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.     

Complex dislocations of the distal radioulnar joint. Recognition and management.

Contrary to most reported series, it has been the authors' experience that dislocations of the distal radioulnar joint (DRUJ) associated with fractures of the forearm are frequently irreducible. This report reviews the authors' experience with these injuries, focusing on the recognition and management of what the authors call "complex" DRUJ dislocations: dislocations characterized by obvious irreducibility, recurrent subluxation, or "mushy" reduction caused by soft tissue or bone interposition. From 1984 until 1989, at the authors' institution, 11 patients were treated for fractures of the radius associated with dislocations of the DRUJ. Eight of these patients had a classic Galeazzi fracture dislocation. Two patients had severe open radius and ulnar fractures. One had an unstable comminuted intraarticular fracture of the distal radius. Of these 11 patients, four had "complex" dislocations of the DRUJ. In two cases, the extensor carpi ulnaris was displaced volar to the distal ulna, necessitating open reduction. A third case involved delayed recognition of multiple wrist and forearm joint dislocations associated with a severe open fracture of both bones of the forearm and required late exploration, reduction, and temporary internal fixation. A fourth case involved recurrent dorsal subluxation of the distal ulna after open reduction and internal fixation of a comminuted intraarticular distal radius fracture. It is clear that complex dislocations of the DRUJ occur more frequently than previously noted. Careful attention to these injuries during initial reduction attempts will reveal "mushy" or unobtainable reductions, an important indication for exploration for entrapped tendon, bone, or soft tissue.     

Galeazzi fractures: Is DRUJ instability predicted by current guidelines?

IntroductionClinically significant distal radioulnar joint (DRUJ) injuries can occur with radial shaft fractures. Several radiographic methods of diagnosis, such as radial shortening of >5 mm or fracture line within 7.5 cm from the lunate facet, have been proposed but not clinically validated. The purpose of this study was to compare radiographic measurements of radial shaft fractures associated with and without clinically significant DRUJ injury (i.e., true Galeazzi fracture-dislocation) in order to evaluate the predictive value of reported parameters of DRUJ injury.Patients and methodsA retrospective record and radiographic review was performed of 66 consecutive skeletally mature patients with isolated radial shaft fractures from 2004 to 2014 treated at one level 1 academic trauma center. Intraoperatively determined DRUJ instability after radial shaft fixation was used as the gold standard for diagnosis of a Galeazzi fracture-dislocation.ResultsAverage age was 34 years old (range: 18–90). By thirds, there were 10 proximal (15%), 27 middle (41%), and 29 distal (44%) fractures. 13 (20%) had an associated ulnar styloid fracture. 7 (11%) patients had DRUJ instability after radial fixation. Radial shortening averaged 4.4 ± 5.2 mm (−2.6–22), and 21 had shortening of >5 mm. Twenty-six (39%) fractures were within 7.5 cm of the wrist joint. Previous guidelines were only moderately accurate. Even greater shortening did not predict instability (3/7 patients with >10 mm shortening had a true injury). Four out of 7 cases with instability had ulnar styloid fractures (p = 0.02).Discussion and conclusionsUsing a larger data set than has historically been evaluated, previously reported radiographic guidelines are only moderately accurate. The presence of an ulnar styloid fracture can be helpful. Surgeons should be aware of these associations but rely primarily on intraoperative assessment of the DRUJ after radial fixation to determine treatment.     

TFCC reattachment after traumatic DRUJ instability: a simple alternative to arthroscopic management

With current trends favoring open reduction with internal fixation for distal radius fractures, distal radius-ulnar joint instabilities that were once clinically silent as a result of prolonged immobilization are now being recognized as a significant cause of morbidity. Arthroscopic management has proven to be both an effective and technically challenging treatment for triangular fibrocartilage complex (TFCC) tears. TFCC reattachment offers a safe, reproducible means of managing acute posttraumatic distal radioulnar join (DRUJ) instability after distal radius volar plating. With this technique, 30 patients at an average of 43 months were examined for continued DRUJ instability, range of motion, and radiographic evaluation for radius union, posttraumatic DRUJ arthritis, and hardware failure. Postoperative Gartland scores showed 88.6% excellent, 5.7% good, and 5.7% fair results. We conclude TFCC reattachment is a safe and effective alternative for treatment of acute DRUJ instability after open reduction with internal fixation of the distal radius, especially when equipment or experience does not support arthroscopic treatment.     

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.     

T型钢板在桡骨远端不稳定骨折治疗中的应用

目的 总结桡骨远端不稳定骨折T型钢板内固定治疗的效果,以提高桡骨远端不稳定骨折的治疗效果。方法 本组45例采用T型钢板固定,其中15例因骨缺损较严重同时植骨。结果 平均随访25．36个月。远期疗效优良者41例（1例双侧）,优良率91．11％。结论 桡骨远端不稳定骨折手法复位较困难,并因外固定难以维持复位而常发生再移位。这类骨折应尽早切开复位内固定,术后配合合理有效的功能锻炼,可以获得较好的效果。对远期功能影响最大的因素是桡骨短缩程度和关节解剖复位的满意程度。     

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.     

