You are in: eMedicine Specialties > Orthopedic Surgery > HAND AND UPPER EXTREMITY Galeazzi FractureArticle Last Updated: Dec 4, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Janos P Ertl, MD, Clinical Assistant Professor, Department of Orthopedic Surgery, University of California at Davis; Director of Amputee Clinic, Chief of Orthopedic Trauma, Kaiser Hospital Janos P Ertl is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Hungarian Medical Association of America, Orthopaedic Trauma Association, and Sierra Sacramento Valley Medical Society Editors: Peter M Murray, MD, Associate Professor of Orthopedic Surgery, Mayo Clinic College of Medicine; Director of Education, Mayo Foundation for Medical Education and Research, Jacksonville; Consultant, Department of Orthopedic Surgery, Mayo Clinic, Jacksonville; Consulting Staff, Nemours Children's Clinic and Wolfson's Children's Hospital; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; Harris Gellman, MD, Consulting Surgeon, Broward Hand Center, Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine Author and Editor Disclosure Synonyms and related keywords: Galeazzi fracture-dislocation, reverse Monteggia fracture, Piedmont fracture, Darrach-Hughston-Milch fracture, fracture of necessity, radial shaft fracture, dislocation of the distal ulna, forearm fracture, broken arm INTRODUCTIONSection 2 of 12
  The Galeazzi fracture-dislocation is an injury pattern involving a radial shaft fracture with associated dislocation of the distal radioulnar joint (DRUJ); the injury disrupts the forearm axis joint. For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education article Broken Arm. History of the ProcedureThe Galeazzi fracture injury pattern was first described 1842, by Cooper, 92 years before Galeazzi reported his results. Ricardo Galeazzi (1866-1952), an Italian surgeon at the Instituto de Rachitici in Milan, was known for his extensive work experience on congenital dislocation of the hip. In 1934, he reported on his experience with 18 fractures with the above-described pattern as a compliment to the Monteggia lesion. Such fractures have since become synonymous with his name. In 1941, Campbell termed the Galeazzi fracture the "fracture of necessity," because it necessitates surgical treatment; in adults, nonsurgical treatment of the injury results in persistent or recurrent dislocations of the distal ulna. Although researchers have been unable to reproduce the mechanism of injury in a laboratory setting, Hughston outlined the definitive management of these fractures in 1957.1 ProblemGaleazzi fractures are isolated fractures of the junction of the distal third and middle third of the radius with associated subluxation or dislocation of the DRUJ. (See also the eMedicine articles Fractures, Forearm and Radius, Distal Fractures.) FrequencyGaleazzi fractures account for 3-7% of all forearm fractures. They are seen most often in males. Although Galeazzi fracture patterns are reportedly uncommon, they are estimated to account for 7% of all forearm fractures in adults. EtiologyThe etiology of the Galeazzi fracture is thought to be a fall that causes an axial load to be placed on a hyperpronated forearm. PathophysiologyThe deforming forces include those of the brachioradialis, pronator quadriceps, and thumb extensors, as well as the weight of the hand. The deforming muscular and soft-tissue injuries that are associated with this fracture cannot be controlled with plaster immobilization. ClinicalPain and soft-tissue swelling are present at the distal-third radial fracture site and at the wrist joint. This injury is confirmed on radiographic evaluation. Forearm trauma may be associated with compartment syndrome. See the eMedicine article Compartment Syndrome, Upper Extremity for further treatment information. Anterior interosseous nerve (AIN) palsy may also be present, but it is often overlooked because there is no sensory component to this finding. A purely motor nerve, the AIN is a division of the median nerve. Injury to the AIN can cause paralysis of the flexor pollicis longus (FPL) and flexor digitorum profundus (FDP) to the index finger, resulting in loss of the pinch mechanism between the thumb and index finger. INDICATIONSSection 3 of 12
Galeazzi fractures are best treated with open reduction of the radius and DRUJ. Closed reduction and cast application have led to unsatisfactory results. The term "fracture of necessity" refers to the fact that the adult Galeazzi fracture is not amenable to treatment by closed means, necessitating surgical stabilization. Open forearm fractures constitute a surgical emergency. Open wounds may require incorporation into the surgical incision. Immediate stabilization of the radial fracture and the DRUJ is recommended. Galeazzi fractures in skeletally immature patients are typically treated with closed reduction and casting because of the enhanced viscoelastic nature of pediatric bone, as well as the presence of a stout periosteal sleeve. RELEVANT ANATOMYSection 4 of 12
CONTRAINDICATIONSSection 5 of 12
The only contraindication to surgical intervention is the existence of life-threatening conditions, which take priority. In these situations, definitive surgical management is deferred until the patient is stabilized. WORKUPSection 6 of 12
Imaging Studies
TREATMENTSection 7 of 12
Surgical TherapyAll adult Galeazzi fractures must be treated with open reduction and internal fixation (ORIF). Anatomic surgical reduction of the radius and the DRUJ provides the best opportunity for healing. Preoperative DetailsAs with any fracture, preoperative planning is necessary. Appropriate radiographs are required, cutout templates are made to simulate reduction, and an implant is chosen. Contralateral extremity radiographs are of benefit as a template. Preoperative planning is as follows:
Intraoperative DetailsIntraoperative details are as follows:
Postoperative detailsPostoperative details are as follows:
Follow-upFollow-up care is as follows:
COMPLICATIONSSection 8 of 12
The overall complication rate in the treatment of Galeazzi fractures approaches 40%. Complications include the following:
Radial nerve injury is reportedly the most common nerve injury to occur during either the volar or dorsal forearm approach to a Galeazzi fracture. The radial sensory nerve is reported to be the most frequently injured branch, with damage occurring in association with the Henry (volar) approach. The PIN, another branch of the radial nerve, also is vulnerable (during the dorsal Thompson approach), especially when there is a failure to identify the PIN at the time of dissection. The occurrence of Tardy ulnar tunnel syndrome has been reported in the closed treatment of a Galeazzi fracture; this resulted from a malunion and the compression of a stretched vascular branch situated over the ulnar head.3 Instability of the DRUJ may occur because of a failure to recognize the injury, a failure to reduce the dislocation intraoperatively, nonanatomic radial reduction, or interposed soft-tissue that blocks reduction. Most often, the ECU is the interposed structure.4 Other soft-tissue structures that have been implicated in the blockage of reduction include the extensor digitorum communis (EDC), the extensor digiti minimi (EDM), the FPL, and the median nerve. It is important to achieve an adequate assessment of the DRUJ preoperatively, intraoperatively, and postoperatively. A CT scan may be necessary to confirm DRUJ reduction. OUTCOME AND PROGNOSISSection 9 of 12
Successful treatment of Galeazzi fractures depends on the reduction of the radius and DRUJ and the restoration of the forearm axis. Hughston outlined the difficulties and complications of nonoperative treatment in 1957.1 An unsatisfactory result—caused by a loss of reduction that, in turn, led to malunion—was identified in 92% of patients (35 of 38) treated with closed reduction and cast immobilization. Reckling and Moore separately reported satisfactory results with compression plating and immobilization in supination.6, 7 FUTURE AND CONTROVERSIESSection 10 of 12
In the future, statically locked intramedullary nailing may prove to be an option for the treatment of Galeazzi fractures, provided that it can neutralize and control the multiple deforming forces associated with these injuries. The indications for intramedullary nailing of forearm fractures have not been clearly defined. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
Article Last Updated: Dec 4, 2007 | |||||||
