Michael R. Boland
DEFINITION
In 1934 Galeazzi7 described a fracture of the junction of the middle and distal thirds of the radius and called attention to the associated dislocation or subluxation of the distal radioulnar joint (DRUJ).
Garcia-Elias and Dobyns8 divided DRUJ dislocations into three types:
Type I: Pure soft tissue dislocations
Type II: Intra-articular fracture dislocations where there is a fracture involving the joint surface of the sigmoid notch of the radius
Type III: Extra-articular DRUJ fracture dislocations for subdivided
Type III fracture-dislocations can be subdivided as follows:
IIIa: abnormal joint surface orientation; usually involve fractures of the distal two thirds of the radius without complete longitudinal disruption of the forearm
IIIb: radioulnar length discrepancy; fractures of the distal two thirds of the radius with complete longitudinal disruption of the forearm; also known as Essex-Lopresti injuries
In this chapter, the term Galeazzi fracture-dislocation refers to a type IIIa (extra-articular) fracture of the distal two thirds of the radius with any disruption at all of the congruency of the DRUJ due to soft tissue injury.
Management of the fractured radius is discussed elsewhere (see HA-8 to HA-13). A fracture of the ulna styloid commonly is associated with a distal radius fracture. Reduction and fixation of this fracture is covered in Chapter HA-14.
ANATOMY
During forearm rotation a complex interaction occurs between the radius and the ulna.
From about 50 degrees pronation to 50 degrees supination there is a nearly pure rotation of the radius around the ulna, with the center of rotation through the middle of the ulna head. The ulna moves out of the way of the radius by virtue of a 9-degree varus–valgus motion that occurs at the elbow.
At 50 degrees supination or pronation, a translational slide of the radius occurs on the ulna at the DRUJ.
In full pronation the radius slides volar, making the ulna head prominent dorsally. The opposite takes place in full supination.
The head of the ulna is the keystone of the DRUJ. It is flattened distally adjacent to the triangular fibrocartilage disc and rounded radially articulating with the sigmoid notch of the radius. The sigmoid notch of the radius is only mildly concave but is functionally deepened by a horseshoe-shaped labrum. A flimsy, somewhat loose capsule attached to this labrum allows the nearly 180 degrees of rotation required of the forearm.
The capsule is relevant only when it is thickened, causing a contracture and limitation in forearm motion.12
Considerable incongruity exists between the curvature of the ulna head and sigmoid notch, which, along with the weak capsule, results in an inherently lax joint.
The triangular fibrocartilage is a specialized structure, part meniscus (to allow compression accommodating the relative shortening of the radius in pronation) and part ligament. It has palmar and dorsal fibrous thickenings known as the palmar and dorsal radioulnar ligaments. These attach to the distal palmar and dorsal rims of the sigmoid notch as separate bundles, and have superficial fibers that attach to the ulna styloid and deep fibers that criss-cross to form a weave as they attach to the foveal fossa of the distal ulna adjacent to the head. These ligaments, along with the distal aspect of the interosseous membrane, are the most important primary stabilizers of the DRUJ.
During rotation, the deep interdigitating fibers create a screw home mechanism, similar to the cruciate ligaments of the knee.
In pronation the deep fibers of the dorsal radioulnar ligament are taut and the superficial fibers are lax, whereas the superficial fibers of the palmar radioulnar ligament are taut and the deep fibers are lax.10
The opposite is true in supination. Avulsion of the foveal attachment is common in Galeazzi injuries.
PATHOGENESIS
The most common mechanism of injury is an axial load in pronation, associated with wrist hyperextension.
Acute dislocations of the DRUJ also can occur in supination. This usually happens after a fall with a rotating body on an outstretched hand, but also can occur in the workplace when the forearm is twisted by rotating machinery.8
The direction of force is radial to ulnar and proximal to distal, through the radius fracture down the interosseous membrane, and through the DRUJ.
The DRUJ zone of injury includes the capsule, avulsion of the foveal attachment of the palmar and dorsal radioulnar ligament, and tear of the extensor carpi ulnaris (ECU) subsheath.
NATURAL HISTORY
Hughston,9 in 1957, brought attention to the poor outcome of these fracture-dislocations without surgical intervention. The criteria used for a perfect result were very strict, leading to a judgment of poor results in 92% of cases. This injury complex has been termed “the fracture of necessity,” meaning open reduction and internal fixation of the radius is necessary for a good result.22
Mikic15 drew attention to the significance of the DRUJ injury. He advocated reduction and percutaneous K-wire fixation, noting poor results otherwise.
