Bilateral Galeazzi fracture-dislocations

We present the case of a patient with bilateral Galeazzi fracture-dislocations with an irreducible distal radioulnar joint (DRUJ) on one side. Current treatments, such as anatomic reduction and stable internal fixation of the radius and anatomic and stable reduction of the DRUJ followed by plaster immobilization in supination, have produced results much better than those associated with historical conservative treatments. The most important part of successful treatment is maintaining intraoperative control of reduction quality, DRUJ stability, and, if necessary, open reduction of the DRUJ. Here we describe the surgical technique and present the rare case of a DRUJ being irreducible because of interposition of the extensor carpi ulnaris tendon.     

Bilateral Galeazzi fracture-dislocations: a case report of early rehabilitation

A 24-year-old man had bilateral Galeazzi fracture-dislocations due to a motorcycle accident. The right radius fracture was a simple fracture and was fixed with a limited contact dynamic compression plate. The left radius fracture was a comminuted fracture and was fixed with a long locking compression plate in the bridging plate fashion while maintaining reduction with a temporary external fixator. Postoperative computed tomography under passive rotation of both forearms showed acceptable congruency of the distal radioulnar joints, and early rehabilitation of forearm rotation was started at 2 weeks after the operation. At 13-month follow-up, bone union of both fractures was achieved, and forearm motion was almost restored to normal. Moreover, no subluxation or dislocation of either distal radioulnar joint was observed.     

Ulnar variance as a predictor of persistent instability following Galeazzi fracture-dislocations

Background

We investigated the radiographic parameters that may predict distal radial ulnar joint (DRUJ) instability in surgically treated radial shaft fractures. In our clinical experience, there are no previously reported radiographic parameters that are universally predictive of DRUJ instability following radial shaft fracture.

Materials and methods

Fifty consecutive patients, ages 20–79 years, with unilateral radial shaft fractures and possible associated DRUJ injury were retrospectively identified over a 5-year period. Distance from radial carpal joint (RCJ) to fracture proportional to radial shaft length, ulnar variance, and ulnar styloid fractures were correlated with DRUJ instability after surgical treatment.

Results

Twenty patients had persistent DRUJ incongruence/instability following fracture fixation. As a proportion of radial length, the distance from the RCJ to the fracture line did not significantly differ between those with persistent DRUJ instability and those without (p = 0.34). The average initial ulnar variance was 5.5 mm (range 2–12 mm, SD = 3.2) in patients with DRUJ instability and 3.8 mm (range 0–11 mm, SD = 3.5) in patients without. Only 4/20 patients (20 %) with DRUJ instability had normal ulnar variance (−2 to +2 mm) versus 15/30 (50 %) patients without (p = 0.041).

Conclusion

In the setting of a radial shaft fracture, ulnar variance greater or less than 2 mm was associated with a greater likelihood of DRUJ incongruence/instability following fracture fixation.     

Galeazzi fractures

A series of 27 Galeazzi fractures treated by open reduction and rigid internal fixation have been reviewed. The average followup was 32 months. Twenty-five patients obtained a satisfactory result. One patient developed a pseudarthrosis after a fracture through a screw hole, an unsatisfactory result. A second patient sustained a severe open fracture with considerable soft-tissue damage and this result also rated as unsatisfactory. There were no infections. The authors believe that open reduction and rigid internal fixation of the radial fracture is the treatment of choice for this injury.     

Galeazzi fracture

Galeazzi fracture is a fracture of the radial diaphysis with disruption at the distal radioulnar joint (DRUJ). Typically, the mechanism of injury is forceful axial loading and torsion of the forearm. Diagnosis is established on radiographic evaluation. Underdiagnosis is common because disruption of the ligamentous restraints of the DRUJ may be overlooked. Nonsurgical management with anatomic reduction and immobilization in a long-arm cast has been successful in children. In adults, nonsurgical treatment typically fails because of deforming forces acting on the distal radius and DRUJ. Open reduction and internal fixation is the preferred surgical option. Anatomic reduction and rigid fixation should be followed by intraoperative assessment of the DRUJ. Further intraoperative interventions are based on the reducibility and postreduction stability of the DRUJ. Misdiagnosis or inadequate management of Galeazzi fracture may result in disabling complications, such as DRUJ instability, malunion, limited forearm range of motion, chronic wrist pain, and osteoarthritis.     

