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Updated: Jun 12 2021

Galeazzi Fracture - Pediatric

  • summary
    • Galeazzi Fractures are rare injuries in the pediatric population and consist of distal radius fractures at the distal metaphyseal-diaphyseal junction with concomitant disruption of the distal radioulnar joint.
    • Diagnosis is made with plain radiographs. 
    • Treatment is generally closed reduction and casting for the majority of fractures. Surgical management is indicated for irreducible DRUJ due to interposed tendon or periosteum.
  • Epidemiology
    • Incidence
      • relatively rare injury (3% of distal radius fractures associated with DRUJ disruption)
        • less frequent than in adults
      • often missed injury pattern (up to 41%)
      • when radial fracture is < 7.5 cm from the articular surface, 55% chance of DRUJ instability (6% chance if > 7.5 cm)
    • Demographics
      • peak incidence 9 to 13 years old
  • Etiology
    • Pathophysiology
      • DRUJ disruption
        • disruption of the DRUJ in a pediatric patient can consist of
          • DRUJ dislocation
          • a displaced ulnar physeal injury (Galeazzi-equivalent)
            • most common
      • pathoanatomy
        • axial loading in combination with extremes of forearm rotation (pronation or supination)
          • pronation produces an apex dorsal radial fracture with the distal ulna displaced dorsally
          • supination produces an apex volar radial fracture with the distal ulna displaced volarly
      • Associated injuries
        • nerve injuries are rare
  • Anatomy
    • DRUJ
      • osteology
        • possesses poor bony conformity in order to allow some translation with rotatory movements
      • ligamentous
        • ligament structures are critical in stabilizing the radius as it rotates about the ulna during pronation and supination
        • triangular fibrocartilage complex (TFCC) is a critical component to DRUJ stability
      • biomechanics
        • the joint is most stable at the extremes of rotation
  • Classification
      • Walsh classification
      • Type I
      • Dorsal displacement of the radius
      • Due to supination force
      • Type II
      • Volar displacement of the radius
      • Due to pronation force
  • Presentation
    • Symptoms
      • wrist and forearm pain
      • radial deformity
      • limitation of wrist motion
      • ulnar head prominence or deformity can sometimes be seen
    • Physical exam
      • pain with movement or palpation of the wrist
      • DRUJ instability may be appreciated by local tenderness and instability to testing of the DRUJ
        • compare to contralateral side
      • careful examination for nerve injury
  • Imaging
    • Radiographs
      • required views
        • AP and true lateral radiographs
          • true lateral radiograph is essential in determining the direction of displacement
          • a slightly oblique view may cause the ulna to appear subluxed
          • in a normal wrist, the ulnar styloid should point to the triquetrum in all views, including oblique projections
      • additional views
        • contralateral radiographs often helpful for comparison
      • findings
        • displaced distal radial shaft fracture
        • DRUJ disruption
          • may be subtle and radiographs must be scrutinized
          • additional signs of DRUJ instability include
            • ulnar styloid fracture
            • widened DRUJ on posteroanterior view
            • greater than or equal to 5mm radial shortening
  • Treatment
    • Nonoperative
      • closed reduction with long arm casting
        • indications
          • first-line of treatment in children
            • 92% of adults experience poor outcomes with non-operative management
        • reduction
          • requires anatomic reduction of both the radius fracture and the DRUJ
          • supination is required for reduction if there is dorsal subluxation of the ulna
          • pronation is required for reduction if there is volar subluxation of the ulna
        • immobilization
          • place in above elbow cast in supination
        • outcomes
          • good to excellent with proper reduction of the radius and concomitant DRUJ reduction, even in cases where the DRUJ injury was not initially recognized
    • Operative
      • open reduction internal fixation +/- DRUJ pinning
        • indications
          • unable to obtain anatomic closed reduction
          • irreducible DRUJ due to interposed tendon or periosteum
        • technique
          • radial fixation can be done with volar plate or flexible IMN (see below)
      • ORIF, soft tissue reconstruction of DRUJ and TFCC, +/- corrective osteotomy
        • indications
          • chronic DRUJ instability (a rare consequence of a missed injury)
      • corrective osteotomy with soft tissue reconstruction of DRUJ and TFCC
        • indications
          • DRUJ subluxation is caused by a radial malunion
            • a corrective osteotomy is also required in addition to reconstruction, otherwise a soft tissue reconstruction of the DRUJ alone will fail
  • Technique
    • ORIF with volar plating, +/- DRUJ pinning
      • approach
        • dorsal approach to DRUJ to remove interposed material (ECU) if unable to obtain closed reduction
        • volar approach for ORIF(with plate)
      • open reduction
        • irreducible DRUJ requires an open reduction to remove interposed material
        • reduction can be blocked by interposed
          • tendon
            • ECU most common interposed tendon
          • periosteum
      • DRUJ stability
        • following fixation, test DRUJ (shuck test)
          • if unstable, pin ulna to radius in supination
          • if unstable with large ulnar styloid fragment, fix ulnar styloid and splint in supination
    • ORIF with flexible intramedullary nailing, +/- DRUJ pinning
      • approach
        • percutaneous (with IMN) of radius fracture
      • open reduction
        • same as above
      • DRUJ stability
        • same as above
  • Complications
    • Delayed diagnosis
    • Malunion/nonunion of the radius
      • commonly a result of persistent ulnar subluxation
    • Chronic DRUJ instability
      • chronic DRUJ instability (a rare consequence of a missed injury)
      • less common in children
    • Acute carpal tunnel syndrome
    • Superficial radial nerve palsy
      • can be seen with IMN
    • Ulnar nerve injury
    • Stiffness
      • limited pronosupination
    • Extensor pollicis longus rupture
    • Ulnar physeal arrest
      • 55% incidence in Galeazzi-equivalent fractures
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