Experiments have shown that with an artificial osteotomy of the radius, up to 5 mm of radial shortening occurs.18 Shortening of more than 10 mm does not occur unless both the interosseous ligament and the triangular ligament are sectioned.
Alexander and Lichtman2 added another subcategory of Galeazzi injury, those in which closed reduction cannot be achieved. The natural history of injuries in this subcategory depends on the recognition and appropriate management of neurologic and vascular complications, in addition to the adequacy of reduction and the degree of DRUJ instability.
The DRUJ component of Galeazzi fracture dislocations, after anatomic reduction and fixation of the radius, can be considered simple (ie, able to be reduced closed) or complex (ie, requiring open reduction).19 Once reduced, the DRUJ is reexamined and judged stable or unstable.
PATIENT HISTORY AND PHYSICAL FINDINGS
Lister13 stated “nothing influences the eventual recovery of hand function more than the mechanism and the force of the injury.” This is certainly true for forearm injuries.
Accurate anatomic bone anatomy is required for perfect functioning of the forearm during rotation.
Patients with a Galeazzi fracture-dislocation usually present acutely to an emergency department due to the severity of the pain.
Three common mechanisms lead to Galeazzi injuries: falls, industrial accidents, and motor vehicle trauma.
It is important to elicit information regarding the degree of energy associated with the injury. A fall off a ladder from a height or from a roof is associated with much greater energy than a ground-level fall.
In industrial accidents, the worker will tend to use technical jargon in referring to machinery, but the examiner must obtain a layman's description of the machinery and get an accurate idea of the force the machinery will generate.
Any motor vehicle accident is associated with high energy.
Any crushing component to the injury must be elicited.
Initially, the fracture pain may overwhelm both the patient and the examiner. Reassessment of the patient following a radiograph showing a radius fracture in the presence of an intact ulna should direct the examiner to the DRUJ as a site of pathology.
The patient must be asked about neurologic symptoms in the hand, in particular numbness and tingling in the median nerve distribution.
Acute carpal tunnel syndrome and forearm and hand compartment syndromes must be ruled out in the Emergency Department.
Forearm swelling and tenderness with dorsal prominence of the distal ulna (ie, caput ulna deformity) will be observed.
The entire carpus and the elbow should be palpated to rule out any longitudinal forearm injury (ie, Essex Lopresti injury).
Forearm, wrist, and digital motion often are extremely limited due to pain.
FIG 1 • Intraoperative distal radioulnar joint (DRUJ) shuck test. The head of the ulna is held with a chuck pinch grip, and the wrist and distal radius are held with a span grasp with the thumb extended across the wrist joint. The radius is held firmly and the ulna is moved back and forth in a palmar-dorsal direction. The test is done first in neutral (A), then in supination (B) and in pronation (C).
A sensory examination using static two-point testing is the most reliable Emergency Department examination for sensation. Vascularity is best assessed by examination of radial and ulnar pulses together with capillary refill in the fingers.
Often the fingers are pale in this situation. A needle stick to the digital pulp should cause bright red bleeding.
The fingers must be passively extended to rule out a forearm compartment syndrome. Inability to extend the fingers combined with tense forearm swelling are the best indicators of a compartment syndrome, which if present, necessitates urgent surgery.
Patients presenting late, in the office, usually complain of ulnar-sided wrist pain, pain with activities requiring pronosupination, and DRUJ instability. In these situations the radius often is malunited or there is unrecognized bowing of the ulna.
The DRUJ is examined initially by direct observation, looking for a caput ulna deformity. Palpation begins at the radial head, along the interosseous membrane to the ulnar head. Tenderness at the DRUJ proper is elicited by palpating the head of the ulna with the examiner's thumb and sliding the thumb off the head in a radial direction. Tenderness just distal to the head dorsally is associated with a dorsal tear of the triangular fibrocartilage complex (TFCC). A volar tear of the TFCC is tender on palpation of the ulnar head between the FCU and ECU and when the examiner slides his or her thumb distally over the head.
DRUJ laxity is assessed with the elbow flexed 90 degrees. A shuck test is done on the DRUJ at neutral, full pronation, and full supination (FIG 1), and then compared with the uninjured wrist.
At full rotation, there should be no motion of the radius relative to the ulna. At neutral, the DRUJ ligaments are loose and there is about 1 cm of shuck (Table 1).
IMAGING AND OTHER DIAGNOSTIC STUDIES
Imaging of the patient with a suspected Galeazzi injury consists of plain radiographs of the elbow, forearm, and wrist.