Intraoperative evaluation of DRUJ instability through dorsal stress radiography in distal radius fractures

IntroductionCertain type of injury of the triangular fibrocartilage complex associated with distal radius fracture can result in distal radioulnar joint instability (DRUJ). Untreated DRUJ instability may lead to poor result in the treatment of acute distal radius fractures. The aim of this study was to evaluate DRUJ instability in distal radius fractures through dorsal stress radiography comparing the affected and unaffected wrists intraoperatively.Materials and methods49 patients with a distal radius fracture who were operatively treated with a volar locking plate were included. Dorsal stress radiography was used to evaluate both affected and unaffected wrists peri-operatively to detect DRUJ instability. Under general anesthesia, a dorsal stress test was performed on the unaffected wrist. Additionally, after fixation of the affected wrist, a dorsal stress test was performed. The ulnar translation ratio (UTR) was measured through the dorsal stress radiograph. Arthroscopic examination was performed on all affected wrists according to Palmer's and Atzei classification.ResultsThe UTR of the affected wrist and the TFCC injury Palmer-type IB tendency were positively correlated (odds ratio: 1.18, p-value: 0.002). Additionally, as the UTR difference between the affected and unaffected wrists enlarged, it revealed a significant DRUJ instability tendency due to Palmer-type IB TFCC injury (p-value: 0.000006, Wilcoxon rank-sum test).ConclusionsDorsal stress radiography is a reliable, simple procedure to evaluate DRUJ instability intraoperatively. UTR value from dorsal stress radiography could be useful for evaluating DRUJ instability associated with distal radius fracture.     

Isolated radial shaft fractures are more common than Galeazzi fractures

PURPOSE: In contrast to isolated diaphyseal fractures of the ulna (so-called night-stick fractures), isolated fractures of the radial diaphysis generally are expected to have associated injury of the distal radioulnar joint (DRUJ), the so-called Galeazzi fracture. This study retrospectively reviewed isolated fractures of the radial diaphysis in a large cohort of patients to determine how often such fractures occur without DRUJ injury METHODS: Thirty-six patients with fracture of the radius without fracture of the ulna were followed up for at least 6 months after injury. Injury of the DRUJ was defined as more than 5 mm of ulnar-positive variance on radiographs taken before any manipulative or surgical reduction. All of the fractures were treated with plate and screw fixation (8 with autogenous bone grafting) and all healed. Patients with DRUJ injury had either temporary pinning or immobilization of the DRUJ or surgical fixation of a large ulnar styloid fracture. Patients without DRUJ injury were mobilized within 2 weeks. RESULTS: Nine patients had dislocation of the DRUJ, 4 with large ulnar styloid fractures. Among the remaining 27 patients 1 had displacement of the proximal radioulnar joint noted after surgery, leading to a secondary procedure for radial head resection. The functional results were satisfactory or excellent in all but 2 patients with functional limitations related to central nervous system injury. No patient had DRUJ dysfunction at the final follow-up evaluation. CONCLUSIONS: Isolated fractures of the radial diaphysis are more common than true Galeazzi fractures. Surgeons should take great care not to overlook injury to the distal or proximal radioulnar joint in association with isolated diaphyseal fractures of the radius; however, fractures without identifiable radioulnar disruption can be treated without specific treatment of the DRUJ and with immediate mobilization. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

Ipsilateral fractures of the distal radius and scaphoid treated by Herbert screw and external skeletal fixation. A report of two cases.

Two patients with comminuted, displaced fractures of the distal radius associated with ipsilateral, undisplaced scaphoid fractures were treated by internal fixation of the scaphoid fracture with a Herbert screw in association with external fixation of the distal radial fracture. One of the patients had a limited open reduction of the distal radius combined with bone grafting. Both patients had satisfactory results. Internal fixation of the scaphoid is indicated if distraction is applied to the carpus to treat an associated fracture of the distal radius, even if the scaphoid fracture is undisplaced.     

Variant of Galeazzi fracture-dislocation in children

Fractures of the radial shaft associated with disruption of the distal ulnar radial joint (Galeazzi fracture) account for a small percentage of forearm fractures in adults but occur even more rarely in children. An equivalent injury in children is a fracture of the radius with separation of the distal ulnar physis in the form of a Salter-Harris type II epiphyseal fracture. Although this lesion has been mentioned in the literature, to our knowledge it has not been described in detail. We report three cases of this fracture. All cases were treated by open reduction internal fixation.     

