Snapshot A 22-year-old man presents to the emergency room with severe left arm pain. 1 hour prior to presentation, he was climbing a tree to retrieve a radio-controlled aircraft and fell 6 feet onto the ground. He landed on his pronated outstretched left arm and developed immediate-onset pain and swelling. On exam, he is tender to palpation with a notable deformity characterized by radial wrist angulation. The distal ulna is palpable. Radiographs demonstrate a fracture of the distal radial diaphysis with associated dislocation of the distal radioulnar joint. Introduction Clinical definition traumatic injury to the distal forearm characterized by the presence of two bony injuries diaphyseal fracture of the distal radius distal radioulnar joint (DRUJ) dislocation given the presence of a fracture and dislocation, these injuries are sometimes referred to as Galeazzi fracture-dislocations Epidemiology incidence 3-7% of forearm fractures demographics males more likely than females Etiology traumatic injury direct blow to the dorsolateral forearm Fall On an OutStretched Hand (FOOSH) falling on a pronated forearm Pathoanatomy normal anatomy of the wrist wrist consists of 3 bony articulations distal radioulnar joint (DRUJ) between distal radius and distal ulna stabilized by the volar and dorsal radioulnar ligaments radiocarpal joint between distal radius and proximal carpal row intercarpal joint between proximal and distal carpal rows fracture anatomy distal radius fracture can be associated with DRUJ disruption depending on the distance of fracture from the radial articular surface if a radial fracture is < 7.5 cm from the articular surface unstable in 55% if a radial fracture is >7.5 cm from the articular surface unstable in 6% primary deforming forces brachioradialis pulls the distal radial fragment radially pronator quadratus rotates the distal radial fragment ulnarly weight of the hand dorsally angulates the radius Associated conditions anterior interosseous nerve (AIN) palsy compartment syndrome ulnar styloid fracture indicator of DRUJ injury Prognosis unfavorable loss of reduction Presentation Symptoms wrist pain swelling Physical exam deformity may be noted depending on fracture severity pain with wrist flexion/extension and forearm pronation/supination must assess for DRUJ instability Imaging Radiography indication radiographs are indicated in any forearm injury in which a fracture is suspected anteroposterior (AP) and lateral views of the wrist, forearm, and elbow are required always important to obtain imaging of the joint above and below the suspected area of injury finding fracture of the distal radius dislocation of the DRUJ Differential Monteggia fracture distinguishing factors Monteggia fracture is characterized by two different bony injuries proximal ulna fracture radial head dislocation Distal radius fracture distinguishing factors in an isolated distal radius fracture, DRUJ will be stable any patient with a distal radius fracture should be assessed for DRUJ instability unstable DRUJ Galeazzi fracture-dislocation stable DRUJ isolated distal radius fracture Treatment Nonoperative closed reduction and casting indications pediatric patients Operative open reduction and internal fixation indications adult patients Complications AIN palsy AIN innervates the flexor pollicis longus (FPL) and flexor digitorum longus (FDP) on exam, will demonstrate loss of pinch between thumb and index finger Compartment syndrome