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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
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 .
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.
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.
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
Open Reduction and Fixation
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.
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.
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.