A Galeazzi-variant type fracture-dislocation in adults

Objective：Fracture of either radius or ulna with a dislocation either at the proximal or distal radioulnar joint （DRUJ） is not a common injury and is inherently unstable.Here we report a case series,with both-bone forearm fractures associated with dislocation of DRUJ,as a Galeazzi-variant type fracture-dislocation,and try to analyze this injury pattern.Methods：The study was based on 6 patients having Galeazzi-variant type fracture-dislocation of different age （20 to 45 years）.All fractures were closed type.Two fractures involved the same level and three fractures were at different levels of radius and ulna shaft.After thorough examination and investigations they were treated with limited contact dynamic compression plate without additional fixation for DRUJ.Results：All cases were followed up for 24 weeks.The maximum incidence occurred in age group between 31 and 40 years.All the fractures of both radius and ulna were united in average time of 12 weeks.Range of motion of wrist and elbow,supination and pronation at final follow-up were normal.There was no subsequent re-subluxation or dislocation of the DRUJ in any of the cases.Conclusion：Galeazzi variant in adult is a new undescribed pattern of forearm with wrist injury.Stable open reduction and internal fixation of both-bone forearm fractures is mandatory,followed by 3 to 4 weeks of immobilization in a cast for the healing of disrupted DRUJ.     

锁定加压钢板在中青年桡骨远端关节内粉碎性骨折中的应用

目的 探讨中青年桡骨远端骨折的临床特点,及锁定加压钢板在桡骨远端关节内粉碎性骨折中的应用效果.方法 2008年2月到2010年6月,对25例桡骨远端关节内粉碎性骨折患者(20～50岁)进行切开复位LCP内固定,术后早期功能锻炼.结果 25例患者均获得随访,随访6～20个月,平均12个月.所有患者掌倾角、尺偏角、桡骨短缩程度、关节面台阶等均得到整复,骨折平均愈合时间为44d,术后6周时腕关节活动度达到正常的80％以上.术后并发腕管综合征1例,无肌腱炎及肌腱断裂,无创伤性关节炎.最终疗效根据Dienst腕关节功能评估标准进行评定:优22例,良2例,可1例.结论 中青年桡骨远端关节内粉碎性骨折常为高能量损伤,多为不稳定骨折,早期切开复位LCP内固定可获得较满意的临床疗效.     

Unilateral external fixator in the treatment of lower third humeral shaft fractures

Lowerthirdhumeralshaftfracturesareoftenmanifestedbyoblique,spiralorcomminutedfractureswithahighincidenceofcomplicatingradialnerveinjury.Thispartofhumerusisirregularanatomicallyandneartheelbowjoint.Soitisdifficult toselectproperinternalfixationinstrumentswhile exploringradialnervethroughanterolateralapproach,whichaddsdifficultyinthetreatmentofthiskindof fractures.Inrecent6yearsweusedunilateralexternal fixatorstotreatsuchkindoffracturesinourdepartment andsatisfactoryresultswereachieved.METHOD…     

Combined internal and external fixation of distal radius fractures

Combined internal and external fixation of distal radius fractures is used most commonly to treat injuries with joint surface or metaphyseal comminution. External fixation aids reduction intraoperatively and facilitates arthroscopic, per-cutaneous, or open manipulation of the fracture.Internal fixation maintains precise reduction of critical anatomy, principally the contour and orientation of the articular surface. Postoperatively the fixator functions as a neutralization device, preventing fracture collapse and decreasing the biomechanical demands on the internal fixation hardware. The combined technique exploits the benefits of both forms of fixation, allowing each to be used to full advantage in the treatment of complex distal radius fractures.     

DVR解剖型桡骨掌侧锁定接骨板治疗桡骨远端骨折

目的探讨开放复位DVR解剖型桡骨掌侧锁定接骨板治疗桡骨远端骨折的疗效。方法回顾性分析自2010年12月。2012年4月用DVR解剖型桡骨掌侧锁定接骨板治疗的不稳定桡骨远端骨折15例。结果15例获随访8～24个月,平均14个月,所有骨折均于术后3个月内愈合。术后平均掌倾角、尺偏角、尺骨变异分别为（7．9±2．3）°、（21．5±3．4）。、（-0．20±1．21）mm,末次随访时平均掌倾角、尺偏角、尺骨变异分别为（7．80±2．24）°、（21．3±3。4）°、（-0．07±1．22）mm,二者差异无统计学意义。按照改良的Green—O＇Bfien功能评分,腕关节功能：优11例,良2例,可1例,差1例。结论开放复位DVR解剖型桡骨掌侧锁定接骨板治疗桡骨远端骨折具有操作简单、骨折复位好、固定牢固、可早期功能锻炼、腕关节功能恢复满意的优点。是治疗桡骨远端比较理想的方法。     

Acute dislocations of the distal radioulnar joint and distal ulna fractures

This article reviews acute dislocations of the distal radioulnar joint (DRUJ) and distal ulna fractures. Acute dislocations can occur in isolation or in association with a fracture to the distal radius, radial metadiaphysis (Galeazzi fracture), or radial head (Essex-Lopresti injury). Distal ulna fractures may occur in isolation or in combination with a distal radius fracture. Both injury patterns are associated with high energy. Outcomes are predicated on anatomic reduction and restoration of the stability of the DRUJ.     

