleagues performed open reduction and internal fixation (ORIF) on 50 patients (20 with square nail fixation, 30 with semitubular plate fixation). Despite overall 80% good results, they found that time to union occurred earlier with plate fixation and concluded that plate fixation is a better construct for this injury pattern. Reckling and Cordell found that all patients treated with ORIF demonstrated good results when compared to fixation with Kirschner wires, screws or Rush rod alone.
The most common, yet rare, complication following ORIF compared to nonoperative treatment is infection. In this review, 13 of 448 patients (3%) undergoing operative fixation were reported to have either superficial or deep infections.
Lastly, a 2010 paper by Gadegone et al. described the use of flexible intramedullary nails for adult patients with Galeazzi fracture dislocations. They analyzed 22 cases in patients aged 20- to 56-year-old (mean 35), reporting excellent outcomes in 18 patients and fair outcomes in 4 by Mikic criteria ( Table 1 ). However, they did experience 4 cases (18%) of recurrent DRUJ instability—including 2 cases with loss of radial reduction. Given these results and the lack of other reported cases of flexible nailing, anatomic reduction, and rigid plate fixation is considered the standard of care.
|Excellent||Union, perfect alignment, no loss of length, no subluxation of the distal radioulnar joint, no limitation of elbow or wrist function, and no limitation of supination or pronation.|
|Fair||One or more of the following: delayed union, minimum malalignment and shortening of the radius, subluxation of the ulnar head, excessive scar, limitation of pronation/supination up to 45 degrees, and some degree of restriction of motion of the elbow and wrist.|
|Poor||One or more of the following: nonunion, remarkable shortening or angulation of the radius, dislocation of the distal radioulnar joint, limitation of pronation/supination of more than 45 degrees, and excessive restriction of elbow and wrist function.|