Galeazzi Fractures - Causes, Symptoms, Diagnosis, and Management

Introduction

The lower part of the arm (forearm) comprises two bones called the ulna and the radius. These bones are very important for complicated wrist and hand movements. The distal radioulnar joint (DRUJ) is where the bones in the arm meet at the wrist. This joint is important for the function and stability of the wrist. The Galeazzi fracture injury pattern was initially documented by Cooper in 1842. Later, in 1934, Ricardo Galeazzi, an Italian surgeon, reported his experience with 18 fractures exhibiting this pattern.

What Are Galeazzi Fractures?

The Galeazzi fracture is a broken bone in the middle to distal one-third of the radius (near the wrist), along with the misalignment or partial dislocation of the joint near the wrist (distal radioulnar joint). Galeazzi fractures make up around 7 % of adult forearm fractures, with one in four radial shaft fractures being true Galeazzi injuries. These fractures occur more frequently in males and are most common in people aged 9 to 12. Bilateral Galeazzi fractures are unusual but rare.

What Causes a Galeazzi Fracture?

Galeazzi fractures result from axial loading (force applied along the length of the bone) and rotational forces applied to the forearm. This commonly occurs when a person falls onto an outstretched hand with the elbow partially flexed, leading to a radius fracture and dislocation or subluxation of the distal radioulnar joint (DRUJ). This injury pattern can destabilize the forearm and disrupt its normal biomechanics. The ulna remains relatively intact in these fractures. Motor vehicle accidents, sports injuries, and other high-impact incidents can generate the forces necessary to produce a Galeazzi fracture.

What Are the Signs and Symptoms of a Galeazzi Fracture?

• Pain: Patients with Galeazzi fractures experience pain in the forearm and wrist.

• Soft Tissue Swelling: Swelling of the soft tissues is common around the distal-third radial fracture and wrist joint. Tenderness and ecchymosis (bruising) over the fracture site may also be present.

• Possible Nerve Issues: In some cases, there might be issues with the anterior interosseous nerve (AIN), a median nerve branch. This can lead to difficulty moving certain hand muscles and a loss of the ability to pinch between the thumb and index finger.

How Are Galeazzi Fractures Diagnosed?

Galeazzi fractures are diagnosed with a thorough clinical evaluation and other imaging tests.

Clinical Evaluation:

• Inspection - The doctor first visually inspects the injured area, searching for visible deformities, skin cuts, muscle bruises, tendon or nerve damage, and any signs of blood vessel damage.

• Palpation - Then, the injured area is gently palpated to detect deformities and identify tender spots. If there are open wounds, special care is taken, as these require immediate surgical attention.

• Assessing the Joint Stability - The doctor checks the stability of nearby joints, especially the distal radioulnar joint. If a patient has fallen on an outstretched hand, suggesting possible wrist injuries, the doctor pays close attention to the DRUJ.

• Neurovascular Examination - In high-impact injuries, the doctor conducts a thorough neurovascular examination, looking for signs of acute compartment syndrome. They inquire about weakness, numbness, tingling, or radiating pain. While nerve injuries are less common, assessing the median and radial nerve distributions is important to identify nerve damage.

Imaging Studies:

X-rays - An anteroposterior (front-to-back) and lateral (side) view X-ray is often enough to identify the injury. Sometimes, an additional oblique view may also be needed. If other injuries are suspected, X-rays of the wrist and elbow are also done.

Signs that the distal radioulnar joint (DRUJ) is disrupted include:

• Widening of the DRUJ on the front-to-back view.

• A broken bone at the bottom of the ulnar styloid.

• Displacement of the radius about the ulna on the side view.

• Shortening the radius by more than 5 mm compared to the unaffected limb.

Advanced Imaging - If doctors need more information before an operation or to make a treatment plan, they may use a CT scan to check for bones that have not healed properly. Sometimes, it is challenging to assess DRUJ integrity with plain X-rays alone. In such cases, a bilateral axial CT scan of the forearm is preferred for diagnosing DRUJ disruption. An MRI can also see any tears in the triangular fibrocartilage complex (TFCC) or if the interosseous membrane is disrupted.

How Are Galeazzi Fractures Managed?

Patients with suspected or confirmed Galeazzi fractures should consult an orthopedic specialist. Open forearm fractures require immediate surgical intervention. Open wounds may be included in the surgical incision. Stabilization of the radial fracture and DRUJ is recommended without delay.

Initial Management:

• Children: In most cases, conservative management is the primary approach. This involves closed reduction (restoring the broken bones) and splinting with an above-elbow cast. Surgical intervention in pediatric cases is considered if closed reduction is unsuccessful or if the initial anatomic reduction cannot be maintained.

• Adults: Surgical intervention is generally preferred over closed reduction and immobilization due to better outcomes. All adult Galeazzi fractures should undergo open reduction and internal fixation (ORIF) for proper anatomical alignment and healing. Surgical treatment includes repairing the radial shaft fracture and, if necessary, addressing the distal radioulnar joint (DRUJ) stability.

Rehabilitation: Recovery time varies depending on the severity of the injury and the patient's intended use of their arm. Rehabilitation typically begins 6 to 8 weeks after surgical fixation, aiming for full range of motion and fine motor skills without pain. Full return to activity can take 8 to 12 weeks for low-physical-demand patients and 12 to 16 weeks for those with high-physical demands.

What Are the Complications of Galeazzi Fractures?

Complications of Galeazzi fractures include the following:

• The broken radius may fail to heal properly (non-union) or heal in a misaligned way (malunion), causing persistent pain and functional limitations.

• Infection can occur following surgery or as a result of an open fracture.

• Removing surgical plates may result in the re-breaking of the radius.

• Radial nerve injuries are relatively common during surgery for Galeazzi fractures, with damage often occurring in the sensory branch of the nerve. The posterior interosseous nerve (PIN) can also be at risk, particularly during certain surgical approaches.

• Instability of the distal radioulnar joint may happen if the injury is not correctly identified, dislocation is not properly reduced during surgery, or obstacles prevent a proper reduction, like soft tissue blockage.

• Ulnar nerve injury has been reported in rare cases.

• Delayed ruptures of tendons may occur many years after the initial injury or treatment.

Conclusion

Galeazzi fractures are challenging to treat but can be effectively managed with the right treatment and surgery if needed. The outlook for patients with Galeazzi fractures is different for each person. However, if they get the right care and treatment at the right time, many of them can recover well and have good outcomes.