Review Article

Galeazzi Fracture

Abstract
Kivanc I. Atesok, Galeazzi fracture is a fracture of the radial diaphysis with disruption at
MD Jesse B. Jupiter, the distal radioulnar joint (DRUJ). Typically, the mechanism of injury is
forceful axial loading and torsion of the forearm. Diagnosis is established
MD
on radiographic evaluation. Underdiagnosis is common because
Arnold-Peter C. Weiss, MD 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 fixation is the preferred
surgical option. Anatomic reduction and rigid fixation 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.

G
aleazzi fracture is a distal radial
joints. Hence, any disruption (eg,
shaft fracture with disruption
fracture) in the length of the radius
of the distal radioulnar joint (DRUJ)
can affect either of these joints.3
(Figure 1). First described by Astley
Cross-sectional properties of cortical
Cooper, the fracture was named after
bone and bone mineral contents of
Galeazzi following a 1934 publica-
the radius suggest that the junction
tion by that author that described
of the middle and the distal one third
18 cases.1 This fracture is also re-
of the radius is at increased risk of
ferred to as reverse Monteggia,
fracture.4
Piedmont, and Darrach-Hughston-
Biomechanically, fractures of the
Milch.1 Galeazzi lesions are fre-
From the Institute of Medical Science, middle to distal one third of the ra-
quently underdiagnosed, and the
University of Toronto, Toronto, ON,
true incidence may vary. Reports in- dius are more likely to cause disrup-
Canada (Dr. Atesok), the Department of tion of the DRUJ than are fractures
Orthopaedic Surgery, Massachusetts dicate an incidence of 3% of all
General Hospital, Boston, MA (Dr. forearm fractures in children and more proximal to the radius.5 Rettig
Jupiter), and the Department of 7% of those in adults.2 and Raskin5 observed that radial
Orthopaedics, Warren Alpert Medical shaft fractures located >7.5 cm from
School, Brown University, and Rhode
Island Hospital, Providence, RI (Dr.
the lunate facet of the distal radial
Weiss). Anatomy and articular surface were not typically
J Am Acad Orthop Surg 2011;19:
Pathophysiology associated with DRUJ injury. Ring
623-633 et al6 stated that there may be
The radius and ulna are constrained excep- tions to the 7.5 cm rule; the
Copyright 2011 by the American
firmly by the interosseous membrane location of the fracture alone may
Academy of Orthopaedic Surgeons.
(IOM) and ligamentous structures at not be suf- ficient to ascertain
the proximal and distal radioulnar whether the DRUJ is stable. The
authors found

October 2011, Vol 19, No 10 623

 Galeazzi

Figure 2

Figure

Illustration of the superficial 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.)

tend to have the worst outcomes. quently, substantial shortening of the

The DRUJ is primarily stabilized fractured radius relative to the ulna
Illustration of a Galeazzi fracture. The by the triangular fibrocartilage com- results in marked disruption of the
arrows indicate the forces acting on the plex (TFCC).7 Dislocation of the TFCC.10
distal radius. (Reproduced with
permission from Haugstvedt JR: DRUJ requires severe disruption of The IOM is a complex ligamentous
Dissociations of the radius and ulna: the TFCC. The base of this soft- structure that connects the interosse-
Surgical anatomy and biomechanics, in tissue complex attaches to the junc- ous borders of the radius and ulna
Berger RA, Weiss AP, eds: Hand
Surgery. tion of the lunate fossa and the sig- and transfers load from the radius to
Philadelphia, PA, Lippincott Williams moid notch of the radius, and the the ulna. It consists of a central
& Wilkins, 2004, vol 1, pp 615-644.) apex of the TFCC attaches to the fo- band, a proximal band, membranous
1 vea and ulnar styloid.8 The distal portions, and accessory bands. The
ulna is primarily stabilized by the central band, the strongest portion of
DRUJ injury in 4 of 28 patients with palmar and dorsal radioulnar liga- the IOM, originates from the proxi-
fractures of the radius that were ments of the TFCC. In the coronal mal one third of the radius and in-
more proximally located. DRUJ in- plane, each radioulnar ligament serts at the distal quarter of the
jury was noted in 5 of 8 patients passes ulnarly and is divided into ulna.11 Because the IOM has no at-
with fractures to the distal one third two limbs. The deep limb attaches to tachment to the distal one third of
of the radial shaft. Hence, distal one the fovea, and the superficial limb at- the radius, fractures involving this
third radial shaft fractures are gener- taches to the base and mid portion of area may be associated with a higher
ally associated with DRUJ injury and the ulnar styloid9 (Figure 2). Conse- risk of shortening. McGinley et al12

