A 35-year-old female presents 4 hours after a fall on an outstretched hand with dorsal wrist pain and swelling. X-rays reveal a fracture of the distal radius with dorsal angulation and a posterior dislocation of the distal radioulnar joint (DRUJ). There is no associated ulnar fracture. What is the most appropriate next step in management?

Explanation

## Galeazzi Fracture-Dislocation: Management Algorithm **Key Point:** A Galeazzi fracture-dislocation is a fracture of the distal radius (typically distal third) combined with dislocation of the distal radioulnar joint (DRUJ). Unlike Monteggia fractures, there is **no ulnar fracture**; instead, the injury involves disruption of the DRUJ complex. ### Anatomic Basis The DRUJ is stabilized by: - The interosseous membrane (proximal) - The triangular fibrocartilage complex (TFCC) — distal - The pronator quadratus muscle A fracture of the distal radius with dorsal angulation typically causes **posterior dislocation of the DRUJ** due to disruption of the TFCC. ### Classification & Presentation | Feature | Monteggia | Galeazzi | | --- | --- | --- | | **Primary fracture** | Ulna (proximal/middle third) | Radius (distal third) | | **Associated injury** | Radial head dislocation | DRUJ dislocation | | **Mechanism** | Fall on outstretched hand + pronation | Fall on outstretched hand + dorsiflexion | | **Reduction priority** | Fix ulna first | Fix radius first | **High-Yield:** The mnemonic **"Galeazzi = Radius fracture + DRUJ dislocation"** helps distinguish it from Monteggia. ### Management Principles ```mermaid flowchart TD A[Galeazzi Fracture-Dislocation]:::outcome --> B[Closed Reduction of Radius]:::action B --> C{DRUJ Stable?}:::decision C -->|Yes| D[ORIF Radius with Plate]:::action C -->|No| E[ORIF Radius + DRUJ Repair/Pinning]:::action D --> F[Immobilize 6 weeks]:::action E --> F ``` **Clinical Pearl:** The standard approach is: 1. **Closed reduction** of the radial fracture under general anesthesia 2. **Assessment of DRUJ stability** — attempt to reduce the DRUJ by supinating the forearm 3. **ORIF of the radius** using a volar or dorsal plate (depending on fracture pattern) 4. **If DRUJ remains unstable or irreducible**, proceed to open reduction of the DRUJ and repair of the TFCC; percutaneous pinning of the DRUJ may be required **Warning:** Closed reduction and casting alone has a high failure rate. ORIF of the radius is the standard of care. Additionally, the DRUJ must be assessed intraoperatively; if it remains unstable, direct intervention is required. **Mnemonic:** **"Galeazzi: Radius first, then DRUJ"** — Fix the radius operatively; assess and treat the DRUJ based on stability. [cite:Rockwood & Green's Fractures in Adults Ch 29]