What is the step-by-step procedure for treating a right Galeazzi fracture with plating?

Step-by-Step Procedure for Galeazzi Fracture Plating of the Right Forearm

The surgical treatment of a right Galeazzi fracture requires open reduction and internal fixation with plate and screws, as this is the gold standard treatment for adults with this injury. 1

Preoperative Assessment and Planning

• Confirm diagnosis with appropriate radiographs, ensuring both AP and lateral views of the entire forearm including the wrist and elbow joints 1
• Evaluate the distal radioulnar joint (DRUJ) disruption, which is a defining characteristic of Galeazzi fractures 2
• Assess for any associated injuries or complications 1
• Plan for appropriate plate selection (typically a dynamic compression plate or locking plate) 3

Anesthesia and Positioning

• Position the patient supine on the operating table with the affected arm on a radiolucent arm board 2
• Administer appropriate anesthesia (general anesthesia or regional block) 3
• Apply a tourniquet to the upper arm and elevate the limb for exsanguination 2

Surgical Approach

• Make an anterior (volar) Henry approach to access the radial shaft fracture 2

  • Begin the incision at the distal forearm over the fracture site and extend proximally along the flexor carpi radialis tendon
  • Develop the interval between the brachioradialis and flexor carpi radialis
  • Identify and protect the radial artery and superficial branch of the radial nerve

• Carefully retract the flexor pollicis longus and pronator quadratus to expose the fracture site 3

Fracture Reduction and Fixation

• Perform anatomic reduction of the radial fracture fragments under direct visualization 1
• Apply temporary fixation with K-wires or reduction clamps to maintain the reduction 3
• Select an appropriately sized plate (typically a 3.5mm dynamic compression plate or locking plate) 2
• Position the plate on the volar (anterior) surface of the radius 2
• Secure the plate with screws, ensuring at least 6-8 cortices of fixation on each side of the fracture 3
• Confirm adequate reduction and fixation with intraoperative fluoroscopy 1

DRUJ Assessment and Management

• After radius fixation, assess the stability of the DRUJ by:

  • Performing a ballottement test of the distal ulna 1
  • Testing forearm rotation for stability and congruency 2

• If the DRUJ is stable after radius fixation:

  • No additional fixation is needed 1
  • Plan for immobilization with the forearm in supination 4

• If the DRUJ remains unstable:

  • Reduce the DRUJ and assess for interposed soft tissues that may block reduction 5
  • Check for ulnar styloid fractures that may need fixation 5
  • Consider temporary K-wire fixation across the DRUJ in supination 4

Wound Closure and Immobilization

• Irrigate the wound thoroughly 2

• Close the wound in layers:

  • Repair the deep fascia
  • Close the subcutaneous tissue
  • Close the skin with sutures or staples 2

• Apply a sterile dressing 2

• Place the forearm in a long-arm cast or splint with the elbow at 90 degrees and the forearm in supination to maintain DRUJ stability 4

Postoperative Management

• Maintain immobilization with the forearm in supination for 4-6 weeks to help maintain DRUJ stability 4
• If K-wires were used for DRUJ fixation, remove them at 4-6 weeks 4
• Begin progressive range of motion exercises after immobilization period 1
• Monitor for complications including DRUJ instability, malunion, limited forearm rotation, chronic wrist pain, and osteoarthritis 1

Common Pitfalls and How to Avoid Them

• Failure to recognize DRUJ instability: Always assess DRUJ stability after radius fixation 1
• Inadequate fixation: Ensure rigid fixation with at least 6-8 cortices on each side of the fracture 3
• Improper immobilization: Maintain the forearm in supination during immobilization to optimize DRUJ healing 4
• Missed interposed soft tissues: Check for soft tissue interposition (especially extensor carpi ulnaris tendon) if DRUJ reduction is difficult 5
• Delayed treatment: Early surgical intervention provides better outcomes than delayed treatment 4