GALEAZZI FRACTURE DISLOCATION DR . P . NAGENDRA

P.G M.S. ORTHO GANDHI HOSPITAL , SECUNDERABAD

INTRODUCTION & HISTORY - Combination of radial shaft # and

dislocation of DRUJ – ist time by sir astley cooper in 1852

- 110 yrs later richardo galeazzi of italy – potentially unstable & loss of reduction occurs in plaster.

- Described his own method of reduction – traction of the thumb in line with radius , forearm in supination & then radial deviation of hand to reduce DRUJ sublaxtion or dislocation

Jack hughston in 1956 during meeting of american academy of orthopaedic surgeons – stunned everyone when he recorded 92% failure in closed reduction

Campbell – need for OR & rigid IF - FRACTURE OF NECESSITY - STEWART – associate of campbell –

fixation should be rigid in the form of plate than nailing , bone graft - esp in comminuted # radius , intraoperative assessment of DRUJ , discouraged excision of lower end of ulna

DEFINITION fractures of shaft of radius

anywhere between radial tuberosity & a point 2 – 4 cms proximal to the wrist, associated with subluxation or dislocation of distal end of ulna

- CLASSIFICATION : two types - Type 1 : # in distal 1/3 rd within in

7.5 cms from distal articular surface

- Type 2 : middle 1/3 rd of radius > 7.5 cms from distal articular surface

-- depending on fracture pattern - type 1 : # running distally & radially

from above downwards , 75% cases , highly unstable .

- type 2 : # running distally & medially from above downwards , 25 % cases , relatively stable

STATISTICS - 30 – 50 % galeazzi # are associated

with multiple injuries - Incidence – 7 % of skeletal injury to

forearm - More common in middle aged - Rarely below < 10 yrs & > 80 yrs - 70 % cases – high velocity injuries - Males four times prone to females - 10 – 20 % - open - 60 % : transverse , 30 % short oblique ,

10 % comminuted

MECHANISM OF INJURY axial loading and hyperpronation of

wrist during fall on a outstretched hand - Fracture generally occurs at ht. of

maximal radial bowing , once fracture occurs, associated hyperpronation causes disruption of DRUJ , if force continues ulna breaks

- Direct injury to radius – very uncommon

- # made more unstable by 5 factors - Pronator quadratus , - Outporing muscles of thumb : Abductor

pollicis longus & ext. pollicis brevis - Brachioradialis - Wt. of hand - Interosseous membrane - DISPLACEMENTS - In majority –RADIUS : medial , volar &

proximal - Dorsal & radial – rare - Ulna – distal & dorsal very rarely – volar

20 % of DRUJ subluxation – occult in nature Hence all single bone fracture radius are

considered as galeazzi , unless proved otherwise

Fortunately most subluxation /dislocations are simple ( reduced spontaneously after radial fixation )

Sometimes – irreducible / recurrent MOST OFTEN - EXT CARPI ULNARIS

tendon is trapped # and dislocation : complimentary greater the fracture displacement , more

severe is dislocation

Radial shortening if > 5mm – always associated with tear of TFCC

If > 10 mm – generally associated with tear of interosseous membrane also

GALEAZZI EQUIVALENT LESIONS can occur in children & elderly IN CHILDREN : radial # 6 – 8 cms proximal to

wrist associated with distal ulnar epiphyseal injury

epiphyseal plate weaker than TFCC, hence no subluxation / dislocation

better prognosis , emenable for conservative treatment

IN ELDERLY radial shaft # 6 – 8 cms proximal to wrist

associated with ulnar fracture 2 cm proximal to wrist

weaker osteoporotic ulna than TFCC Ulnar # always caused after disruption of

DRUJ difficult to treat poor prognosis unless DRUJ is properly

reduced after fixation of both radius & ulna

DIAGNOSIS radius fractures between insertion of

pronator teres & pronator quadratus usually at jn. of middle 1/3rd & lower 1/3rd Good quality x- ray needed - concave deformity of radius - radial shortening - dorsal prominence of ulnar head - postero-lateral angulation

