A 28-year-old female presents with a fracture of the distal third of the radius with dorsal angulation and an associated dislocation of the distal radioulnar joint (DRUJ). Neurovascular examination is normal. After initial closed reduction and immobilization in a long-arm cast, repeat X-rays at 1 week show loss of reduction with re-angulation of the radius fracture and DRUJ subluxation. What is the most appropriate next step in management?

Explanation

## Galeazzi Fracture: Definition & Principles **Key Point:** A Galeazzi fracture is a fracture of the distal third of the radius (typically in the distal or middle-distal third) combined with dislocation or subluxation of the distal radioulnar joint (DRUJ). It is often called a "fracture of necessity" because it frequently requires operative fixation. ### Galeazzi vs. Monteggia Comparison | Feature | Monteggia | Galeazzi | |---------|-----------|----------| | **Radius fracture location** | Proximal/middle third | Distal third | | **Associated injury** | Radial head dislocation | DRUJ dislocation | | **Mechanism** | FOOSH, fall on extended elbow | Fall on extended wrist, direct blow | | **Closed reduction success** | High (70%) | Low (20-30%) | | **ORIF indication** | Unstable or failed reduction | Majority of cases | | **Immobilization position** | Supination | Supination | **High-Yield:** Galeazzi fractures are notoriously unstable and have a high failure rate with closed treatment alone. Loss of reduction, as in this case, is a strong indication for ORIF. ## Management Algorithm for Galeazzi Fracture ```mermaid flowchart TD A["Galeazzi Fracture Diagnosed"]:::outcome --> B{"Neurovascular Status?"}:::decision B -->|"Compromised"| C["Urgent ORIF"]:::urgent B -->|"Intact"| D["Attempt Closed Reduction"]:::action D --> E["Immobilize in supination"]:::action E --> F["X-ray at 1 week"]:::action F --> G{"Reduction Maintained?"}:::decision G -->|"Yes"| H["Continue conservative treatment"]:::action G -->|"No"| I["ORIF with plate fixation"]:::action I --> J["Restore DRUJ stability"]:::action ``` ### Why Closed Reduction Fails in Galeazzi 1. **Soft tissue interposition:** The extensor carpi radialis longus (ECRL) and other soft tissues may be trapped in the fracture site, preventing reduction. 2. **DRUJ instability:** The DRUJ dislocation is often secondary to the radius fracture; reduction of the fracture alone may not restore DRUJ stability. 3. **High mechanical forces:** The distal radius is subject to significant muscular and ligamentous forces that promote re-displacement. 4. **Loss of reduction is common:** Studies show that 20–30% of Galeazzi fractures lose reduction within the first 2 weeks of closed treatment. **Clinical Pearl:** The phrase "fracture of necessity" refers to the high necessity for operative fixation. Closed treatment has a poor track record. ## Indications for ORIF in Galeazzi Fracture - **Loss of reduction** on follow-up radiographs (as in this case) - **Unstable fracture pattern** (comminution, angulation >10°) - **DRUJ subluxation** that cannot be maintained with closed reduction - **Neurovascular compromise** - **Open fracture** - **Polytrauma** requiring early mobilization **Warning:** Accepting loss of reduction in a Galeazzi fracture leads to chronic DRUJ instability, wrist pain, and loss of forearm rotation. This must be corrected. ## Operative Technique - **Plate fixation:** 3.5 mm compression plate (LC-DCP or volar plate) with at least 6 cortices (3 screws) on each side of the fracture. - **DRUJ assessment:** After radius fixation, assess DRUJ stability. If unstable, consider percutaneous pinning or ligament repair. - **Restoration of radial bow:** Critical to maintain forearm rotation; volar plate placement helps restore anatomic radial bow. **High-Yield:** ORIF with plate fixation is the gold standard for unstable or displaced Galeazzi fractures. It provides superior outcomes compared to repeated closed reduction attempts. [cite:Rockwood & Green's Fractures in Adults 9e Ch 28]