62 Journal of the American Academy of Orthopaedic Surgeons

 Kivanc I. Atesok, MD, et
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.

October 2011, Vol 19, No 10 62

Galeazzi

described patterns of IOM disrup- based on the distance of the radial

forces that can shorten the fractured
tion in a cadaver study. The authors
radius.
simulated forearm trauma due to ax-
ial loading at different rotational po- Mechanism of Injury and
sitions and observed that most inju- Fracture Classification
ries to the IOM occurred along its
distal ulnar insertion. An axial load
that is strong enough to fracture the Forceful axial loading of the forearm
radius and tear the IOM distally may with the wrist in extension and max-
result in dissociation between the ra- imum pronation is one reported
dius and the ulna, such as that asso- mechanism of injury associated with
ciated with Galeazzi fractures. Galeazzi fracture; however, some au-
In a cadaver study, Schneiderman thors believe that loading in supina-
et al13 reported that the amount of tion also can cause Galeazzi in-
shortening in the fractured radius jury.2,3,5 In addition to falls, other
correlated with the nature of soft- reported mechanisms of injury in-
tissue injury associated with Galeazzi clude motor vehicle accidents, elec-
fracture. They noted radial shorten- tric shock, and blunt trauma.15,16
ing of approximately 5 mm follow- Various systems have been used to
ing radial osteotomy. Radial classify this fracture type. In a study
shorten- ing of 5 to 10 mm was of
achieved with osteotomy of the 41 pediatric patients with Galeazzi
radius and transec- tion of either the fractures, Walsh et al17 observed pos-
TFCC or IOM. Shortening >10 mm terior (dorsal) displacement of the
following os- teotomy required radius fracture in 20 and anterior
transection of both the TFCC and displacement in 21. This report led
IOM. Therefore, ra- dial shaft to the development of a fracture clas-
fractures with shortening sification based on displacement of
>5 mm may indicate injury to either the distal fragment of the fractured
the TFCC or IOM. radius. Type I fracture (apex volar) is
These cadaver studies were limited characterized by dorsal displacement
by the elimination of muscle strength of the distal fragment of the radius
and variation in the age of the speci- with anterior (volar) dislocation of
mens, some of which had decreased the distal ulna. Typically, type I frac-
bone density and ligamentous consis- ture is caused by axial loading with
tency that does not reflect the clinical the forearm in supination.18 In a type
situation.12 To date, no ex vivo stud- II fracture (apex dorsal), the distal
ies have successfully reproduced the fragment of the radius is displaced
Galeazzi injury pattern in cadaver anteriorly with posterior (dorsal) dis-
models in which axial impact load- location of the distal ulna. These
ing was applied to the forearm in dif- fractures typically occur as a result
ferent rotational positions.14 of axial loading with the forearm in
Several muscles may exert deform- pronation19,20 (Figure 4). In a retro-
ing forces on the distal radius (Figure spective series, 73% of pediatric pa-
3). The pronator quadratus muscle tients with Galeazzi fractures had
exerts a rotational force on the distal type II, which suggests a higher inci-
radius that may compromise closed dence of pronation injuries in the pe-
reduction. The brachioradialis mus- diatric population.2
cle pulls the distal fragment of the In a series of 40 adult patients with
radius proximally; the abductor pol- Galeazzi fracture-dislocation, Rettig
licis longus and extensor pollicis bre- and Raskin5 divided the fracture-
vis muscles also can exert deforming dislocation patterns into two classes

