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Galeazzi Fracture

  • Theodoros H. TosounidisEmail author
  • Paul J. Harwood
Chapter
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Abstract

Galeazzi fracture or otherwise known as “fracture of necessity” is a fracture of the distal radius with disruption of the distal radioulnar joint (DRUJ). It is called fracture of necessity because in adults its management necessitates the surgical treatment with anatomic reduction and stable fixation of both the radial fracture and the DRUJ. It is well established that nonsurgical management of this highly unstable fracture results in malunions with significant functional deficit and unsatisfactory results. In this chapter reduction and fixation of Galleazzi fracture is discussed.

Anatomical Fracture Location: Radiograph of Fracture Pattern

Galeazzi fracture or otherwise known as “fracture of necessity” is a fracture of the distal radius with disruption of the distal radioulnar joint (DRUJ). It is called fracture of necessity because in adults its management necessitates the surgical treatment with anatomic reduction and stable fixation of both the radial fracture and the DRUJ. It is well established that nonsurgical management of this highly unstable fracture results in malunions with significant functional deficit and unsatisfactory results [1]. The fracture of the radius that involves the distal third of the bone is the result of the axial loading of the forearm in either supination or rotation. A short oblique fracture with apex anterior (volar) [2] (Fig. 22.1a, b) or apex posterior (dorsal) [3] (Fig. 22.2a, b) angulation of the radius occurs, respectively. The torsional mechanism of the injury results to concomitant disruption of the DRUJ and injury to its primary stabiliser (triangular fibrocartilage complex—TFCC) [4].
Fig. 22.1

AP and lateral radiographs demonstrating an apex anterior (a, b) Galeazzi fracture

Fig. 22.2

AP and lateral radiographs demonstrating an apex posterior (a, b) Galeazzi fracture

The above translates into the characteristic radiographic appearance of the Galeazzi fracture, i.e. a short oblique distal third ulnar fracture and a subluxation/dislocation of the DRUJ. Most of the times, the latter is obvious on the anteroposterior and true lateral radiographs of the wrist, but when this is not the case, indirect radiographic signs of DRUJ injury include the fracture of the ulnar styloid and the shortening of the radius more than 5 mm. A contralateral wrist radiograph for comparison is always helpful in equivocal cases [5].

Brief Preoperative Planning

Anatomic reduction and stable fixation are the goals of surgical management of Galeazzi fracture. This mandates for open reduction and internal fixation. Indirect and minimally reduction and fixation techniques yield suboptimal result and should be avoided. Standard open reduction and internal fixation techniques with meticulous soft tissue handling should be employed.

Preoperative planning should take into account the reduction and fixation of the radius as well as the potential reduction and fixation of the DRUJ.

Fixation of radius: 3.5 mm and dynamic compression plates with 3.5 mm cortical screws (Fig. 22.2a). 2.7 mm and 3.5 mm cortical screws.

DRUJ fixation: 1.6 mm k-wires.

Fixation of the ulnar styloid and or TFCC: 1 mm cerclage wires and 1 mm k-wires, cannulated mini fragment screws.

Patient Setup in Theatre

General anaesthesia is preferred over regional due to potential masking of postoperative compartment syndrome when the latter is used.

The patient is positioned supine on a standard table, and the affected arm is placed on a radiolucent hand table. The table is placed in such a way that unobstructed intraoperative imaging can be performed. This usually requires rotation of the table 45° or 90° so that the affected extremity is placed at the centre of the operating theatre. A tourniquet is placed, and the affected extremity is prepped and draped following the administration of intravenous antibiotics. The image intensifier is brought from the top or the side of the patient.

Closed Reduction Manoeuvres

Closed reduction manoeuvres are not used for Galeazzi fractures.

Reduction Instruments

For the radius, reduction tools that can be used are the following: small Hohmann retractors, small periosteal elevators, Howarth elevator, pointed reduction clamps, blunt/serrated bone holding forceps/clamps (small “crocodile” clamps) and articulated tension device.

DRUJ reduction is performed manually.

For the reduction of the ulnar styloid, a pointed reduction clamp or a stay suture (e.g. No 1 Vicryl) is needed.