The forearm views help in preoperative planning for fixation of the radius fracture.
The wrist views help to determine the degree of disruption to the DRUJ. On a posteroanterior (PA) view of the wrist, the degree of ulna shortening has been shown to differ depending on which structures are torn at the DRUJ.18Less than 5 mm of positive variance of the ulna indicates that TFCC disruption is unlikely; more than 1 cm indicates interosseous membrane disruption.
Mino et al16 described a technique for interpreting the lateral wrist radiograph whereby the radial styloid is aligned with the center of the lunate and an assessment of the overlap of the radius and ulna is made. The head of the ulna should be completely obscured by the radius. If only part of the ulna head is obscured by the radius, then there is subluxation of the head, and if the ulnar head is clearly seen, then the joint is dislocated. In the operating room a C-arm image in neutral forearm rotation is obtained with the radial styloid in the mid-lunate position to interpret DRUJ subluxation.
A CT scan is very useful in measuring the degree of subluxation or dislocation of the DRUJ. A CT scan in the acute situation can be useful in interpreting the degree of DRUJ congruity, but the test is more often performed in the setting of a chronic injury.
This is most reliably interpreted by the radioulnar ratio (FIG 2), calculated as follows:
The center of the ulnar head is found using concentric circles.
A line similar to that used in the epicenter method is drawn from the dorsal and volar margins of the sigmoid notch (line A-B).
A line perpendicular to this line is drawn to the center of the ulnar head (line C).
The AD:AB ratio is the radioulnar ratio. The normal ratios are 0.5 to 0.71 for pronation, 0.42 to 0.58 for neutral, and 0.19 to 0.55 for supination.
FIG 2 • Radioulnar ratio method to measure DRUJ subluxation on a CT scan. See text for details. (Adapted from Lo IK, MacDermid JC, Bennett JD, et al. The radioulnar ratio: A new method of quantifying distal radioulnar joint subluxation. J Hand Surg Am 2001;26:236–243.)
MRI shows foveal avulsion injuries well and is useful for the assessment of the TFCC.
DIFFERENTIAL DIAGNOSIS
The differential diagnosis of ulnar wrist pain in the presence of a radius fracture includes:
Fracture of the ulna: shaft, metaphysis, head, styloid
Triangular fibrocartilage complex injury. Any of the following structures may be injured: fibrocartilage disc, palmar and dorsal radioulnar ligaments, ulnotriquetral ligament, ulnolunate ligament, ECU subsheath.
Lunotriquetral ligament: isolated and as part of either a perilunate dislocation or a longitudinal wrist
Carpal fractures: triquetrum, hamate, lunate
Essex-Lopresti injury
Monteggia fracture-dislocation
Elbow fracture-dislocation
Stress and pathologic fractures of the radius
NONOPERATIVE MANAGEMENT
The only time the radius is not internally fixed is when other patient factors make such surgery unsafe.
In the Emergency Department, the longitudinal injury to the forearm should be reduced and held in a splint.
The reduction maneuver is performed under conscious sedation with the thumb and index fingers placed in finger traps and 10 pounds of traction applied.
A sugartong or long-arm splint with an interosseous mold is applied.
Radiographs must be obtained to confirm reduction.
If the DRUJ is reduced, then surgery can be delayed for up to 2 weeks. If the DRUJ remains dislocated, surgery should be performed within 72 hours.
This interval allows an MRI or CT scan to be ordered and interpreted to plan for the operative procedure.
Options for nonoperative management of the DRUJ after fixation of the radius are discussed later in this chapter.
SURGICAL MANAGEMENT
The key to the management of a Galeazzi fracture is determination of the degree of injury to the DRUJ. It can be classified as stable, unstable but reducible, or unstable and irreducible.
The following information is considered in deciding whether the DRUJ is unstable:
If, on the initial pre-reduction PA radiograph, the ulna variance is more than 5 mm positive
If frank dislocation remains after evaluation of the postreduction lateral radiograph using the Mino technique (discussed under Imaging And Other Diagnostic Studies)
A foveal avulsion of the TFCC is noted on the preoperative MRI scan.
Intraoperative fluoroscopic examination of the DRUJ after fracture fixation
Intra-operative C-arm assessment includes PA and lateral views in neutral rotation. In most cases the DRUJ should be reduced following fixation.
If increased ulna variance, joint diastasis, or subluxation of the ulna head is seen, the first possibility to consider is a malreduction of the radius fracture.
Most importantly, instability is determined by intraoperative physical examination after fracture fixation.