62 Journal of the American Academy of Orthopaedic Surgeons

 Kivanc I. Atesok, MD, et
Figure 3

Illustration of the anatomic structures

shaft fracture from the that have a biomechanical effect on the
midarticular surface of the Galeazzi fracture pattern. The pronator
quadratus muscle exerts a rotational
distal radius. Twenty- two
force on the distal radius. The
fractures were located interosseous membrane transfers load
within from the radius to the ulna. The distal
7.5 cm of the midarticular fragment of the radius is pulled
proximally by the brachioradialis
surface of the distal radius; muscle.
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 instabil- ity following
open reduction and in- ternal
fixation (ORIF) of the radius
fracture.
Maculé Beneyto et al21
classified Galeazzi fracture-
dislocation based on the
location of the radius fracture
in a series of 33 patients. In 20
pa- tients (61%), the fracture
was lo- cated between zero and
10 cm from the styloid process
(type I), and in 10 patients
(30%), the fracture was lo-
cated 10 to 15 cm from the
styloid

October 2011, Vol 19, No 10 62

 Galeazzi

Figure 4 Figure 5

AP (A) and lateral (B) radiographs

demonstrating type II Galeazzi
Illustration of a Galeazzi fracture classification based on the direction of radius fracture. The ulna is dislocated
displacement. A, Type I fractures (apex volar) occur as a result of axial loading of dorsally, and the radius is shortened
the forearm in supination, which causes dorsal displacement of the radius and volar and displaced anteriorly.
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.
angulated radial shaft fracture with
incongruity or dislocation of the
DRUJ confirms Galeazzi fracture.
process (type II). Three patients (9%) ever, in rare instances, closed reduc-
Radiographs of the contralateral
had type III fractures, which were tion is not possible due to soft-tissue
wrist should be obtained for compar-
>15 cm from the styloid process. In interposition, and ORIF may be re-
ison.25
this series, the worst results were quired.23
Radiographic evaluation of the
seen in patients with type I (distal)
DRUJ is crucial for accurate diagno-
injuries.
Diagnostic Evaluation sis. On plain radiographs, findings
suggestive of DRUJ injury include
Galeazzi-equivalent Lesion Clinical examination usually reveals fracture of the ulnar styloid base,
swelling, deformity, and tenderness widening of the DRUJ on the AP
The Galeazzi-equivalent lesion is a of the distal forearm. Forearm rota- view, dislocation or subluxation of
variant of the classic Galeazzi frac- tion and wrist motion are painful the radius relative to the ulna on the
ture and is seen in skeletally imma- and limited as a result of disruption true lateral view, shortening of the
ture children and adolescents. It is of the DRUJ and fracture of the ra- radius >5 mm relative to the dis-
characterized by fracture of the ra- dius. Injury to the DRUJ is character- tal ulna, and asymmetry compared
dius with fracture through the distal ized by joint tenderness, and the ul- with the uninjured contralateral
growth plate of the ulna but without nar head may be prominent dorsally DRUJ.3,7,25 Subtle DRUJ injury may
disruption of the DRUJ.20 The distal or palmarly. Depending on the be overlooked. Mikic´ 26 noted that
epiphysis separates, but the ligamen- sever- ity of the injury, there may be in 26 of 125 patients (20%), the
tous restraints of the DRUJ do not re- markable deformation in the DRUJ appeared normal on
rupture, probably because, in chil- forearm with shortening and radiographs de- spite ulnar head
dren, the epiphyseal plate is biome- angulation of the radius.3 subluxation. Axial CT has been
chanically weaker than the ligamen- Neurovascular injury is rare. 24
recommended for diag- nosis of
tous complex that stabilizes the Radiographic assessment is per- DRUJ disruption when as- sessment
DRUJ.22 formed to confirm the diagnosis of of the integrity of the DRUJ is
Typically, Galeazzi-equivalent le- Galeazzi fracture (Figure 5). Separate difficult on plain radiographs;
sions are managed nonsurgically AP and lateral radiographs of the el- however, CT is not routinely per-
with closed reduction and immobili- bow, forearm, and wrist should be formed.8 The use of MRI in the diag-
zation in an above-elbow cast. How- obtained. A displaced, shortened, or nosis of Galeazzi fractures has not
been rigorously studied.7,27
62 Journal of the American Academy of Orthopaedic Surgeons
 Kivanc I. Atesok, MD, et

