galeazzi fracture..23

GALEAZZI FRACTURE PART-2

BY LATHA.VK DHZ…

topic…..

Conservative and surgical management of galeazzi fracture,ComplicationPrognosis

INTRODUCTION The combination of the distal third of the

shaft of the radius and dislocation of the distal radio-ulnar joint was called “the fracture of necessity”

This injury is the counterpart of the MONTEGGIA fracture.

INITIAL EVALUATION,MANAGEMENT, SURGICAL PLANNING

Initial evaluation of the patient & the radiographs is necessary for developing a treatment plan.

A detailed history related to mechanism of injury, hand dominance, occupation, previous injury & associated medical problem is re equipped.

Examine the entire extremities for associated injuries.

INSPECTION: identify the presence of open #.Assess the extent &severity of soft tissue injury.Ecchymosis,fracture blister, edema denotes suspicion of COMPARTMENT SYNDROME.

PALPATION: Tenderness& instability should performed from shoulder to hand. Neurological examination should focused include motor sensory status of radial (post.interosseous,superficial radial), ulnar, median nerves. Vascular examination also focus-palpate pulses.

Radio graph: AP & lateral view of elbow and wrist.

A treatment regimen of closed reduction & cast immobilization has high unsatisfactory.

Open reduction of the radial shaft fracture through anterior approach & internal fixation with 3.5mm AO dynamic compression plate is the treatment of choice in adults.

If this joint is still unstable, it should be temporarily transfixed with kirschner wire with forearm supination. wire is removed after 6wks. Radial shaft # too distal to allow fixation with intra medullary device.

GENERAL SURGICAL TECHNIQUES…

1.General anesthesia can be utilized.The patient is positioned supine & arm is

placed on a radiolucent arm board.2.Surgical incision drawn on the

extremity, and # site is localized.3.Loop magnification may utilized &

control bleeding.

OPEN REDUCTION AND INTERNAL FIXATION(ORIF)

SURGICAL APPROCHES: 1. FLEXOR CARPI RADIALIS APPROACH Surgical incision is located just radial to FCR Tendon. Splits the sheath longitudinally &

FCR tendon is retracted ulnarly. Then Flexor pollicis longus(FPL) is encountered& retracted ulnarly.pronater quadrates is Incised elevated from periosteum & retract

To expose distal third of radius.This exposure Offers the benefit of avoiding direct dissection Of radial artery. which FCR sheath protects.

VOLAR APPROCH OF HENRYMost often use to exposure the radius

surgical incision is just lateral to the FCR tendon.i.e biceps tendon to radial styloid. Pierce the fascia emerges on the superficial surface ofBrachioradialis. deep dissection distally

incising the pronater quadrates &retracted Ulnarly along with FPL .

The distal third of radial shaft is exposed

with retraction of bracioradialis radially &FCR Medially.

Pronater teres has been elevated sharply to expose the middle third of radius.

The Henry approach can be extended to the proximal third of radius if needed. The probe shows the insertion of the bicipital tendon.

DORSOLATERAL APPROACH Described by THOMPSON. It provide

access to the posterior aspect of radius. In experience it is less suited if the

extension to the distal third of radius. In this distal 3rd abductor pollicis longus &

extensor pollicis brevis muscle cross the surgical field.

In proximal 3rd approach is limited by supinator with the enclosed of PIN.

It may be useful in posterior interosseous

Nerve palsy when the nerve to be explored.

If in this case the supinator canal can be split

in order to expose the entire length of the nerve.

INTERNAL FIXATION WITH PLATING….

Internal fixation with plates allows excellent control of fracture fragments and permits accurate restoration of the anatomy.

The fracture is reduced with the aid of sharp or broad fracture reduction forceps and manual traction.C-arm radiographic visualization can be used to confirm fracture/bone alignment.

3.5mm AO dynamic compression plate(DCP),limitated contact-dynamic compression plate(LC-DCP) are used, which provide more secure fixation.

The concept of limited contact between the plate& bone has development of point contact-fixator(PC-Fix).

The screws of pc-fix have conical heads to fit identically formed fixator holes exactly, therefore giving them angular stability.

The pc-fix &the later locking compression plates(LCP) were designed to be used with unicortical screws.

The plate must be accurately centered over the reduced fracture & must be of sufficient length to permit a minimum of 4, preferable 6 cortices secured by screws on each side of fracture.

Evaluate fracture and DRUJ for realignment &reduction.

Rotate the forearm and assess for any DRUJ instability.

If the DRUJ is stable, specifically evaluate in supination.

We do not advise routine removal of forearm plates. Remove only if they cause symptoms because of their subcutaneous location.

Once a plate has been removed, forearm should protected by splint for 6 wks.

If DRUJ is reducible in supination,stabilize by placing two 0.045 kirschner wires(k-wires) from the ulna into the radius, just proximal to the articular surface.

Bone graft may be applied to grossly comminuted #.but routine grafting is not indicated..

Check the reduction with radiographs. Irrigate and close wounds. Apply a long arm splint with the forearm

placed in supination.

POST OPERATIVE DETAILS.. Elevate the upper extremity. Apply ice to the operative site as needed Check neurologic and vascular status.

Specifically, evaluate for function of the AIN and for the presence of COMPARTMENT SYNDROME

Immobilize the forearm in supination for 4 wks with removal of any percutaneous pins at 4th wk

Immediately after surgery, institute occupational therapy for digital& shoulder range of motion.

FOLLOW-UP….

AFTER SURGERY: 7&14th day-wound examined 10-14th day-remove suture 4th wk-obtain radiograph to

recheck Alignment & remove pins if present. 6wk-physical therapy. Reexamine radiographs.

COMPLICATION Over all complication rate in treatment of

galeazzi # approaches 40%.complication include following:

1.nonunion 2.malunion Are primarily associated with inadequate

plate fixation.

3.infection 4.compartment syndrome-major complication. there are 3 compartment 1.flexor,2.extensor,3.mobile wad(brachio Radialis& extensor carpi radialis longus andBrevis).SIGN: increased pain , which can be tested passively stretching the fingers.PATHOLOGY: hypoxia followed by swelling which reduce the perfusion pressure at the capillary level, leading to ischemic muscle and myonecrosis.another way direct muscleDamage-increased intra compartmental pressure

TREATMENT-FASIOTOMY….

5. Re- fracture following plate removal 6.PIN injury 7.instabilty of the DRUJPROGNOSIS: It influence of the timing of surgery,

due to delayed diagnosis in relation to the time Of injury,# associated with complication-

WORST OUTCOME…The proper reduction of radius with concomitant reduction of DRUJ-EXCELLENT

OUTCOME…

REFERENCES…

THANK YOU…