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Galeazzi Fractures: our Modified Classification and Treatment Regimen

Article in Handchirurgie · Mikrochirurgie · Plastische Chirurgie · February 2014

DOI: 10.1055/s-0034-1367035 · Source: PubMed

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Galeazzi Fractures: our

Modified Classification
and Treatment Regimen

DOI 10.1055/s-0033-1367035
Handchir Mikrochir Plast Chir 2014; 46: 31–33

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Galeazzi Fractures: our Modified Classification
and Treatment Regimen
Galeazzi-Frakturen: unser modifiziertes Klassifikations-
und Behandlungsregim
Authors
Affiliation
Key words
●▶ Galeazzi fracture
●▶ Galeazzi like lesion
●▶ modified classification
Schlüsselwörter
●▶ Galeazzi-Fraktur
●▶ Galeazzi like lesion
●▶ modifizierte Klassifikation
received 16.8.2011
accepted 20.1.2014
Bibliography
DOI http://dx.doi.org/
10.1055/s-0034-1367035
Handchir Mikrochir Plast
Chir 2014; 46: 31–33
© Georg Thieme Verlag
KG Stuttgart · New York
ISSN 0722-1819
Correspondence
Hangama C. Fayaz MD, PhD
Department of Orthopaedic
Surgery, Harvard Medical
School, Massachusetts
General Hospital, Yawkey
Center, Suite 2100, 55 Fruit
Street, Boston, Massachusetts
USA
dr.hana.fayaz@hotmail.de
H. C. Fayaz, J. B. Jupiter
Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston,
Massachusetts, USA
Abstract
▼ ▼
While diaphyseal fractures of the forearm are a
common orthopedic injury, Galeazzi fractures are
difficult to treat. The current knowledge
pathobiomechanics and modified therapeutic decisions
implicate the need to devise an updated classification
and treatment regimen of Galeazzi fractures. We
challenge the concept that isolated fractures of the
radius should be considered as a Galeazzi fractures as
long as stability of the distal radioulnar joint is not
proven. Contrary to others we demonstrate that the
fracture location alone is not sufficient to determine the
stability of the distal radioulnar joint.
Similar to Monteggia fractures, and Essex-Lopresti
lesions, Galeazzi fractures occur as com-bined
injuries of the forearm (●▶ Fig. 1). These injury
patterns typically include a fracture of either the
radius or ulna of the forearm with dis-location of
either the proximal or distal radioul-nar joint
(DRUJ). Failure to diagnose these fracture-
dislocations accounts for a high inci-dence of
unsatisfactory results. Galeazzi fracture was first
described by Sir Astley Cooper in 1822, but was
named after the Italian surgeon Riccardo Galeazzi,
who presented 18 cases of this fracture in 1934 [1].
According to Mikic in 1975, the Galeazzi fracture is
a fracture of the middle to distal third of the radius
and is associated with dislocation and/or instability
of the DRUJ [2]. Galeazzi fractures are associated
with poor out-comes with closed reduction and cast
immobili-zation. Campbell has referred to this
fracture as the fracture of necessity [3].
Classification schemes of Galeazzi fractures were
described by Bruckner et al. in 1992 [4], Macule et
al. in 1994 [5], and Rettig and Raskin in 2001 [6]. ●▶
Table 1–3 provide useful starting guidelines but
may not always apply to individual treatment
options.We have utilized current knowledge on
pathobiome-
Fayaz HC, Jupiter JB. Galeazzi Fractures: our Modified … Handchir Mikrochir Plast Chir 2014; 46: 31–33
Original Article 31
Zusammenfassung
Galeazzi-Frakturen sind weder einfach zu erken-nen,
noch zu behandeln. Neuere Erkenntnisse die
on Pathobiomechanik betreffend verlangen nach einer
Überarbeitung der Klassifikation und zugleich des
Behandlungskonzepts. Nach unserer Meinung sollte
jede isolierte Radiusfraktur so lange als Galeazzi-
Fraktur betrachtet werden, bis die Stabilität des
distalen Radioulnargelenkes bewiesen ist. Im
Gegensatz zu anderen Autoren sind wir nicht der
Meinung, dass allein die Loka-lisation der Fraktur
schon eine Aussage zur Sta-bilität des distalen
Radioulnargelenkes zulässt.
chanics and therapeutic decisions to devise an
updated classification and treatment regimen ( ●▶
Fig. 2, 3).
I Isolated diaphyseal (proximal or middle-third)
fractures of the radius
II Diaphyseal fractures of the radius and ≥ 5 mm
ulnar positive variance
IIa Stable DRUJ (acute TFCC tears: 1A, 1D)
IIb Partially Stable DRUJ (acute TFCC tears:
1B, 1C) IIc Unstable DRUJ (simple or complex)
As reported by Nicolaidis et al., Lichtman and Col-lins
combined classification of DRUJ injuries, stable DRUJ
injuries include types 1A and 1D triangular
fibrocartilage complex (TFCC) tears and are recog-
nized as “nondestabilizing TFCC tears” [7].
In these injuries, the dorsal and palmar radioul-nar
ligaments generally remain intact. While types 1B and
1C TFCC tears lead to a partial desta-bilization, type
1C also includes an ulnocarpal disruption. An extensor
carpi ulnaris subluxation is also recognized as a partial
destabilizing factor. According to Nicolaidis et al., a
massive tear of the TFCC as well as ulnar styloid
avulsion and a distal radius fracture will lead to a
complete rup-ture of the TFCC, which is classified as
an unsta-ble DRUJ injury-dislocation [7].
32 Original Article
a Comments on Type I
b injury cannot be based solely upon fracture location.
Fig. 1 a, b Isolated fractures of the radius (Type I).
Table 1 Classification of Galeazzi fractures according to Macule et al. [5].
type I – fracture of the radius occurs between 0 and 10 cm from the
styloid process
type II – fracture of the radius occurs between 10 and 15 cm from the
styloid process
type III – fracture of the radius occurs more than 15 cm from the styloid
process
Table 2 Classification of Galeazzi fractures and treatment concept by Rettig
and Raskin [6].
type I – Distance between the midarticular surface of the distal radius
and the fracture is within 7.5 cm. DRUJ joint more unstable, when
tested intraoperatively.
type II – Distance between the midarticular surface of the distal radius
and the fracture is more than 7.5 cm. Only 6 % of patients required
ORIF of the DRUJ.
Table 3 Radiographic signs that lead to the Galeazzi diagnosis [15].
– fracture at the base of the ulnar styloid
– widening of the DRUJ-Joint space (on a true antero posterior view)
– dislocation of the radius relative to the ulna (on a true lateral view)
– more than 5 mm of shortening of the radius relative to the ulna
a b
Fig. 2 a, b Showing the displacement; space between DRUJ and ulnar
positive variance (Type II).
Fayaz HC, Jupiter JB. Galeazzi Fractures: our Modified … Handchir Mikrochir Plast Chir 2014; 46: 31–33
▼
Based on findings by Mestdagh et al., Hattoma et al., and Rettig
and Raskin [6,8,9], we challenge the concept that isolated frac-
tures of the radius are always Galeazzi fractures. Contrary to
Rettig and Raskin, we demonstrate that the fracture location
alone is not sufficient to determine the stability of the DRUJ.
Which indicates that the distinction of lesions with greater DRUJ
Comments on Type II
▼
These studies are based on biomechanical studies, which have
shown that greater than 5 mm of ulnar positive variance dis-
placement indicates injury to all of the soft tissue stabilizers of
the DRUJ.
Galeazzi-like Lesion
▼
In Galeazzi-like lesions, a fracture of the radial shaft is associated with
an additional fracture of the distal ulna. Road traffic acci-dents are the
main etiology of this type of injury [6]. An essential soft tissue stabilizer
of the DRUJ is the TFCC. Rupture of this complex typically occurs
secondary to extreme pronation and extension of the wrist [10,11].
According to Renfree and Ring in 2004 and 2006, injury to the DRUJ
occurs in 20 % of Galeazzi frac-tures, and by this logic, any fracture of
the distal third of the radius should be considered a Galeazzi fracture
and the DRUJ should be carefully examined [12,13]. However, in our
review of the current literature, we support the concept established in
Europe that isolated fractures of the radius occur more often without
major associated DRUJ ligament injury [8].
Non-operative Treatment
▼
Conservative treatment of Galeazzi fractures is associated with
a high percentage of malfunction. In 1957, Hughston outlined
the factors that cause a loss of reduction as follows: 1) thumb
abduc-tors and extensors trigger shortening and relaxation of
the radial collateral ligament, which inhibits stretching of the soft
tissue bridge, 2) subluxation of the DRUJ may be induced by
gravity acting through the weight of the hand, 3) the
brachioradialis uses DRUJ as a pivot point on which to rotate
the distal fragment of the radius and results in shortening, 4)
insertion of the prona-tor quadratus on the palmar surface of the
distal radius fragment rotates it towards the ulna and pulls it in a
proximal, palmar direction [14].
Operative Treatment
▼
Surgical management of Galeazzi fractures consists of a palmar
approach to the radial shaft. All patients undergo open reduc-
tion and fracture stabilization with a 3.5 mm AO dynamic com-
pression plate or low contact dynamic compression plate
applied to the palmar surface. Following anatomic fixation, the
DRUJ should be clinically evaluated for forearm supination
stability. Gross instability of the DRUJ should be identified.

