What is the management approach for a patient presenting with a Galeazzi fracture?

Management of Galeazzi Fracture

All Galeazzi fractures in adults require open reduction and rigid internal fixation of the radial shaft fracture, typically with plate fixation, performed as early as possible to restore anatomic alignment and prevent chronic distal radioulnar joint (DRUJ) instability. 1, 2, 3

Immediate Assessment and Preoperative Management

Initial Evaluation

• Provide immediate pain management with appropriate analgesics before diagnostic workup, tailored to patient comorbidities and renal function 4, 5
• Obtain complete radiographs of the entire forearm including wrist and elbow to identify the radial shaft fracture and assess DRUJ disruption 2
• Classify the fracture based on location: Type I (distal third, within 7.5 cm of distal radius articular surface) or Type II (middle third, >7.5 cm from articular surface) 2
• Type I fractures carry a 55% risk of intraoperative DRUJ instability, while Type II fractures have only a 6% risk 2

Preoperative Optimization

• Perform comprehensive medical assessment including ECG, complete blood count, renal function, and electrolyte status 4
• Ensure adequate fluid management and correction of any volume or electrolyte disturbances 4
• Schedule surgery within 24-48 hours of injury to minimize complications and improve outcomes 4

Surgical Management

Primary Fixation of Radial Shaft

• Perform open reduction and rigid internal fixation with plate osteosynthesis of the radial shaft fracture 1, 3, 6
• Add cancellous bone grafting if needed to promote union 3
• Achieve anatomic reduction to restore normal length, alignment, and rotation of the radius 3, 6

Intraoperative DRUJ Assessment

• After achieving rigid fixation of the radius, test DRUJ stability intraoperatively through full range of pronation and supination 2, 6
• If DRUJ remains unstable after anatomic radial reduction:
  • For Type I fractures (high instability risk): Perform supplemental Kirschner wire transfixion of the DRUJ 2, 6
  • If soft tissue interposition prevents reduction: Perform open reduction and triangular fibrocartilage complex (TFCC) repair 2, 6
• If DRUJ is stable after radial fixation, no additional DRUJ intervention is required 3, 6

Immobilization Protocol

• If DRUJ was pinned: Apply above-elbow cast with forearm in full supination for 6 weeks 1, 6
• If DRUJ was stable without pinning: Apply forearm cast only during wound healing (typically 2 weeks) 6
• Remove Kirschner wires at 6 weeks before initiating range of motion 6

Postoperative Management

Early Mobilization

• Begin supervised range of motion exercises immediately after cast removal 4
• Implement physical training and muscle strengthening as pain allows 4, 7
• Avoid immobilization beyond necessary period to prevent stiffness 6

Monitoring and Follow-up

• Obtain serial radiographs to confirm maintenance of reduction and fracture healing 1, 3
• Monitor for signs of DRUJ instability, loss of pronation/supination, or nonunion 1, 6
• Assess for complications including infection, hardware failure, or complex regional pain syndrome 3

Management of Delayed or Inadequate Initial Treatment

Late Presentation (Up to 10 Weeks)

• Still perform open reduction and internal fixation with immobilization in full supination 1
• Expect potentially inferior outcomes compared to acute treatment 1

Previously Inadequately Treated Cases

• Perform revision surgery with radial fixation AND excision of distal ulna at the same operation 1
• Counsel patient that poor functional outcome is likely despite revision surgery 1

Chronic DRUJ Instability (>6 Months)

• Consider distal ulnar excision (Darrach procedure) only if symptomatic and after 6-month observation period 1
• Note that ulnar styloid union status does not affect final outcome 1

Critical Pitfalls to Avoid

• Never treat adult Galeazzi fractures conservatively—this leads to malunion, chronic DRUJ instability, and poor functional outcomes 1, 3
• Do not routinely explore or repair the DRUJ unless it remains unstable after anatomic radial fixation—most cases achieve stability with radial fixation alone 3, 6
• Avoid Kirschner wire or rush pin fixation of the radius—these lead to pseudarthrosis and require rigid plate fixation 6
• Do not delay surgery beyond 48 hours—early intervention reduces complications and improves outcomes 4
• Maintain high suspicion for DRUJ instability in Type I fractures—test stability intraoperatively in all cases 2