Figure 6

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

ment are likely the result of the sta- In a study of 26 children with
Management
bility of the reduction. Factors that Galeazzi fracture, Eberl et al2 treated
contribute to this stability include 22 patients with closed reduction
Nonsurgical the presence of thick periosteum, su- and cast immobilization. The au-
Management of Galeazzi injury dif- perior fracture remodeling capacity, thors stated that
fers in children and adults (Figure 6). and the increased ligamentous
In children, the nonsurgical treat- proper reduction of the radius
strength and elasticity of the DRUJ.
ment of choice consists of closed re- with subsequent reduction of
In a review of 41 children with
duction performed under general an- the ulna in the DRUJ and cast
Galeazzi fracture, Walsh et al17 re-
esthesia and fluoroscopic guidance, immobilization provide good
ported that only 2 required ORIF.
followed by immobilization in an to excellent outcomes even if
They recommended closed reduction
above-elbow cast for 4 to 6 weeks; the Galeazzi lesion is primarily
for fracture management. After en-
this option is associated with satis- underdiagnosed. Long-term in-
suring that the DRUJ is reduced, the
factory long-term outcomes.2,3 Fol- stability of the DRUJ after
forearm should be immobilized in
lowing closed reduction of the radius Galeazzi lesions was not ob-
supination in a long-arm cast; how-
fracture, the forearm is immobilized served in our series of pediatric
ever, immobilization in a neutral or
in supination to maintain the reduc- patients.
pronated position can be equally suc-
tion of the DRUJ and allow healing cessful. The authors reported worse In adults, Galeazzi fractures are ex-
of the TFCC.28 Satisfactory outcomes results in more distally located frac- tremely unstable, and the results of
associated with nonsurgical manage- tures. nonsurgical treatment are uniformly

