Reconstructing a chronic, malunited Galeazzi fracture with distal radial ulnar joint instability: a simple, modified technique
- Spencer R Anderson 1,
- Hunter Charles Spitz 2,
- Timothy Charles Frommeyer 3 and
- Sunishka M Wimalawansa 1
- 1 Division of Plastic and Reconstructive Surgery, Wright State University Boonshoft School of Medicine, Dayton, Ohio, USA
- 2 Division of Orthopaedic Surgery, Mount Carmel Health System, Columbus, Ohio, USA
- 3 Wright State University Boonshoft School of Medicine, Fairborn, Ohio, USA
- Correspondence to Dr Spencer R Anderson; spencer.anderson@wright.edu
Abstract
A male in his 70s presented with a chronic malunited comminuted Galeazzi fracture dislocation, including angular malunion, radial shortening (1.3 cm ulnar-plus variance) and distal radioulnar joint (DRUJ) instability secondary to chronic dislocation with mechanical rotation block. A modified, single-stage radius corrective osteotomy with bone grafting technique to overcorrect radius length was employed, restoring normal DRUJ motion and stability by engaging the secondary DRUJ stabilisers without triangular fibrocartilage complex repair. DRUJ stability was restored via radius lengthening, engaging the DRUJ’s secondary stabilisers, bypassing the need for complex ligamentous reconstruction. The patient returned to full activity. We recommend our simple yet effective approach to treat chronic, malunited Galeazzi fractures with DRUJ instability.
Background
The Galeazzi fracture dislocation is a deformity of the middle to distal third of the radius associated with disruption of the distal radioulnar joint (DRUJ) and resultant ulna luxation.
This injury was first recognised by Sir Astley Cooper in 1822, but named after Italian surgeon Galeazzi, who presented a series of reports on this pattern in 1934.1–4 Untreated Galeazzi fracture dislocations result in predictable and painful forearm deformities with loss of pronosupination.5 In adults, adequate and timely reduction and stabilisation is essential as these fractures tend to progress to malunion and/or nonunion if untreated for greater than 6 weeks.6 7
Chronic Galeazzi fractures can present a challenge to the reconstructive upper extremity surgeon, pending degree of injury and time-lapse from initial insult. Current published literature on technique recommendations for chronic Galeazzi fracture management is lacking.8 The purpose of this paper is to act as a stepwise educational tool for the upper extremity reconstructive surgeon via elaborating on a simplified, single-stage technique to simultaneously correct a chronic malunited Galeazzi fracture dislocation restoring pronosupination, DRUJ stability and avoiding a separate reconstructive DRUJ procedure. In addition to operative pearls, we discuss our recommendations for postoperative therapy and management to achieve an optimal functional outcome.
Case presentation
A man in his 70s presented multiple months after sustaining an injury to the right forearm secondary to a work-related accident. Despite gross functional limitation, the patient did not seek medical attention until he subsequently felt a ‘pop’ associated with new swelling and pain at the level of the right forearm and wrist.
On exam, the patient displayed gross radial mid-shaft angular deformity (figure 1). He had severe limitation in active range of motion (ROM) and pronosupination of the forearm and wrist. Preoperative X-ray (figure 2) and three-dimensional (3D) CT (figures 3 and 4) showed malunited Galeazzi fracture dislocation pattern and signs of comminution at the malunion site. The imaging demonstrated stigmata of the obliquely oriented fracture at the distal one-third of the radius shaft with 20° of palmar and radial angulation, and an associated 1.1 cm distal radius volar translocation with chronic DRUJ dislocation. The DRUJ was markedly incongruent with significant radial shortening and 1.3 cm of ulnar positive variance. Extensive periosteal and endosteal callus-containing bone fragments was noted at the malunion site. Following lengthy discussion, the patient agreed to proceed with corrective surgery.
Intraoperative view of the grossly deformed right forearm, prior to incision.
X-ray of the right forearm, demonstrating gross deformity and shortening of the radius.
3D CT reconstruction oblique view of the right forearm, showing gross deformity of the radius, comminution, malunited fragments, and bony callus formation. 3D, three dimensional.
3D CT reconstruction volar view of the right forearm, showing gross deformity of the radius, comminution, malunited fragments and bony callus formation. 3D, three dimensional.