Irreducible Galeazzi injury

We present a case of a Galeazzi-type of fracture dislocation with an irreducible distal radioulnar joint. This is illustrated by intraoperative pictures which may assist others who find themselves faced with this injury. Received: 24 February 1997     

Radiocarpal fracture-dislocations

Radiocarpal fracture-dislocations most often are caused by high-energy trauma. These difficult, uncommon injuries involve significant soft-tissue and osseous trauma, requiring meticulous reduction and fixation. The mechanism of injury is generally a severe shear or rotational insult. Anatomically, the dislocation results in disruption of the radiocarpal ligaments and, usually, both the radial and the ulnar styloid. Understanding the anatomy of the radiocarpal joint is central to understanding the osseous and soft-tissue constraints that are disrupted with a radiocarpal dislocation. Diagnosis can be reliably made on physical examination and radiographic evaluation. Radiocarpal fracture-dislocation injuries must be differentiated from Barton fractures. Associated injuries such as open fractures, neurovascular involvement, and distal radioulnar dislocations also must be taken into account. Closed reduction can be obtained relatively easily, but open reduction and internal fixation is typically necessary to ensure accurate anatomic restoration of injured bone and ligaments.     

Monteggia fracture-dislocations

Monteggia fracture-dislocations remain a relatively uncommon injury. Prompt recognition of this injury is imperative. The character of the ulnar fracture is useful in determining optimal treatment. It is imperative to look for associated injuries of the radial head and coronoid, which alter the management and lead to altered outcomes.     

Galeazzi fractures and dislocations

In 1934, fractures of the middle and distal third of the radius associated with instability of the distal radial ulnar joint (DRUJ) were described by Galeazzi. This type of lesion is characterized by its unstable nature and the need for open reduction and internal fixation to achieve a satisfactory functional outcome. A high index of suspicion should be maintained by the surgeon, and a thorough examination for instability of the DRUJ must be conducted. The marked instability of this fracture-dislocation complex is further enhanced by the disruption of the triangular fibrocartilage complex, either with or without ulna styloid fracture. Treatment in adults is surgical, and both bone and soft tissue injuries should be addressed.     

Galeazzi fractures in children

We have reviewed 41 children under 15 years of age with a fracture of the radius and disruption of the inferior radio-ulnar joint. Despite the fact that the joint injury had not at first been recognised in 41% of cases and a variety of treatments had been used, the final results of conservative management were generally good. The more distal the radial fracture, the greater were the problems encountered.     

Open radiocarpal fracture-dislocations

Ten open radiocarpal fracture-dislocations in nine patients were treated by wound debridement, open reduction, and maintenance of reduction by casting supplemented with internal or external fixation. Eight patients had associated fractures or dislocations of the ipsilateral extremity: elbow fracture or dislocation (three patients), shoulder fracture (one patient), fractured humerus (two patients), and phalangeal fractures (three patients). In seven of ten cases the median and/or ulnar nerve was severely contused and required immediate decompression. Six patients were followed at least 15 months. All had mild asymptomatic sensory neurologic deficit, diminished range of motion of the wrist, and wrist pain with activity. The prognosis should be guarded.     

Management of the Galeazzi fracture

Summary Fifty-one adults with Galeazzi fractures were treated by operation and the results compared in cases treated early, late and after inadequate initial treatment. We conclude that in cases treated up to 10 weeks after injury, immobilisation with the forearm in full supination in an above elbow cast helps to maintain stability of the inferior radioulnar joint. The distal end of the ulna should only be excised after 6 months, and if the symptoms warrant it. In patients who were inadequately treated initially, the distal end of the ulna should be excised at the time of the operation on the radius, but a poor result is the inevitable outcome. Union, or nonunion of the ulnar styloid did not affect the end result.