Grade I: less than 0.5 cm motion at extremes, with a firm endpoint. Probable intrasubstance tearing of either the proximal radioulnar ligament or the DRUL. Management is in a cast in neutral rotation.
Grade II: more than 0.5 cm motion at extremes, with a soft endpoint but no dislocation. This injury usually is associated with foveal avulsion of the TFCC, which can be confirmed by arthroscopy of the DRUJ and repaired. The distal interosseous membrane is not ruptured. Cast in midsupination.3
Grade III: reduced joint prior to stress with dislocation of the DRUJ at extremes. Requires rupture of the distal aspect of the interosseous membrane. Repair the foveal avulsion as in grade II and pin the DRUJ in mid-supination.
Grade IV: dislocated joint. “Mushy” feeling with stressing joint. This joint may be reducible with rotation; consider malposition of radius fragments if easily dislocatable. If truly mushy throughout forearm rotation, then there is interposition of soft tissue, and open treatment is required.
Positioning
The patient is positioned supine on the operating table with a hand table, and the affected extremity is abducted at the shoulder and extended across the table.
The hand table is positioned so that it adjoins the main table at the level of the shoulder. When the extremity is abducted 90 degrees, it lies in the mid portion of the table.
A tourniquet is applied at the mid-humerus level, and a layer of towels is placed between the humerus and the arm. A layer of padding is placed on the upper arm just proximal to the elbow, and the arm is taped firmly to the hand table. This allows traction to be applied along the axis of the forearm for arthroscopy.
Following fixation of the radius, finger traps are applied to the long and index fingers, and 10 to 12 lb of traction is applied.
Approach
The DRUJ can be approached using arthroscopy,28 a miniopen technique,6 or an open dorsal approach.22
TECHNIQUES
ARTHROSCOPICALLY ASSISTED REPAIR OF FOVEAL TFCC AVULSIONS
Arthroscopy of the Distal Radioulnar Joint
A 1.9-mm scope and 2.0-mm shaver are the working instruments for DRUJ arthroscopy.
Two principal portals are used.
The dorsal-proximal DRUJ (PDRUJ) portal is located in the axilla of the joint, just proximal to the sigmoid notch of the radius and the flare of the metaphysis of the ulna. It is easily palpated with the wrist supinated, which relaxes the dorsal capsule and facilitates introduction of the trocar and scope sheath.
The joint is insufflated with about 3 mL of saline (which helps as a direction guide), the skin is incised with a no. 15 blade, and a hemostat pierces the deep fascia and capsule, followed by scope sheath insertion.
After initial joint penetration, the scope is withdrawn slightly until the sigmoid notch and neck of the ulna are brought into view.
Systematically, the steps of a diagnostic arthroscopy are as follows
Evaluate the sigmoid notch while in supination.
Look down into the axilla of the joint (loose bodies sometimes hide here).
The scope is then swept distally over the head of the ulna and pushed anteriorly between the disc of the TFCC and the seat of the head while relaxing the rotation of the forearm to neutral.
Rotate into pronation and visualize the anterior compartment of the DRUJ.
Then slightly withdraw the scope and visualize the foveal region.
The distal DRUJ (DDRUJ) portal is located just distal to the seat of the ulna between the fifth and sixth dorsal compartments. It is about 5 mm proximal to the 6R portal.
The DDRUJ portal allows entry of the scope between the disc of the TFCC and the head of the ulna.
A 21-gauge hypodermic needle is inserted as a direction finder with the scope in the PDRUJ portal.
A probe can be inserted to stress the undersurface of the TFCC disc and ligament insertion into the fovea.
A shaver and other instruments also can be introduced through the DDRUJ portal.
Repair of Foveal TFCC Avulsion
Diagnostic arthroscopy of the radiocarpal joint may reveal a peripheral tear in the TFCC.
Mid-carpal arthroscopy is performed primarily to evaluate the integrity of the lunotriquetral ligament.
DRUJ arthroscopy shows the status of the proximal surface of the TFCC and confirms a foveal tear of the TFCC (TECH FIG 1A).
A shaver is introduced through the DDRUJ portal to débride this area (TECH FIG 1B), and the mini C-arm is brought in to confirm position over the fovea.
A curette is used to freshen the ulna at the foveal insertion.
Using a C-arm and arthroscopic guidance, a 1.8-mm drill hole is made (TECH FIG 1C–E).
The DDRUJ portal is then enlarged to about 1 cm in size with the drill bit in place (TECH FIG 1F).