Corrective osteotomy
We employed a modified volar Henry approach, with corrective osteotomy performed through the malunited fracture lines (figures 5 and 6). Due to constriction of the soft tissue capsule, a combination of manoeuvres using olive wires, a mini tubular plate, and K-wires was used to apply distracting forces and adequately align the fragments when the distal radial length was sufficiently restored. We manipulated the fracture under fluoroscopy to restore the natural bow of the radius with provisional plate fixation. Following osteotomy and mobilisation of the key fragments and adequate soft tissue release, distraction manoeuvres allowed correction of the angulation deformity and restored length to the distal radius.
Intraoperative view of the right forearm, with exposure of the fracture site showing gross bony callus formation encompassing comminution of the radius.
Artistic representation created by coauthor TCF demonstrating our modified approach to a chronic Galeazzi fracture presentation, using the volar Henry approach. Associated local anatomy is shown.
Secondary DRUJ stabilisation via radial lengthening with autologous bone graft
Despite adequate correction of radius length, bow and anatomy, the DRUJ remained lax and unstable. To avoid the need for further ligamentous reconstruction of the DRUJ, the radial length was serially overcorrected, millimetre-by-millimetre, to engage the secondary DRUJ stabilisers. After adding each millimetre of overcorrected length to the radius, we re-evaluated DRUJ stability. At 3.5 mm of radius overcorrection (ie, 3.5 mm ulnar-minus variance), the DRUJ became stable to stress in both fully pronated and fully supinated positions while maintaining full natural passive ROM.
With restoration of ROM and joint stability, the radius reconstruction was stabilised using plate fixation spanning the site of comminution and the newly generated bone gap. Intraoperatively, full supination and pronation of the forearm was re-demonstrated with gentle passive ROM. The DRUJ was found to be congruent and stable in all positions, indicating appropriate restoration of DRUJ anatomy.
The malunion correction and overdistracted bone gap were bone grafted using autologous iliac crest cancellous bone packed tightly at the radial osteotomy site to optimise healing. Both donor and recipient sites were injected with liposomal bupivacaine for postoperative analgesia. The patient was placed in a fibreglass posterior long arm splint with the forearm supinated. X-rays confirmed anatomic reduction, restoration of radius anatomy, 3.5 mm ulnar minus variance, tight compression of the osteotomy bone graft and restoration of DRUJ anatomy (figures 7 and 8).
Immediate postoperative X-ray, lateral view, of the right forearm confirming anatomic reduction and restoration of radius anatomy, tight compression of the osteotomy bone graft reconstruction site and restoration of DRUJ anatomy.
Immediate postoperative X-ray, anterior–posterior view, of the right forearm and wrist confirming anatomic reduction and restoration of radius anatomy, ulnar minus variance and restoration of DRUJ anatomy. DRUJ, distal radioulnar joint.
Outcome and follow-up
Postoperative period
The long-arm splint was converted to an orthoplast forearm-based short-arm brace 1 week after surgery to allow active elbow motion and gentle pronosupination. Following X-ray evaluation at 2 weeks, we initiated gentle active wrist motion as well. Light strengthening, with a 5 lb. weight limit was initiated at 6 weeks postoperative. By 3 months postoperative, excellent bone graft consolidation was noted on X-ray and the weight limit was progressively increased to 40 lb. Full symmetric pronosupination was also noted on this visit. By 5 months postoperative, all restrictions were discontinued and instructed to continue strengthening as tolerated. At 1-year postoperative, the patient had achieved full pronation and supination, 25° of radial wrist deviation, 45° of ulnar wrist deviation, 60° of wrist flexion and 70° of wrist extension (figures 9–11). The patient could perform all necessary work-related activities (including heavy lifting) without limitation, and reported no pain at hardware sites or with motion. See table 1 for preoperative and postoperative active ROM findings up to 1-year postoperative, represented in degrees. Now 7 years postprocedure, the patient now lives out of town and was contacted by phone for a long-term outcome update. The patient reported to maintain an active lifestyle with all outdoor activities and no functional limitation of the upper extremity. The patient reports no pain with use and is very happy with the outcome.