Surgical Approach

The volar approach to the radius is the workhorse for the surgical treatment of Galeazzi fractures. This can either be a flexor carpi radialis (FCR) sheath or the classic Henry’s approach. The latter is used when the radial fracture is more proximal. For the FCR approach, the volar sheath of the FCR tendon is identified after the skin incision which is centred over the short oblique radial fracture and measures 10–12 cm (Figs. 22.3 and 22.4). Then the FCR tendon is retracted ulnarly (Fig. 22.5). The dorsal (deep) sheath of the investing fascia is identified and incised (Fig. 22.6). The flexor pollicis longus tendon is identified and retracted ulnarly (Fig. 22.7). This manoeuvre protects the median nerve. The fracture of the radius is then visible (Fig. 22.8).
Fig. 22.3

Marking of the incision centred over the radius fracture in line with the FCR

Fig. 22.4

The FCR tendon is identified, and the investing sheath is dissected

Fig. 22.5

The FCR tendon is retracted ulnarly

Fig. 22.6

The dorsal (deep) sheath of the investing fascia is identified and incised

Fig. 22.7

The flexor pollicis longus tendon is identified and retracted ulnarly

Fig. 22.8

Identification of the radius fracture. Note its short oblique configuration

The dorsal and direct radial approaches to the radius are not indicated for the surgical fixation of the Galeazzi fractures. The former has been associated with soft tissue complications (irritation/attrition of tendon with risk of postoperative rupture), whilst the latter is technically more challenging since it requires mobilisation of the brachioradialis tendon and the sensory branch of the radial nerve.

Open Reduction Manoeuvres

The fracture is identified, and it is debrided from soft tissue debris and hematoma. A dental pick is an instrument quite useful for manipulation of fracture fragments whilst minimising the soft tissue damage. The facture can also be manipulated with pointed reduction forceps, and debridement is performed using a small curette (Fig. 22.9). Minimal dissection of the periosteum (especially in areas of infolded periosteum) is performed along the edges of the fracture. The fracture fragments are exposed sufficiently enough without stripping the periosteum and violating the surrounding soft tissue envelope.
Fig. 22.9

The facture is manipulated with pointed reduction forceps, and debridement is performed using a small curette

Open Reduction and Fixation

The fracture fragments are mobilised using small serrated reduction clamps (Fig. 22.10). The fracture is then provisionally stabilised with a pointed or serrated clamp. Galeazzi fractures have usually short oblique configuration, and a Howarth’s elevator or a small Hohmann retractor can be used to lever the fracture with intra-focal manipulation. Combinations of longitudinal traction along with twisting of the fragments represent useful manoeuvres in fracture reduction. The surgeon should keep in mind that the fracture was produced by a torsional moment to the bone, and reversing the mechanism of injury helps reducing the fracture. Pure traction or pure rotation of the fracture fragments is not enough for reduction.
Fig. 22.10

Small serrated clamps are used to manipulate and reduce the fracture fragments

At that stage the fracture is inspected, and the plan for anatomic reduction is confirmed. This means that the preoperative radiographs and the intraoperative fracture configuration are correlated, and the plan for anatomic reduction and fixation either with a lag screw and neutralisation plate or with plate used as a reduction tool is confirmed. When a lag screw is utilised, the correct entry point and the trajectory of the screw are of paramount importance. In order to achieve the above, the three-dimensional configuration of the fracture has to be taken into account. Most of the times, a 3.5 mm lag screw is sufficient, but in short oblique fractures, a 2.7 mm lag screw is sometimes useful in achieving the compression without propagation of the fracture ends (Fig. 22.11a–c). At that stage intraoperative fluoroscopic confirmation is obtained with particular attention paid at the DRUJ. Good quality true AP and lateral wrist views are obtained.
Fig. 22.11

Intraoperative picture (a) and fluoroscopic images (b, c) showing the lag screw fixation of the radius

A neutralisation plate is then applied taking into account the natural bent of the radius which has “two concavities”, one facing volarly and one facing ulnarly (Figs. 22.12, 22.13 and 22.14). Bending the plate on the sagittal plane allows for proper sitting of the plate on the bone. An 8 hole 3.5 mm DCP is usually sufficient to support a short oblique fracture, but occasionally a longer plate is necessary. Three bicortical screws proximally and three screws distally are needed for adequate fixation. In the vast majority of cases, the use of locking plates is neither needed nor advocated. Fluoroscopic confirmation is again obtained.
Fig. 22.12