October 2011, Vol 19, No 10 62

 Galeazzi

unsatisfactory.2,26 A high risk of defor-

between these techniques have not of the radius is not the preferred fix-
mation following nonsurgical manage-
been well studied due to the rela- ation method in patients with
ment has been linked to various de- tively small number of cases man- Galeazzi fracture. This approach can
forming forces, including gravity, aged surgically. Nevertheless, plate be technically challenging because it
which acts through the weight of the fixation of the radius may be advis- requires elevation of the brachioradi-
hand and causes fracture able if open reduction is inevitable. alis muscle and extensor tendon as
displacement and subluxation of the Depending on the age of the child well as additional dissection and mo-
DRUJ, as well as the deforming forces and size of the bone, a 3.5- or 2.7- bilization of the radial sensory
associated with the brachioradialis, mm dynamic compression plate nerve.35 Furthermore, ex vivo biome-
pronator quadra- tus, and thumb (DCP) or a one-third tubular plate chanical studies have not demon-
abductors and exten- sors.3,8,21,29 can be used. strated superior outcomes associated
In adults, ORIF is considered the with lateral plating compared with
In a study of 40 adult patients with
standard of care for most patients anterior plating.35
Galeazzi fractures, Reckling29 re-
with Galeazzi fracture.2,3,5,11,21,29,30 Be- Alternative fixation methods, such
ported that none of the 11 patients
cause this fracture requires surgical as percutaneous intramedullary
treated nonsurgically with closed re-
treatment to obtain satisfactory re- Kirschner or Rush pinning, have been
duction and immobilization in a
sults, it is known as the “fracture of reported. However, these stabilization
plaster cast had a good result. Four
necessity.”31 Anatomic reduction and methods are less effective than plate
of these patients had fair results,
stable fixation of the radius fracture fixation in controlling rotation and
and seven had poor results. The
with intraoperative assessment and shortening of the radius.3,26 No studies
authors stated that “all of these
repair of associated soft-tissue dam- have com- pared plate fixation with
patients had restriction of pronation
age in the DRUJ is essential to other fixa- tion methods in patients
and supina- tion due to malunion of
achieve favorable outcomes. with Galeazzi injury.
the radial fracture, and all had some
Plate fixation is the preferred Anatomic reduction and stable fix-
deformity and discomfort in the method of osteosynthesis for radius ation of the radius is essential to
distal radio- ulnar joint.” fracture and is best performed with a achieve a concentric and stable re-
Mikic´ 26 studied 125 patients DCP applied through an anterior ap- duction of the DRUJ. Hence, it is
(14 children, 86 adults) with classic proach.5,15,29,30 Restoration of the ra- critical to assess the DRUJ intraoper-
Galeazzi fractures. In 46 (12 chil- dial bow at the time of open reduc- atively following reduction and fixa-
dren, 34 adults), the authors per- tion is important in reconstituting tion of the radius.30 After anatomic
formed closed reduction with immo- the normal architecture of the fore- reduction has been performed and
bilization in a plaster cast. The arm and the DRUJ.32 Care must be the plate has been applied, AP and
results of nonsurgical treatment were taken to contour the plate accurately true lateral radiographs of the DRUJ
excellent in 75% of children and to restore the normal sagittal bow are obtained. Radiographs must be
poor in 80% of adults. and eliminate subluxation of the obtained without undue force to
DRUJ.33 minimize the possibility of forcing
Surgical Insufficient evidence exists to sup- the DRUJ into a reduced position de-
In children, surgical treatment is in- port the use of locked plates for fixa- spite soft-tissue or bone interposi-
dicated in rare cases in which initial tion of radius fracture in patients tion.5
closed reduction of the radius and with Galeazzi injury. Reports indi- Once the DRUJ has been reduced,
DRUJ is not possible or when ana- cate that compression plates may stability is tested clinically with the
tomic alignment achieved with provide better torsional stability forearm in supination and through-
closed reduction is lost. A variety of than locked plates with unicortical out forearm rotation. The DRUJ is
surgical techniques can be used to screws.34 Decreased torsional stabil- defined as unstable in the setting of
manage pediatric Galeazzi injuries, ity appears to be a potential disad- gross AP translation of the radioul-
including open reduction without in- vantage of locked plating in patients nar joint with displacement of the ul-
ternal fixation; open reduction with with Galeazzi fractures, in whom nar head out of the sigmoid notch.
Kirschner wire (K-wire) fixation, in- torsional forces should be minimized The amount of joint relaxation may
tramedullary nailing or dorsal plate postoperatively. Moreover, bending a vary in patients under anesthesia;
fixation of the radius; and open re- locked plate to preserve the radial thus, the contralateral DRUJ is used
duction with radioulnar transfix- bow may deform the locking system. for comparison.3,5 At this stage, the
ation.2,21,26 Differences in outcome In general, lateral (radial) plating DRUJ can be confirmed as either re-