Preoperative and postoperative active range of motion, in degrees
| Preoperative | 4 weeks postoperative | 7 weeks postoperative | 3 months postoperative | 5 months postoperative | 1-year postoperative | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| N/A, not available. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Radial wrist deviation | N/A | N/A | 5 | 25 | 25 | 25 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Ulnar wrist deviation | N/A | N/A | 45 | 40 | 45 | 45 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Wrist flexion | 30 | N/A | 40 | 55 | 55 | 60 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Wrist extension | 20 | N/A | 55 | 60 | 60 | 70 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Pronation | 60 | 65 | 65 | 80 (symmetric) | 80 (symmetric) | 80 (symmetric) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Supination | 40 | 65 | 65 | 80 (symmetric) | 80 (symmetric) | 80 (symmetric) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Discussion
The current standard of treatment of acute Galeazzi fractures is open reduction and internal fixation of the radius and DRUJ.9–12 Typically, osteosynthesis of the radial fracture is achieved with rigid plate fixation using a 3.5 mm or 4.5 mm dynamic compression plate. Proper restoration of the anatomic bow of the radius must be achieved to regain normal function and full pronosupination.6 13 Fixation can be achieved using a variety of techniques, including but not limited to K-wires, obliquely placed transfixation screws, intramedullary pins, square nails, Rush rods or external fixation. The fracture must be aligned in anatomic position to allow for full pronosupination and to avoid the chronic debilitating arthritic sequelae.
To achieve a return-to-normal function postoperatively, the anatomy of the DRUJ must be fully restored.14 In most acute cases, the DRUJ will fall into position following adequate reduction and stabilisation of the radius. If the DRUJ is found to be stable, immobilisation of the joint in a neutral or supine position is recommended for 2–6 weeks to allow healing of the volar and dorsal marginal ligaments.15 However, if the DRUJ remains unstable and fails to reduce following fixation, further surgical treatment of the DRUJ may include ligamentous repair of the triangular fibrocartilage complex (TFCC) with consideration of DRUJ transfixion pinning for protection using K-wires and/or immobilised in a neutral position for 6 weeks.6 13
Due to the complex and chronic nature of the presented case, the senior author (SMW) employed a modified approach to restore length and stability at the DRUJ. Typically, radial shortening and angulation occur with distal to mid shaft Galeazzi fractures and may lead to instability of the DRUJ. Cadaveric studies demonstrate that shortening of just 0.5 cm or less results in DRUJ instability, while shortening of greater than 1 cm results in instability with disruption of the TFCC and interosseous membrane.16 Our patient presented with severe radial shortening, creating an ulnar-plus variance of 1.3 cm. Prior approaches described to treat the complex chronic presentation of Galeazzi malunion with a non-repairable TFCC ligament lesion have relied on a complex combination of malunion correction via radius osteotomy in combination with a tendon graft-based TFCC ligament reconstruction.17
However, we sought a simpler yet equally effective solution. Given that the TFCC ligament injury was chronic and irreparable, we opted to bypass the TFCC entirely and engage the DRUJ’s ‘secondary stabilisers’ by overcorrecting the radius length (by 3.5 mm) to restore DRUJ stability. This was performed by lengthening the radius in 1 mm increments, serially assessing the DRUJ stability until the construct was stabilised to stress with full anatomic ROM. Functional radial lengthening achieved appropriate tightening of the secondary DRUJ stabilisers, comprised the extensor carpi ulnaris subsheath, ulnolunate and ulnotriquetral ligaments, lunotriquetral interosseous ligament and the distal interosseous ligament. Cancellous bone autografting optimised healing and promoted union at the osteotomy site, facilitating the additional lengthening of the distracted radius. Use of cancellous bone graft has been previously described in the literature for patients with nonunion and malunion presenting for treatment greater than 6 weeks postinjury.6 18
Our modified technique for chronic, malunited Galeazzi fracture management yielded a single-stage restoration of radial anatomy, stability of the DRUJ and full ROM without the need for further ligamentous repair or revision fixation. The patient was able to perform all necessary work-related activities, including heavy lifting without limitations or pain. We recommend our described technique and associated operative pearls to be included in the reconstructive surgeon’s armamentarium when presented with complicated, chronic Galeazzi fractures.
Learning points
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Chronic, malunited Galeazzi fracture patterns require complex operative planning and management for a successful functional outcome.
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Distal radioulnar joint stability can be restord without triangular fibrocartilage complex repair by way of radius length overcorrection.
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With our simplified technique, chronic, malunited Galeazzi fracture patterns can be successfully repaired in a single-stage procedure, without additional operative intervention.
Ethics statements
Patient consent for publication
Footnotes
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Contributors SRA: organisation, chart review, literature review, preliminary draft, final draft, submission. HCS: chart review, literature review, preliminary draft. TCF: chart review, literature review. SMW: preoperative assessment, operative procedure, postoperative care, final draft.
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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
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Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
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Competing interests None declared.
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Provenance and peer review Not commissioned; externally peer reviewed.
- © BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.
References
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