What is the step-by-step treatment for a fracture Galeazzi using a volar approach with plating?

Step-by-Step Surgical Treatment for Galeazzi Fracture Using Volar Approach with Plating

The optimal treatment for a Galeazzi fracture is open reduction and internal fixation with a volar plate approach, followed by assessment and appropriate management of the distal radioulnar joint (DRUJ). 1

Preoperative Planning

• Obtain appropriate imaging including anteroposterior and lateral radiographs of the forearm to confirm the diagnosis of Galeazzi fracture (fracture of distal third of radius with DRUJ disruption) 1
• Assess for any associated injuries including possible radial head or coronoid process injuries 2
• Plan for appropriate anesthesia (general or regional block) and surgical setup with fluoroscopy availability 1

Surgical Approach

1. Patient Positioning

   • Position the patient supine on the operating table with the affected arm on a radiolucent hand table 1
   • Prepare and drape the entire forearm in sterile fashion 1

2. Volar Approach to the Radius

   • Make a longitudinal incision along the volar aspect of the forearm over the fracture site 1
   • Develop the interval between the flexor carpi radialis and the radial artery 1
   • Retract the flexor tendons and neurovascular structures medially 1
   • Identify and protect the radial artery throughout the procedure 1
   • Expose the pronator quadratus and elevate it from its radial attachment to expose the fracture site 1

3. Fracture Reduction and Fixation

   • Perform anatomic reduction of the radial shaft fracture under direct visualization 2, 1
   • Apply a volar locking plate to the radius, ensuring proper alignment and rotation 3
   • Use appropriate screws to secure the plate to the bone, typically with at least 3 screws proximal and 3 screws distal to the fracture 1
   • Confirm reduction and hardware placement with fluoroscopy in multiple views 1

DRUJ Management

1. Assessment of DRUJ Stability

   • After radius fixation, assess the stability of the DRUJ by performing pronation and supination maneuvers 4
   • If the DRUJ is stable after radius fixation, no additional fixation is needed 4

2. If DRUJ is Unstable:

   • Reduce the DRUJ by direct manipulation 5
   • If persistent instability is present, temporary fixation with Kirschner wires through the DRUJ in a fully supinated position is recommended 2, 6, 5
   • K-wire fixation should be limited to 6 weeks to prevent stiffness 2, 4

Wound Closure and Postoperative Care

1. Closure

   • Repair the pronator quadratus muscle if possible 1
   • Close the wound in layers with attention to hemostasis 1
   • Apply sterile dressing and splint 1

2. Immobilization

   • If DRUJ was stable: Apply a forearm cast until wound healing is complete 4
   • If DRUJ required K-wire fixation: Apply an above-elbow cast with the forearm in supination for approximately 6 weeks 6, 4

3. Rehabilitation Protocol

   • Begin active finger motion exercises immediately to prevent stiffness 7
   • Avoid weight bearing for approximately 2 weeks 7
   • After 2 weeks, if clinically appropriate, begin protected weight bearing with a splint that limits dorsiflexion 7
   • Remove K-wires at 6 weeks if used 2
   • Begin progressive range of motion exercises focusing on pronation and supination after cast/splint removal 2

Follow-up and Monitoring

• Obtain radiographs at 2 weeks post-surgery to assess fracture alignment and hardware position 3
• Additional radiographs should be obtained only if clinically indicated (e.g., new trauma, significant pain, loss of motion) 7
• Monitor for complications including malunion, nonunion, DRUJ instability, and limited pronation/supination 1, 4

Potential Complications and Management

• Failed or inadequate treatment may lead to chronic pain, malunion, or DRUJ instability 1
• Patients with K-wire fixation of the DRUJ may experience diminished pronation or supination compared to those without K-wire fixation 4
• If pseudarthrosis develops (more common with K-wire or rush-pin osteosynthesis than with plate fixation), revision surgery may be necessary 4
• Chronic DRUJ instability may require salvage procedures 1