FRCS (Tr & Orth) Oral Examination: Abbreviated Galeazzi Fracture Case Presentation
These are the radiographs of a 20-year-old man who fell on his outstretched hand during a rugby match.
1. Describe the appearances shown in these radiographs.
These are an AP and lateral radiographs of the forearm. They show a midshaft diaphyseal fracture of the radius, which is displaced. The distal ulna is also dorsally displaced, indicating an injury to the distal radioulnar joint (DRUJ). This injury pattern is referred to as a Galeazzi fracture dislocation.
These radiographs show a midshaft diaphyseal fracture of the radius that is displaced, as well as a dorsally displaced distal ulna indicating injury to the distal radioulnar joint (DRUJ). This pattern of injury is known as a Galeazzi fracture dislocation.
2. How would you choose to manage this injury?
In a patient who is fit enough to undertake surgery, I would choose to treat this operatively. After obtaining the necessary consent and preoperative work up and under general anaesthesia with prophylactic antibiotics and a proximal arm tourniquet, I would use a modified Henry’s approach in order to reduce and fix the radius fracture with a 3.5 mm LC-DC plate. I would operate with image intensifier guidance. Reduction of the radius fracture usually facilitates reduction of the DRUJ, but I would check this directly and with the image intensifier. I would also make an assessment of DRUJ stability in the forearm neutral, supinated, and pronated positions. If the DRUJ is entirely stable, I would allow early active movement. DRUJ instability in either forearm supination or pronation would be treated by splinting the forearm in the forearm position of stability (pronation or supination). If I found gross instability in both supination and pronation, then I would percutaneously K-wire the DRUJ in a reduced position in supination. I would use two 2 mm K-wires and would protect the wires for a period of 6 weeks by placing the patient in a hinged elbow brace to allow flexion and extension but to prevent forearm supination and pronation.
In a patient fit enough for surgery, operative treatment would be chosen. After obtaining consent and preoperative workup, the radius fracture would be reduced and fixed with a 3.5 mm LC-DC plate using a modified Henry's approach and image intensifier guidance with general anesthesia, prophylactic antibiotics, and a proximal arm tourniquet. DRUJ stability would be assessed in the forearm neutral, supinated, and pronated positions. If stable, early active movement would be allowed, but if unstable, the forearm would be splinted in the forearm position of stability (pronation or supination). For gross instability in both supination and pronation, percutaneous K-wiring of the DRUJ in a reduced position in supination would be performed using two 2 mm K-wires, and the patient would be placed in a hinged elbow brace for 6 weeks to prevent forearm supination and pronation.
3. What features on a plain radiograph would make you suspicious of a Galeazzi type injury rather than an isolated diaphyseal fracture of the radius?
DRUJ injury is suggested by fracture of the ulnar styloid base, widening of the DRUJ on the PA radiograph, dorsal subluxation of the distal ulna on the lateral radiograph, or marked shortening of the radius relative to the ulna. However, the gold standard for assessment is clinical examination of the DRUJ.
A Galeazzi type injury is suggested by the displacement of the distal ulna, indicating injury to the DRUJ. Features on a plain radiograph that suggest DRUJ injury include fracture of the ulnar styloid base, widening of the DRUJ on the PA radiograph, dorsal subluxation of the distal ulna on the lateral radiograph, or marked shortening of the radius relative to the ulna. However, the gold standard for assessment is clinical examination of the DRUJ.
4. What are the stabilisers of the distal radioulnar joint?
The distal radioulnar joint is stabilized by both bony and soft tissue stabilizers. The bony component is provided by the articulation of the distal ulna with the sigmoid notch of the distal radius. The soft tissue stabilizers include the triangular fibrocartilaginous complex (TFCC), a group of ligaments consisting of the articular disc or triangular fibrocartilage, meniscal homologue, the ulnolunate and the ulnotriquetral ligaments, as well as the dorsal and volar radioulnar ligaments, the extensor carpi ulnaris sub sheath, and the ulnar collateral ligament.
The distal radioulnar joint is stabilized by both bony and soft tissue stabilizers. The bony component is provided by the articulation of the distal ulna with the sigmoid notch of the distal radius. The soft tissue stabilizers include the triangular fibrocartilaginous complex (TFCC), a group of ligaments consisting of the articular disc or triangular fibrocartilage, meniscal homologue, the ulnolunate and the ulnotriquetral ligaments, as well as the dorsal and volar radioulnar ligaments, the extensor carpi ulnaris sub sheath, and the ulnar collateral ligament.
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