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http://upload.orthobullets.com/topic/1029/images/druj.jpg
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http://upload.orthobullets.com/topic/1029/images/galeazzi fracture orif.jpg
Introduction
  • Definition
    • distal 1/3 radius shaft fx AND
    • associated distal radioulnar joint (DRUJ) injury
  • Incidence of DRUJ instability
    • if radial fracture is <7.5 cm from articular surface
      • unstable in 55% 
    • if radial fracture is >7.5 cm from articular surface
      • unstable in 6% 
  • Mechanism
    • direct wrist trauma
      • typically dorsolateral aspect
    • fall onto outstretched hand with forearm in pronation
Anatomy
  •  DRUJ
    • sigmoid notch
      • found along ulnar border of distal radius
      • is a shallow concavity for the articulating ulnar head
    • volar and dorsal radioulnar ligaments 
      • function as the primary stabilizers of the DRUJ
    • most stable in supination
Classification
  • OTA classification of radius/ulna
    • included under subgroups and qualifications 
OTA classification of radius/ulna
22-A2.3 Radius/ulna, diaphyseal, simple fracture of radius with dislocation of DRUJ
22-A3.3 Radius/ulna, diaphyseal, simple fracture of both bones (distal zone radius) with dislocation of DRUJ

22-B2.3 radius/ulna, diaphyseal, wedge fracture of radius with dislocation of DRUJ
22-B3.3 radius/ulna, diaphyseal, wedge of both bones with dislocation of DRUJ
 
Presentation
  • Symptoms
    • pain, swelling, deformity
  • Physical exam
    • point tenderness over fracture site
    • ROM
      • test forearm supination and pronation for instability
    • DRUJ stress
      • causes wrist or midline forearm pain
Imaging
  • Radiographs
    • recommended views
      • AP and lateral views of forearm, elbow, and wrist
    • findings
      • signs of DRUJ injury
        • ulnar styloid fx
        • widening of joint on AP view
        • dorsal or volar displacement on lateral view
        • radial shortening (≥5mm)
Treatment
  • Operative
    • ORIF of radius with reduction and stabilization of DRUJ
      • indications
        • all cases, as anatomic reduction of DRUJ is required
        • acute operative treatment far superior to late reconstruction
Surgical Techniques
  • ORIF of radius
    • approach
      • volar (Henry) approach to radius  
    • plate fixation
      • perform anatomic plate fixation of radial shaft
      • radial bow must be restored/maintained
  • Reduction & stabilization of DRUJ   
    • approach
      • dorsal capsulotomy
    • reduction technique
      • immobilization in supination (6 weeks)
        • indicated if DRUJ stable following ORIF of radius
      • percutaneous pin fixation 
        • indicated if DRUJ reducible but unstable following ORIF of radius
        • cross-pin ulna to radius
          • leave pins in place for 4-6 weeks
      • open surgical reduction
        • indicated if reduction is blocked
          • suspect interposition of ECU tendon
      • open reduction internal fixation
        • indicated if a large ulnar styloid fragment exists
        • fix styloid and immobilize in supination
Complications
  • Compartment syndrome
    • increased risk with
      • high energy crush injury
      • open fractures
      • vascular injuries or coagulopathies
    • diagnosis
      • pain with passive stretch is most sensitive
  • Neurovascular injury
    • uncommon except type III open fractures
  • Refracture
    • usually occurs following plate removal
    • increased risk with
      • removing plate too early
      • large plates (4.5mm)
      • comminuted fractures
      • persistent radiographic lucency
    • prevention
      • do not remove plates before 18 months after insertion
        • amount of time needed for complete primary bone healing
  • Nonunion
  • Malunion
  • DRUJ subluxation
    • displaced by gravity, pronator quadratus, or brachioradialis
 

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