a b
Fig. 4 Showing a substantial DRUJ
displacement that has been treated
by ORIF of the ulnar styloid, using
Kirschner wires with a tension
band and ORIF of the radius.
Surgical Technique
▼ radioulnar joint. Hand Clin 2000; 16: 449–459
The Henry approach is the preferred method for surgical treat-
ment of Galeazzi fractures. After fracture reduction, stable fixa-
tion is performed by applying a DCP plate. A minimum of 6
cortices on either side of the fractures is inserted. Initially, the
plate is fixed with 2 screws, and X-ray is then used to confirm
the accuracy of fracture reduction and precision of DRUJ reduc-
tion. Forearm stability should also be tested by passively rota-
tion. According to Mudgal and Jupiter, if there is no forearm
instability, then postoperative immobilization is not mandatory.
The authors also indicated that if “the DRUJ is reducible but
unstable with forearm rotation,” then in this situation they
offered several treatment options depending upon whether the
ulnar styloid had been fractured at its base. An open reduction
and internal fixation (ORIF) of the ulnar styloid (using Kirschner
wires with a tension band or small screw) has been recom-
mended (●▶ Fig. 4). However, according to Moore et al. and
Strehle and Gerber, 4 weeks of immobilization appears to be
sufficient for DRUJ healing [15,16]. In 2000, Nicolaidis et al.
Fayaz HC, Jupiter JB. Galeazzi Fractures: our Modified … Handchir Mikrochir Plast Chir 2014; 46: 31–33
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Original Article 33
c
Fig. 3 a Stable DRUJ, minimal displacement (Type
IIa) b Partially Stable DRUJ (Type IIb) c Unstable
DRUJ (Type IIc).
outlined a precise treatment regimen indicating the need for
casting and wrist arthroscopy in stable DRUJ cases and repair
of TFCC in unstable DRUJ. They recommend a reduction of
DRUJ, crossing Kirchner wires, and repair of the ulnar styloid in
unsta-ble DRUJ cases [7].
Conflict of interest: None
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