The deep fascia and capsule are opened in line with the incision. A Mitek Mini QuickAnchor (Mitek Products, Norwood, MA) is inserted into the drill hole (TECH FIG 1G).
Each suture end is placed through the TFCC, and the needle is brought out the 6R window made in the radiocarpal capsule.
The suture is then tied, pulling the TFCC back to its anatomic position.
A DRUJ shuck test is performed to ensure restoration of stability, the wounds are closed, and a long-arm splint is added in mid-supination.
TECH FIG 1 • Diagnostic arthroscopy and distal radioulnar joint (DRUJ) arthroscope-assisted repair of the triangular fibrocartilage complex (TFCC). A. Foveal avulsion tear. B. Hand placement and portal position using 1.9-mm scope and 2.0-mm shaver. C. Hand placement for drilling before Mitek anchor insertion. D. Position of the mini–C-arm, which is brought in to confirm placement of the drill bit in the fovea for insertion of the Mitek anchor. E. C-arm image confirming placement of the drill bit at the foveal insertion of the TFCC. F. The distal DRUJ portal is opened to about 1 cm, and dissection is carried down through the deep fascia in line with the incision. Care is taken to avoid the dorsal branch of the ulnar nerve. G. C-arm image confirming placement of the Mitek anchor.
ARTHROSCOPICALLY ASSISTED REPAIR OF FOVEAL TFCC AVULSION WITH RADIOCARPAL ARTHROSCOPY AND OPEN TECHNIQUES
Mini-Open Approach
In the mini-open approach, a diagnostic arthroscopy of the radiocarpal joint is carried out.
The 6R portal should be made in a longitudinal orientation. This is a guide for creation of a longitudinal 2to 3-cm incision incorporating the 6R portal.
The incision usually is about 5 mm distal to the 6R portal and 2 cm proximal.
The dorsal branch of the ulnar nerve is found in the soft tissues at the distal end of the incision and is preserved.
The deep fascia is incised in line with the incision.
A 21-gauge needle is inserted through the capsule of the DRUJ into the interval between the head and the proximal edge of the TFCC.
The joint capsule is incised from just proximal to the TFCC disc to the metaphysis of the ulna.
A 21-gauge needle is then inserted just distal to the TFCC disc into the radiocarpal joint.
The radiocarpal joint capsule is incised transversely about 6 or 7 mm (not quite to the lunate).
The 6R portal also can be enlarged to see the distal aspect of the TFCC disc. This gives the surgeon good visualization of both surfaces of the TFCC disc and associated ligaments.
Repair of Foveal TFCC Avulsion
The avulsed TFCC is identified and débrided.
The ulnar fovea is roughened with a curette and drilled with a 1.8-mm bit, after which a single Mitek Mini QuickAnchor (Mitek Products, Norwood, MA) is inserted into the drill hole.
The torn ulnar border of the TFCC is then advanced and sutured down to the ulnar fovea (TECH FIG 2). The suture on the Mitek Quick Anchor is double ended. Each needle is passed from a proximal to distal direction about 5 mm apart, and then the needles are cut off and the sutures tied within the radiocarpal joint. I use a onehanded suture-tying technique. No additional suturing is necessary.
The capsule, retinaculum, and skin are closed, and a sterile dressing and long-arm splint are applied.
TECH FIG 2 • Sotereanos triangular fibrocartilage complex repair. The technique involves a 3-cm incision centered on the distal aspect of the head of the ulna. Small windows are created in the capsule of the DRUJ and the radiocarpal joint, and the foveal tear of the TFCC is identified. C. The TFCC is lifted and the fovea cleared of soft tissue debris. A bone anchor (usually a 2-0 suture mini-Mitek) is placed in the head of the ulna at the fovea. D.The sutures are passed through the TFCC. E. The sutures are tied, repairing the TFCC back to its foveal insertion.
OPEN DRUJ ARTHROTOMY AND TFCC REPAIR 11
Two-Window Exposure of the DRUJ
The forearm is pronated and extended at the elbow.
A dorsal incision is made beginning 3 cm distal to the ulnar styloid.
The incision is carried proximally at 45 degrees to the long axis of the forearm in a radial direction until it reaches the dorsal aspect of the radius at the sigmoid notch.
At this point it is continued proximally, longitudinally down the forearm for about 7 cm (TECH FIG 3A).
The soft tissues are spread, taking care to preserve the dorsal sensory branch of the ulnar nerve, which passes onto the dorsum of the hand about 1 to 2 cm distal to the ulna styloid.
