A 28-year-old female falls on her extended right wrist while rollerblading. She presents with pain and swelling over the dorsal aspect of the distal forearm. On examination, there is loss of pronation and a prominence over the dorsal wrist. X-rays reveal a fracture of the distal third of the radius with dorsal displacement, and the distal radioulnar joint (DRUJ) appears widened on the AP view. What is the most appropriate initial management?

Explanation

## Diagnosis and Management: Galeazzi Fracture-Dislocation ### Clinical Recognition **Key Point:** A Galeazzi fracture-dislocation is a fracture of the distal third of the radius (typically at the junction of middle and distal thirds) combined with dorsal dislocation of the distal radioulnar joint (DRUJ). The loss of pronation is the clinical hallmark. ### Distinguishing Features from Monteggia | Feature | Monteggia | Galeazzi | |---------|-----------|----------| | **Ulnar involvement** | Fracture of proximal/middle ulna | Intact ulna | | **Radial involvement** | Intact radius | Fracture of distal radius | | **Dislocation site** | Proximal radioulnar joint (radial head) | Distal radioulnar joint (DRUJ) | | **Direction of dislocation** | Anterior (usually) | Dorsal | | **Lost function** | Supination | Pronation | | **Mechanism** | FOOSH, direct blow to forearm | Fall on extended wrist | **High-Yield:** The DRUJ dislocation in Galeazzi is often missed because attention is focused on the obvious radial fracture. Always examine the DRUJ on both AP and lateral views; widening of the DRUJ space on AP view suggests dislocation. ### Why Pronation is Immobilized **Clinical Pearl:** After reduction, the forearm MUST be immobilized in **pronation**, not supination. This is because: 1. Pronation tightens the interosseous membrane and dorsal radioulnar ligaments 2. Pronation reduces tension on the DRUJ and helps maintain reduction 3. Supination would allow the DRUJ to re-dislocate This is a commonly tested detail — students often confuse the position with Monteggia management. ### Management Algorithm ```mermaid flowchart TD A[Galeazzi Fracture-Dislocation]:::outcome --> B{Reduction Stable?}:::decision B -->|Yes: Closed reduction achieved| C[Long-arm cast in PRONATION]:::action B -->|No: Unstable or irreducible| D[ORIF of radius ± DRUJ repair]:::action C --> E[6 weeks immobilization]:::action C --> F[X-ray at 2 weeks to confirm]:::action D --> G[DRUJ exploration if needed]:::action E --> H[Early ROM exercises]:::action F --> I{Reduction maintained?}:::decision I -->|Yes| H I -->|No| D ``` **Mnemonic:** **GALEAZZI = Distal Radius fracture + DRUJ dislocation; Pronation immobilization** ("Galeazzi = distal radius; pronation prevents re-dislocation") ### Why Option 0 is Correct 1. **Closed reduction** is attempted first — most Galeazzi fractures can be reduced by longitudinal traction and realignment 2. **Long-arm cast** is required to immobilize both the radial fracture and DRUJ 3. **Pronation position** is essential to maintain DRUJ reduction by tightening the interosseous membrane 4. **6 weeks** is the standard duration for union of a distal radial fracture ### When to Consider ORIF - Unstable fracture pattern (comminution, intra-articular extension) - Failure to achieve or maintain closed reduction - Associated injuries requiring operative intervention - Displaced DRUJ dislocation that cannot be reduced [cite:Rockwood & Green's Fractures in Adults Ch 31]