63 Journal of the American Academy of Orthopaedic Surgeons

 Kivanc I. Atesok, MD, et

ducible and stable, reducible and un-

unstable DRUJs who underwent Figure 7
stable, or irreducible.
temporary pinning of the DRUJ in
No further surgical intervention is
supination for 4 to 6 weeks follow-
needed when the DRUJ is reduced
ing ORIF of the radius fracture with-
and confirmed as stable. If the DRUJ
out exploration or repair of the
remains unstable, the TFCC can be
TFCC.5,26 No studies demonstrate su-
explored and repaired, and the
DRUJ can be temporarily transfixed perior results with TFCC repair
with K-wires (Figure 7). TFCC injury com- pared with pinning the DRUJ in
in patients with Galeazzi fracture is su- pination alone in patients with
typically repaired through an open unstable Galeazzi injury.
dorsal approach, which allows visu- In rare cases, the DRUJ may be ir-
alization of the TFCC injury and reducible; this is most commonly
open repair via drill holes or suture caused by the interposition of soft
anchor technique.36 TFCC avulsion tissues, in particular the extensor
from the ulnar styloid base in the ab- carpi ulnaris tendon.23,31 Entrapment
sence of ulnar styloid fracture is the of fracture fragments avulsed from
typical pathology; however, theoreti- the distal articular surface or from
cally, radial-sided TFCC injury can the fovea of the ulna can prevent re-
occur. Although arthroscopy can be duction of the DRUJ, as well.39,40 In
a useful adjunct for evaluation and these cases, the interposition must be
treatment of acute TFCC injury, its surgically extricated to reduce the
use in Galeazzi fractures has not DRUJ. Further management is deter-
been substantiated.37 mined based on the stability of the
Ideally, the DRUJ is transfixed DRUJ.
with two 1.6-mm K-wires that are
placed transversely proximal to the Postoperative AP radiograph
sigmoid notch with the forearm in Surgical Outcomes demonstrating fixation of the radius
with a dynamic compression plate in a
supination. The K-wires are inserted patient with a Galeazzi fracture. The
Rettig and Raskin5 evaluated 40 pa-
percutaneously from ulnar to radial distal radioulnar joint is transfixed in
tients (average age, 35 years) with supination with two parallel Kirschner
and should protrude somewhat from
Galeazzi fracture. All patients under- wires.
the radial side of the radius to make
went ORIF with a volar DCP. Fol-
retrieval easier if they break. The K-
lowing fixation of the radius frac-
wires are left in place for 4 to 6 weeks
ture, the authors identified persistent open anatomic reduction and
to protect the repaired TFCC and
gross instability of the DRUJ in 13 stable fixation of the fractured
postoperative congruency of the
patients. In 10 of these patients, the radius often completely cor-
DRUJ.3,5 The ulnar styloid contrib-
DRUJ was reduced and stabilized in rects the pathologic condition.
utes vitally to the stability of the
supination using two transversely Instability of the DRUJ can be
DRUJ at the attachment of the
placed percutaneous K-wires. The encountered, however, even af-
TFCC. Therefore, in the patient with
DRUJ was irreducible in the remain- ter rigid stabilization of the
ulnar styloid fracture, ORIF should
ing three patients due to interposi- fracture. After ORIF of the ra-
be performed using a cannulated lag
tion of the TFCC, which was avulsed dial shaft fracture, we recom-
screw, pins, or tension band tech-
from its insertion on the base of the mend evaluating the stability of
nique depending on the size of the
ulnar styloid. These patients under- the DRUJ for all Galeazzi
fragment (Figure 8). If the DRUJ is
went open reduction and repair of fracture-dislocations.5
clinically stable following internal
the TFCC through a dorsal approach
fixation of the ulnar styloid, the fore-
followed by transfixation of the In a study of 36 patients with iso-
arm can be immobilized in supina-
DRUJ with K-wires. At an average lated radial shaft fractures, Ring et
tion without further intervention38
follow-up of 38 months, 38 patients al6 identified 9 patients with Galeazzi
(Figure 9).
(95%) had excellent results and 2 injuries and treated them with ORIF
Satisfactory results have been re-
ported in adults with reducible but (5%) had poor results. The authors using compression plates. In five pa-
stated that tients, temporary pinning or immobi-

October 2011, Vol 19, No 10 63

 Galeazzi

Figure 8 dysfunction at final follow-up

(mean, 43 months).