At the level of the deep fascia the soft tissues are swept off the fascia in the region of the ulna head (TECH FIG 3B).
The distal aspect of the antebrachial fascia and the proximal 50% of the extensor retinaculum are incised longitudinally between the EDM and ECU tendons, and an ulnarly based flap is created (TECH FIG 3C).
A 21-gauge needle can be inserted to assess the proximal and distal margins of the TFCC disc.
TECH FIG 3 • Open dorsal DRUJ approach. A. Marker of initial incision. The incision is made 3 cm distal to the ulnar styloid at a 45-degree angle toward the sigmoid notch, then continued parallel to the interosseous interval proximally up the forearm. B. The dissection is taken down to the deep fascia. On the fascia, the fifth compartment is clearly visualized. C. The deep fascia is opened with an L shape along the border of the fifth compartment and the proximal edge of the extensor retinaculum. D. The dorsal capsule of the DRUJ and periosteum of the distal ulna are opened longitudinally from the proximal edge of the TFCC. E. A second window is created ulnar to the ECU tendon from the styloid. The length of this window usually is 2 to 3 cm.
The capsule of the DRUJ is incised proximal to the TFCC disc to the point where it blends with the periosteum over the metaphysis of the ulna (TECH FIG 3D).
The ulnocarpal joint capsule is opened to the lunotriquetrum.
Both capsular incisions are in line with retinaculum– fascial incision.
The TFCC disc and associated ligaments, the DRUJ, and ulnar aspect of the radiocarpal joint can be inspected.
A second, more ulnar window to the distal ulna can be made by sharp dissection to the ulna styloid and carried proximally parallel with the ECU sheath (TECH FIG 3E).
Care is taken to avoid opening the EDM and ECU sheaths.
TFCC Repair
The peripheral foveal avulsion is débrided, and the fovea freshened with a curette.
Two drill holes are made with 0.045-inch K-wires at a 45-degree angle about 1 cm from the articular surface of the head of the ulna, directed from the medial cortex of the ulna and exiting at the ulnar fovea.
The holes are parallel, beginning 1 cm apart, and converge toward the fovea.
A transverse arthrotomy is made in the radiocarpal capsule at the distal edge of the TFCC disc.
Three separate loops of a 3-0 braided nylon suture are passed through one hole, through the peripheral TFCC, and back out the other hole, and tied individually over the medial ulna.
The capsulotomy incisions are closed first, then the retinaculum is closed, and finally the skin is closed.
Two 0.062-inch K-wires are placed through the ulna and into the radius in a neutral position (TECH FIG 4).
The capsule, retinaculum–fascia, and skin are closed in layers.
TECH FIG 4 • Repair of the TFCC. A. Three 3-0 nonabsorbable sutures are placed through the retracted medial TFCC and passed through holes at the medial base of the ulna styloid. B. Before tightly suturing the TFC to the prepared trough, the distal radioulnar relationship is secured by two percutaneous 0.062-inch K-wires placed through the ulna into the radius in neutral position. Care must be exercised to avoid injury to the DRUJ.
OPEN DRUJ ARTHROTOMY AND TFCC RECONSTRUCTION USING A PALMARIS GRAFT 1
Rarely, the TFCC can be completely shredded in a high-energy injury. In this instance the TFCC is excised and reconstructed using a palmaris graft.
POSTOPERATIVE CARE
All of the following protocols assume that rigid and stable fixation of the radius fracture has been obtained.
Stable DRUJ
The patient is placed in a sugar-tong splint for 2 weeks, and is given a Carter block arm pillow for strict elevation and encouragement of finger and thumb motion.
At 2 weeks, the patient returns to the office for suture and splint removal.
The patient is referred to a hand therapist for active, passive, and gentle resisted motion up to 10 lbs resistance.
Motion of all joints from the elbow distally is encouraged.
Further resistance and weight bearing depend on union of the radius.
Usually, union occurs by 6 weeks and restrictions are lifted.
Return to work status depends on the level of repetition and lifting required by the patient's job.
Rehabilitation following bone anchor fixation of a foveal avulsion of the TFCC and full palmaris graft reconstruction
Long-arm splint, elbow at 90 degrees, forearm in midsupination, wrist neutral; fingers not included
At 2 weeks the patient returns to the office for suture removal and the arm is placed in a cast in the same position.
Four weeks later (ie, 6 weeks postoperatively), the cast is removed and active gentle passive motion is begun to all joints from the elbow distally.
At 12 weeks postoperatively, graduated lifting activity is begun, and continues for 6 more weeks.
At week 18 all restrictions are removed.