Divergent elbow dislocation with radial shaft fracture,distal ulnar deformation,and distal radioulnar joint instability: an unclassifiable Monteggia variant

Originally described by Monteggia and later classified by Bado, elbow dislocations with concurrent radial and ulnar shaft fractures with distal radioulnar joint (DRUJ) disruption are considered operative cases with high-energy injurious etiologies. Here, we present an unclassifiable Monteggia variant fracture suffered through a high axial load mechanism in a 47-year-old female. The fracture pattern initially exhibited included a divergent elbow dislocation, a radial shaft fracture, plastic deformation of the distal ulna, and DRUJ instability. Here we describe the pattern in detail, along with definitive treatment and clinical outcome at 1 year follow-up.     

Outcome following distally locked volar plating for distal radius fractures with metadiaphyseal involvement

BackgroundThe surgical treatment of metadiaphyseal distal radius fractures may be difficult due to the associated articular or periarticular extension that limits standard fixation techniques. Longer distal radius volar locking plates allow stable fixation of the distal fragments while providing standard plate fixation in the proximal radius. We hypothesize that this plating technique allows adequate fixation to both the distal radius and metadiaphyseal fragments. The purpose of the study is to describe the outcomes, radiographic parameters, secondary surgeries, and complication rate with this device.MethodsA retrospective chart review was conducted on adult patients with a distal radius fracture and metadiaphyseal involvement treated with a volar, distally locked plate. All patients were followed up for radiographic union, with a mean time of 219 days (range 38–575). Fracture patterns, outcomes of range of motion, grip strength, and complications, as well as injury, post open reduction and internal fixation (ORIF), and finally, healed radiographic parameters were recorded.ResultsTwenty patients with 21 fractures were included. At union, mean radiographic parameters were the following: volar tilt of 8°, radial inclination of 27°, radial height of 14 mm, and ulnar variance of −1 mm. The mean final range of motion was 52° flexion, 50° extension, 68° pronation, and 66° supination. Complications included one infection and one plate removal. Four patients developed a nonunion requiring secondary procedures. There were no incidents of hardware failure or adhesions requiring tenolysis.ConclusionDistally locked long volar plating for metadiaphyseal distal radius fractures is a safe and effective treatment option for these complex fracture patterns allowing anatomic restoration of the radial shaft and distal radius.     

手法间接复位掌侧锁定板固定治疗桡骨远端C3型骨折

目的 ：探讨手法间接复位后AO 2.4 mm桡骨远端锁定板联合经皮穿针固定治疗C3型（AO/OTA分型）桡骨远端骨折的临床疗效及操作技巧。方法：自2009年5月至2012年3月采用手法间接复位AO 2.4 mm桡骨远端掌侧锁定板联合经皮穿针固定治疗桡骨远端骨折AO/OTA分型C3型患者19例21腕（双侧2例）。年龄31~66岁,平均（45.3±17.4）岁;并发尺骨茎突骨折14腕,下尺桡关节不稳6腕;均为闭合性骨折;发病时间4.5~9 d,平均（6.7±3.5）d。采用Henry切口显露骨折部位,保留关节囊、韧带连续性,手法间接复位,C形臂X线透视关节面复位情况,仍存在塌陷者予以撬拨复位后桡骨远端掌侧锁定板固定。下尺桡关节发现不稳定和并发尺骨茎突骨折者均予前臂旋后位石膏托固定6周。结果：19例（21腕）获得随访,时间7~17个月,平均10.5个月。X线示患者桡骨远端骨折均达到骨性愈合,尺骨茎突骨折未愈合3例,下尺桡关节不稳0例,1例出现背侧伸肌腱激惹,内固定取出后激惹消除。术后随访观测患者掌倾角、尺偏角、桡骨茎突高度、关节面和下尺桡关节情况,按照Batra和Gupta评分标准行影像学评定：70分以下3腕,70~79分5腕,80分以上13腕。同时对患者进行主观和客观疗效评定,观测残留畸形和腕关节活动度、并发症情况等,根据Sarmiento改良的Gartland-Werley评分系统评定术后疗效：优17腕,良3腕,可1腕。结论：AO/OTA分型C3型桡骨远端骨折手法间接复位可获得良好复位效果,应用锁定板联合穿针可为其提供内固定架支撑式固定以满足早期功能锻炼要求,患腕功能预后良好。