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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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Hangama C Fayaz Jesse Jupiter

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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 on
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 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
View publication stats
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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