Open foveal repair and K-wire
At 6 weeks, K-wires are removed.
Begin protocol as for bone anchor fixation.
OUTCOMES
The key to a successful outcome of acute Galeazzi fracturedislocations is accurate reduction and rigid fixation of the radius along with recognition and appropriate repair or reconstruction of the disrupted DRUJ.15 Conservative management seems to be successful only in children.
In a classic article by Mikic,15 conservative management in adults resulted in failure in 80% of cases. The results of operative treatment were much better, and the conclusion was that rigid internal fixation is necessary for the dislocation as well as the fracture.
So-called “isolated” fractures of the radial diaphysis, where there is less than 5 mm of positive ulna variance, are more common than true Galeazzi fractures. Fractures without identifiable radioulnar disruption can be treated without specific treatment of the DRUJ and with immediate mobilization.23 In this situation, patients with anatomic fracture reduction have minimal sequelae and better or equal functional results than patients with imperfect reduction.20
In a series of 50 Galeazzi fracture dislocations treated by early open reduction and internal fixation, Mohan et al17 found, at 1 year, 40 good, 8 fair, and 2 poor results. Their conclusion was that early open reduction and rigid internal fixation re-establishes the normal relation of the fractured fragments and the DRUJ without repair of the ligaments. Thus, in many situations, ligament repair is unnecessary. (However, in Mohan et al's series, 1 in 5 had a less than good result.)
Rettig and Raskin,21 in a more recent series, found that the more distal the fracture the greater the likelihood of DRUJ disruption. In this series, 12 out of 22 fractures within 7.5 cm of the midarticular surface of the distal radius had intraoperative DRUJ instability, whereas only one of 18 more proximally were unstable. Their conclusion was that a high index of suspicion, early recognition, and acute treatment of DRUJ instability will avoid chronic problems in this complex injury.
This high index of suspicion will lead to the recognition that dislocations of the DRUJ associated with fractures of the forearm often are irreducible.5 These have been termed “complex” DRUJ dislocations: dislocations characterized by obvious irreducibility, recurrent subluxation, or “mushy” reduction caused by soft tissue or bone interposition.
With the advent of internal fixation of the radius, most Galeazzi fractures are predictably reduced. It is mandatory that the DRUJ be evaluated and managed according to the degree of instability to the joint. A high index of suspicion means the outcome is associated more with the degree of energy involved in the injury than with any inability on the part of the surgeon to care for the DRUJ appropriately.
COMPLICATIONS
The most common complication of a Galeazzi fracture is malunion of the radius and residual DRUJ instability,9 due to malrotation and residual angulation of the radial shaft.8 In most cases a DRUJ-stabilizing tenodesis cannot restore the joint, and a corrective osteotomy is required.4
A preoperative three-dimensional CT reconstruction of the bones of the entire forearm is very helpful in this situation.
Management of a missed dislocation5 depends on the timing of presentation.
If less than 10 weeks after the injury, open reduction and repair usually is possible.
After 10 weeks, reconstruction with ligament grafting is required.
The incidence of radius nonunion is directly related to the number of screws used: the rate is four times higher for bones plated with four screws compared to those plated with five or more screws.26
Radioulnar synostosis may be seen, particularly in patients with multiple system trauma involving head injury.
Osteomyelitis may develop in open and crush injuries.
Nerve palsies, including the anterior interosseous and ulna nerves, have been associated with Galeazzi fractures,24,25 and acute carpal tunnel syndrome is a common complication, particularly in crush and high-energy injuries.
Compartment syndrome of the forearm also is a known complication.
Osteoarthritis of the DRUJ is a long-term complication and can be managed by arthroscopy, interposition arthroplasty, ulna shortening, ulna head replacement, or total joint arthroplasty, depending on severity of the injury and age of the patient.
Complications in Galeazzi fracture-dislocations can be minimized with attention to detail, in particular accurate anatomic reduction of the radius fracture, thorough assessment and repair of instability of the DRUJ, and appropriate postoperative rehabilitation.
REFERENCES
1. Adams BD, Berger R. An anatomic reconstruction of the distal radioulnar ligaments for posttraumatic distal radioulnar joint instability. J Hand Surg 2002;27:243–251.
2. Alexander AH, Lichtman DM. Irreducible distal radioulnar joint occurring in a Galeazzi fracture—case report. J Hand Surg Am 1981;6: 258–261.
3. Boland MR, Bader J, Pienkowski D. Joint reaction forces at the distal radioulnar joint: A biomechanical model presentation at the ASSH Annual Meeting 2006, Washington, DC.