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Résumé Cinquante et un adultes présentant une fracture de Galeazzl ont été traités chirurgicalement, et les résultats comparés entre les blessés opérés tôt, tardivement ou après un traitement initial incorrect. Nous concluons que jusqu'à dix semaines après l'accident l'immobilisation dans un plâtre brachio-palmaire, l'avant-bras en supination complète, aide à maintenir la stabilité de l'articulation radio-cubitale inférieure. L'extrémité distale du cubitus ne doit pas être réséquée avant 6 mois, et seulement si une gêne fonctionnelle le justifie. Chez les sujets dont le traitement initial a été mal conduit on peut réséquer l'extrémité inférieure du cubitus en même temps que l'on intervient sur le radius, mais le résultat sera toujours médiocre. La consolidation, ou non, de la styloïde cubitale n'a aucune influence sur le résultat final.

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Reprint requests to: S. Bhan     

Percutaneous osteosynthesis of Galeazzi fracture-dislocation

Background:

A Galeazzi fracture is defined as a fracture of the radius associated with dislocation of the distal radio-ulnar joint (DRUJ). The conventional surgical technique of nailing does not give enough stability and open reduction, internal fixation with the plate is associated with numerous complications. The stacked nailing for the management of these injuries provides adequate stability, maintains the relationship of the DRUJ and promotes uneventful union by closed technique. The purpose of this study is to evaluate the results of simple, user-friendly, low cost elastic stacked nailing for the management of Galeazzi fracture dislocation.

Materials and Methods:

We treated 22 young adults with fresh Galeazzi fracture-dislocation of the forearm, from January 2004 to January 2008, by percutaneous fixation of fracture by stacked elastic nailing at our institute. There were 19 males and three females and the age group ranged from 20-56 years (average 35 years). Surgery was performed within 48 to 72 hours under the guidance of image intensifier. Medullary cavity was filled with two elastic titanium nails having unequal lengths and diameter. One nail acts as a reduction nail and the other acts as a stabilizing nail. The results were evaluated using Mikic criteria based on union, alignment, relationship of the DRUJ, and movements at the inferior radio ulnar joint, elbow and wrist.

Results:

In six cases, following radiological union, nails in the radius were extracted between six to nine months after operation because of discomfort complained by the patient at site of insertion. After one year follow-up, 18 patients had excellent, four had fair results.

Conclusion:

Closed reduction and internal fixation of Galeazzi fracture by two elastic rods re-establishes the normal relationship of the fractured fragments and the DRUJ without repair of the ligaments. The stability is achieved by the flexibility and elasticity of the nails, crowding of the medullary canal and anchorage they gain in the radial diaphysis. Elastic nailing can produce excellent clinical results for Galeazzi fracture-dislocation. It has the advantages of technical simplicity, minimal cost, user-friendly instrumentation, and a short learning curve.     

陈旧性跖跗关节骨折脱位

目的分析跖跗关节(Lisfranc)骨折脱位急诊处理的不当所导致的后期功能障碍的原因,并结合现今在这一领域的研究状况进行讨论。方法从2000年3月～2005年2月共收治陈旧性Lis-franc骨折脱位34例,24例行切开复位内固定,10例患者行关节融合术。结果按美国骨科足踝外科协会(AOFAS)中足部分的评分标准,50～60分2例,60～70分4例,70～80分5例,80～90分18例,90～100分5例。结论Lisfranc损伤晚期并发症的出现与复位不彻底、固定不牢靠以及固定时间不充分有关。临床医生在遇到中足扭伤的患者时,要提高警惕,以免漏诊。对大多数患者而言,以伤后6周内进行切开复位内固定为好。     

A historical report on Riccardo Galeazzi and the management of Galeazzi fractures

Fracture of the shaft of the radius associated with a dislocation of the distal radioulnar joint is an uncommon injury. In 1934, Riccardo Galeazzi of Milan reported his experience with the management of 18 such cases before the Lombard Surgical Society and subsequently received the eponym for this injury. Galeazzi was one of Italy's pioneering orthopedic surgeons, with an extensive bibliography that included nearly 150 publications. This article examines the evolution of management of the Galeazzi fracture and sheds light on this notable physician's life.