Features s/o injury to DRUJ - # styloid process of ulna - widening of lower end of radius and ulna in

AP view – meaning diastasis - dorsal displacement of distal ulna - shortening of radius > 5 mm relaitive to

distal ulna ASSOCIATED INJURIES - carpal injuries - metacarpal injuries - # both bones of forearm doesn’t rule out

galeazzi # because 20 % may be associated with ulnar #

Assessment of DRUJ integrity is often difficult using plain radiography alone

BILATERAL AXIAL FOREARM C.T SCAN is imaging of choice

TREATMENT : CONSERVATIVE : only in children with galeazzi classic or equivalent forearm is immobilised in above elbow cast

with SUPINATION for 4 – 6 wks - cast may be extended distally as thumb

spica – enhances immobilisation - Volar ulnar head – in PRONATION

CONSERVATIVE – in very old osteoporotic bone of galeazzi equivalent lesion

SURGICAL timing : as early as possible ( most

complications are related to timing of surgery )

- A.O 3.5 mm plate – implant of choice - 6 – 7 holed - preferred - primary bone graft – generally not needed ( probably indicated in comminuted fracture ) - Radial fracture : approached anteriorly /

posteriorly

ANTERIOR APPROACH - advantages : easier & familiar esp for distal radius better soft tissue coverage over implant useful when DRUJ needs exploration

through separate dorsoulnar incision - disadvantages : iatrogenic injury to superficial br. of radial

N. lower ¼ plate has to be accurately bent may restrict movement of wrist more then

posterior approach

POSTERIOR APPROACH - advantages : it is the tension side , hence ideal helps surgeon to identify & isolate PIN in

proximal third fractures - Disadvantages : doesn’t provide good soft tissue coverage

to distal ½ of radius difficult to explore DRUJ can precipitate chronic tenosynovitis

HENCE VOLAR APPROACH FOR DISTAL RADIUS & DORSAL APPROACH FOR PROXIMAL RADIUS

- Once radius fixed rigidly - DRUJ is assessed both clinically & radiologically

- Rotate forearm and assess DRUJ instability ( esp in supination )

- Reducible & stable – splint in supination * 4 wks - Reducible & unstable – two K wires ( in

supination ) ulna to radius , just proximal to articular surface

- Irreducible & recurrent – open reduction ( dorsal approach ) remove interposing soft tissue & stabilise as above

EXTENSOR CARPI ULNARIS – mc interposing soft tissue

Dorsal DRUJ disruption – needs supination Volar DRUJ disruption - needs pronation If K wire used to transfix – immobilise by

cast than slab to prevent K wire breakage in situ

Primary excision of ulnar head – not advised

If TFCC torn – repaired or reconstructed Primary stabilisers of DRUJ : TFCC Secondary stabilisers : pronator quadratus

& interosseous membrane

TFCC ( TRIANGULAR FIBRO-CARTILAGENOUS COMPLEX )

- functions : share the load to about 20 – 30 %

produced by axial compression stability of DRUJ distal connection suspends ulnar side of

carpus with ulna – needed for adequate grip

Parts of TFCC - articular disc also called TFCC proper - volar & dorsal radioulnar ligament - ulno carpal ligament - thick firous sheath to ext. carpi ulnaris - ulnar collateral ligament

COMPLICATIONS Loss of grip strength Loss of range of motion Dalayed or nonunion Nerve injuries – ulnar N . - superficial br. Of radial N.

( IATROGENIC ) -- extensor tenosynovitis due to dorsal plate -- reflex sympathetic dystrophy – rare

Essex – lopresti injury rare complex injury of forearm – described

as radio - ulnar dissociation . fall on outstretched hand , fracture of head

of radius and disruption of both the interosseous membrane and DRUJ leading to proximal migration of radius

often missed , because of attention directed to radial head fracture

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