4. Bowers WH. Instability of the distal radioulnar articulation. Hand Clin 1991;7:311–327.
5. Bruckner JD, Lichtman DM, Alexander AH. Complex dislocations of the distal radioulnar joint. Recognition and management. Clin Orthop Relat Res 1992;275:90–103.
6. Chow KH, Sarris IK, Sotereanos DG. Suture anchor repair of ulnarsided triangular fibrocartilage complex tears. J Hand Surg Br 2003; 28:546–550.
7. Galeazzi R. Uber ein Besonderes Syndrom bei Verltzunger im Bereich der Unteraumknochen. Arch OrthoUnfallchir 1934;35:557–562.
8. Garcia-Elias M, Dobyns J. Dorsal and palmar dislocations of the distal radioulnar joint. In Cooney WP, Linscheid RL, Dobyns JH, eds. The Wrist: Diagnosis and Operative Treatment. St. Louis: Mosby, 1998.
9. Hughston JC. Fracture of the distal radial shaft: Mistakes in management. J Bone Joint Surg Am 1957;39A:249–264.
10. Ishii S, Palmer AK, Werner FW, et al. An anatomic study of the ligamentous structure of the triangular fibrocartilage complex. J Hand Surg Am 1998;23:977–985.
11. Kleinman WB. Repair of chronic peripheral tears/avulsions of the triangular fibrocartilage. In Blair W, ed. Techniques in Hand Surgery. Baltimore: Williams & Wilkins, 1996.
12. Kleinman WB, Graham TJ. The distal radioulnar joint capsule: Clinical anatomy and role in posttraumatic limitation of forearm motion. J Hand Surg Am 1998;23:588–599.
13. Lister G. The Hand: Diagnosis and Indications. Edinburgh: Churchill Livingstone, 993:2.
14. 14. Lo IK, MacDermid JC, Bennett JD, et al. The radioulnar ratio: A new method of quantifying distal radioulnar joint subluxation. J Hand Surg 2001;26:236–243.
15. Mikic ZD. Galeazzi Fracture-Dislocations. J Bone Joint Surg Am 1975;57A:1071–1080.
16. Mino DE, Palmar AK, Levinsohn EM. The role of radiography and computerized tomography in the diagnosis of subluxation and dislocation of the distal radioulnar joint. J Hand Surg Am 1983; 8:23–31.
17. Mohan K, Gupta AK, Sharma J, et al. Internal fixation in 50 cases of Galeazzi fracture. Acta Orthop Scand 1988;59:318–320.
18. Moore TM, Lester DK, Sarmiento A. The stabilizing effect of softtissue constraints in artificial Galeazzi fractures. Clin Orthop Relat Res 1985;194:189–194.
19. Nicolaidis SC, Hildreth DH, Lichtman DM. Acute injuries of the distal radioulnar joint. Hand Clin 2000;16:449–459.
20. Reckling FW. Unstable fracture-dislocations of the forearm (Monteggia and Galeazzi lesions). J Bone Joint Surg Am 1982;64A:857–863.
21. Rettig ME, Raskin KB. Galeazzi fracture-dislocation: A new treatmentoriented classification. J Hand Surg Am 2001;26:228–235.
22. Richards RR, Corley FG. Fractures of the shafts of the radius and ulna. In Rockwood CA, Green DP, Buckholz RW, et al, eds. Rockwood and Green's Fractures in Adults, ed 4. Philadelphia: Lippincott-Raven, 1996.
23. Ring D, Rhim R, Carpenter C, et al. Isolated radial shaft fractures are more common than Galeazzi fractures. J Hand Surg Am 2006; 31:17–21.
24. Saitoh S, Seki H, Murakami N, et al. Tardy ulnar tunnel syndrome caused by Galeazzi fracture-dislocation: neuropathy with a new pathomechanism. J Orthop Trauma 2000;14:66–70.
25. Stahl S, Freiman S, Volpin G. Anterior interosseous nerve palsy associated with Galeazzi fracture. J Pediatr Orthop B 2000;9:45–46.
26. Stern PJ, Drury WJ. Complications of plate fixation of forearm fractures. Clin Orthop Relat Res 1983;175:25–29.
27. Strehle J, Gerber C. Distal radioulnar joint function after Galeazzi fracture-dislocations treated by open reduction and internal plate fixation. Clin Orthop Relat Res 1993;293:240–245.
28. Whipple TL. Arthroscopy of the distal radioulnar joint. Hand Clinics 1994;10:589–592.