Postoperative
Immobilization

It is widely accepted that stable re-

duction of Galeazzi fracture in chil-
dren can be best accomplished with
immobilization of the forearm in su-
pination in an above-elbow cast for
Illustration of open reduction and internal fixation of an ulnar styloid fracture using 4 to 6 weeks following nonsurgical
a cannulated lag screw (A), pins (B), and tension band technique (C). In cannulated
screw fixation, the wire is withdrawn following placement of the screw. (Adapted treatment with closed reduction.2,3,17
with permission from Katolik LI, Trumble T: Distal radioulnar joint dysfunction. Some physicians immobilize the fore-
Journal of the American Society for Surgery of the Hand 2005;5[1]:8-29.) arm in supination for type II (prona-
tion) injuries and in pronation for
type I (supination) injuries; others
Figure 9 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 post-
operatively to control forearm rota-
tion and maintain DRUJ reduction.
In adults, postoperative immobiliza-
tion in an above-elbow cast with the
forearm in supination is preferred,
particularly if the DRUJ is unstable
or irreducible following plate fixa-
tion of the radius.5,21,29 This position
decreases the rotational forces
around the DRUJ, allows for healing
A, AP radiograph demonstrating fracture of the radius (red arrow) with disruption of of the ligamentous restraints, mini-
the distal radioulnar joint (DRUJ) (circle) and fracture at the base of the ulnar mizes the risk of breakage or dis-
styloid (white arrow). B, Lateral radiograph demonstrating dorsal dislocation of the
ulnar head with volar displacement of the fractured radial fragment. Postoperative placement of the pins, and protects
AP (C) and lateral (D) radiographs demonstrating volar plate fixation of the radial the repaired TFCC.3,5 The literature
fracture. The DRUJ was stabilized following tension band wiring of the ulnar also includes unusual case reports in
styloid. (Reproduced with permission from Schoonhoven JV, Lanz U: Acute injuries
which DRUJ stability was achieved
of the distal ulna, in Berger RA, Weiss AP, eds: Hand Surgery. Philadelphia, PA,
Lippincott Williams & Wilkins, 2004, pp 297-320.) with immobilization in an above-
elbow cast with the forearm in full
pronation following plate fixation of
radius fracture in adult patients
with type I Galeazzi fracture (ie,
supina- tion injury with anterior
dislocation of the ulna).20 If the
DRUJ is reduced
lization of the DRUJ (4 to 6 weeks) fracture at the base of the ulnar sty- and stable throughout full forearm
was performed to address the DRUJ loid and underwent ORIF. There rotation following plate fixation of
injury. Four patients had a displaced were no signs or symptoms of DRUJ the radius, a protective splint can be
63 Journal of the American Academy of Orthopaedic Surgeons
 Kivanc I. Atesok, MD, et

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, fixation 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

may report persistent pain in the forearm and wrist function; they do
can be permitted.38
DRUJ due to instability, limited fore- not restore normal anatomy. Hence,
arm rotation, and loss of grip some compromise of function and
Complications and strength. With late presentation, it incomplete pain relief often occur.36
Prognosis may be possible to perform an os-
teotomy of the radius with plating
Summary
Complications are similar to those and bone graft to restore length and
associated with the other forearm improve congruency of the DRUJ3 The Galeazzi fracture is an inher-
fractures and include nerve compres- (Figure 10). ently unstable injury involving dis-
sion, tendon entrapment, nonunion, In chronic cases in which DRUJ ruption of the DRUJ and deforming
delayed union, malunion, and infec- congruity is not attainable, salvage muscle forces acting on the distal ra-
tion.3,23,24,41 The most devastating options are indicated.42 Salvage tech- dius. Addressing the DRUJ, which
complication of this fracture type is niques include the Darrach proce- may be irreducible or unstable even
malunion of the radius with chronic dure, hemiresection arthroplasty, the with anatomic reduction and fixa-
subluxation and instability of the Sauve-Kapandji procedure, and im- tion of the radius fracture, is of
DRUJ as a result of misdiagnosis or plant arthroplasty.36,43,44 The goal of particular importance. Appropriate
inappropriate treatment. Patients these procedures is to decrease pain management of this fracture differs
with a malunited Galeazzi fracture and increase range of motion and in children and adults. In children,

October 2011, Vol 19, No 10 63

 Galeazzi

nonsurgical management with closed 5. Rettig ME, Raskin KB: Galeazzi

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63 Journal of the American Academy of Orthopaedic Surgeons