Picture showing the bent applied to a straight DCP plate in order to accommodate the volar concavity of the radius

Fig. 22.13

Plate holed with clamps in the reduced radius

Fig. 22.14

Lateral (a, c) and AP (b, d) intraoperative pictures and fluoroscopic images showing the lag screw and the neutralisation plate

When lagging of the fracture is not possible due to the configuration of the fragment (transverse, short oblique <30°), then the DCP plate should be applied in compression mode after provisional stabilisation of the fracture. In short oblique fractures, this can be done by initially fixing the plate in one of the bone fragments in such a way that an obtuse angle (axilla) between the plate and the bone can be created. This is followed by re-apposition of the other fragment and eccentrically loading the screws and thus compressing the gap providing absolute stability. In transverse fractures, the plate is fixed to one fragment, and then the other fragment is reduced onto the plate. Maintenance of the reduction using serrated clamps is needed in this situation.

After the fixation of the radius, the DRUJ is checked and classified as reduced/stable, reduced/unstable or irreducible [5] (Fig. 22.15). Reduction and stability are tested both clinically and fluoroscopically. Intraoperative true AP and lateral fluoroscopic views are obtained without excessive forcing the wrist. If undue force is applied, the DRUJ can be potentially reduced even with existing soft tissue interposition. After its reduction, the stability of the DRUJ is tested, and in supination and pronation, instability is defined when gross translation of the ulna in relation to the sigmoid notch is observed.
  • If reduced/stable status is observed, then no further intervention is required.

  • If the DRUJ is in reduced/unstable state, then the TFCC should be explored and repaired. This is performed through a dorsal approach to the DRUJ. The TFCC is usually avulsed from its ulnar attachment and is repaired with anchor and bone sutures through drill holes. In these situations, transfixation of the ulna to the radius is advocated using two 1.6 mm k-wires, which are driven from the ulnar border of the distal ulna to the radial border of the radius. The k-wires should be parallel to each other, should not be placed to the DRUJ (the most distal one should be placed just proximal to DRUJ) and should be left protruding to the medial border of the ulna and the lateral border of the radius (making easier their later retrieval). In the case that the DRUJ is stable only in supination and not in pronation, consideration could be given to the immobilisation of the arm initially in long arm cast and later in a brace for 4–6 weeks without application of transfixation k-wires. If there is an ulnar styloid fracture, this is reduced and fixed with cannulated screws or more commonly with k-wires using a tension band technique.

  • If the DRUJ is irreducible, then exploration of the joint is required. Commonly the reduction is prohibited by the interposition of the extensor carpi ulnaris tendon or small fracture fragments. After the reduction via a dorsal approach to the wrist, the joint is again tested for stability, and the aforementioned steps are performed.

Fig. 22.15

Lateral (a) and AP (b) fluoroscopic images showing a reduced DRUJ

Summary of Tips and Tricks-Pitfalls

  • Obtain good quality intraoperative fluoroscopic views.

  • Aim for anatomic reduction of the radius that facilitates anatomic reduction of the DRUJ. This can be achieved either by a lagging screw and neutralisation plate (Fig. 22.16a, b) or by a compression plate (Fig. 22.16c, d).

  • Open reduction necessitates manoeuvring of both fracture fragments.

  • Use small serrated reduction forceps/clamps without causing soft tissue and periosteal stripping.

  • Reduction of the radius is achieved by combination of traction and rotation.

  • Test the reduction and stability of the DRUJ after fixation of the ulna.

  • Irreducible DRUJ necessitates open reduction via a posterior approach

  • Reduced but not stable DRUJ should be managed with fixation of the TFCC and transfixation k-wires. Make k-wires tetracortical to facilitate their retrieval in case they break.

  • Reduced and stable DRUJ does not require any further surgical intervention. Protective splint and early forearm range of motion are advocated.

  • After fixation of the reduced/unstable and irreducible DRUJ conditions, the arm should be immobilised in an above-the-elbow cast with the forearm in supination from 4 to 6 weeks. The transfixation k-wires should be kept in place for the same period of time.

Fig. 22.16

Postoperative radiographs showing the fixation of a Galeazzi fracture with a lag screw and neutralisation plate (a, b) and a DCP applied in a compression mode (c, d)

References

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Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  1. 1.Academic Department of Trauma and Orthopaedic SurgeryUniversity of LeedsLeedsUK

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