Open reduction and internal fixation of Galeazzi fracture-dislocation — distal-third radial shaft fracture with disruption of the distal radioulnar joint: recognition of DRUJ instability, volar Henry approach, anatomic plate fixation, DRUJ assessment, and staged management of residual instability
High-yield overview
Open reduction and internal fixation of the Galeazzi fracture-dislocation — distal-third radial shaft fracture with DRUJ disruption | intermediate
Surgical Imaging
Galeazzi injury: the distal radial shaft fracture is plated to anatomical length and rotation, then the distal radioulnar joint is assessed and stabilised.Credit: AI-generated medical illustration · OrthoVellum
Critical Danger Structures and Exam Traps
Radial Artery — Henry Approach Wrist
Location: The radial artery runs between brachioradialis and FCR in the distal forearm. At the level of the distal radial metaphysis it lies directly on the volar radius, just radial to the flexor carpi radialis tendon.
Risk: In the distal third of the Henry approach, the artery is closely applied to the bone. Aggressive subperiosteal dissection radially can lacerate the artery before the surgeon is aware of it. Retract the artery radially with brachioradialis after identifying it; keep the blade on bone throughout the exposure.
Posterior Interosseous Nerve — Proximal Henry
Location: The PIN (deep branch of the radial nerve) pierces the supinator muscle from anterior to posterior, winding around the radial neck. It lies approximately 6-8 cm proximal to the radiocapitellar joint line.
Risk: When extending the Henry approach proximally beyond the radial tuberosity, the PIN is at risk between the two heads of the supinator. The nerve is protected by keeping dissection on bone, supinating the forearm (which moves the PIN posteriorly), and NOT dissecting within the supinator muscle belly itself.
Superficial Radial Nerve
Location: The superficial radial nerve (SRN) emerges from beneath brachioradialis about 8-10 cm proximal to the radial styloid, piercing the deep fascia to lie in the subcutaneous plane on the dorsoradial forearm.
Risk: The SRN is vulnerable during subcutaneous dissection on the radial side of the forearm. It is not seen in the standard Henry interval, but retraction of brachioradialis radially can stretch it. Prolonged or vigorous retraction causes a neurapraxia presenting as numbness on the dorsoradial hand. Use intermittent, careful retraction and avoid retractors placed deep to brachioradialis distally.
DRUJ Assessment — The Critical Step
What to do: After plate fixation of the radius, the DRUJ must be assessed before wound closure. Examine stability in pronation, neutral, and supination with the elbow flexed 90 degrees. Apply volar and dorsal stress to the ulnar head.
Interpretation: (1) Stable in full ROM → cast in neutral. (2) Reducible but unstable (subluxates with stress) → K-wire transfixion in supination. (3) Irreducible (cannot seat the ulnar head) → open reduction of DRUJ — most commonly ECU tendon or capsule incarcerated in the joint.
Galeazzi vs Monteggia — Classic Exam Trap
Galeazzi (the memory aid: 'G' = radius 'goes' away from ulna): radial shaft fracture (usually distal third) with DRUJ disruption. The radial fracture is the obvious injury; the DRUJ disruption is the hidden one.
Monteggia ('M' = ulnar fracture 'meets' the radial head): proximal ulnar fracture with radial head dislocation. Different injury, different approach, different fixation — do not confuse them. The treatments are opposite (Galeazzi: radius fixation + DRUJ management; Monteggia: ulna fixation + radial head reduction).
Compartment Syndrome — Forearm
Risk: Forearm compartment syndrome can develop after high-energy Galeazzi fractures, particularly those with significant soft tissue swelling, crush mechanisms, or delayed presentation.
Recognition: Pain on passive stretch of the digits (particularly with wrist/finger extension), tense swollen compartments, paresthesiae. The radial artery pulse may still be present early. Compartment pressures greater than 30 mmHg (or within 30 mmHg of diastolic pressure) indicate the need for urgent fasciotomy. Do not rely on pulse status — it is a late finding.
Acute Galeazzi fracture-dislocation in an adult patient
Irreducible DRUJ dislocation (ECU or other soft tissue interposition)
Open fracture requiring debridement and stabilisation
Floating forearm (ipsilateral radius and ulnar shaft fracture)
Relative Indications
Displaced distal radial shaft fracture with radiographic evidence of DRUJ disruption (ulnar styloid base fracture, positive ulnar variance greater than 2 mm, ulnar head dislocation on lateral view)
Failed closed treatment in a paediatric patient approaching skeletal maturity
Contraindications
Absolute:
Active infection over the surgical site
Unstable medical comorbidity precluding anaesthesia
Relative:
Non-displaced or minimally displaced distal radial shaft fracture with a clearly stable DRUJ on examination under anaesthesia (rare — only in lower-demand patients)
Severe osteopenia precluding plate fixation (consider alternative fixation, external fixation, or non-operative management with informed consent)
The 'Fracture of Necessity' — Why Non-Operative Treatment Fails
Non-operative management of Galeazzi fractures in adults has been abandoned because of an unacceptably high rate of treatment failure:
Closed reduction and cast immobilisation fails to maintain radial length in the vast majority
The brachioradialis and pronator quadratus produce deforming forces that shorten and malrotate the distal fragment
Persistent radial shortening greater than 2 mm leads to ulnar impaction, DRUJ incongruity, and pain
The classic study by Mikic (1975) showed 92% poor results with non-operative treatment versus 92% good-to-excellent with ORIF in his series
Evidence for Treatment
Surgical versus Non-Operative Management
Union rate
Non-Operative
60-70% (with late displacement)
ORIF
greater than 95%
DRUJ instability at follow-up
Non-Operative
Up to 50%
ORIF
5-10%
Malunion rate
Non-Operative
30-50%
ORIF
less than 5%
Return to work
Non-Operative
Delayed (prolonged casting)
ORIF
Mean 10-14 weeks
Grip strength recovery
Non-Operative
60-80% of contralateral
ORIF
85-95% of contralateral
Patient-reported satisfaction
Non-Operative
40-60% good-excellent
ORIF
85-95% good-excellent
Parameter
Non-Operative
ORIF
Union rate
60-70% (with late displacement)
greater than 95%
DRUJ instability at follow-up
Up to 50%
5-10%
Malunion rate
30-50%
less than 5%
Return to work
Delayed (prolonged casting)
Mean 10-14 weeks
Grip strength recovery
60-80% of contralateral
85-95% of contralateral
Patient-reported satisfaction
40-60% good-excellent
85-95% good-excellent
Plate Fixation
3.5 mm LC-DCP (limited contact dynamic compression plate) is the historical gold standard; requires precise contouring to the volar radial bow
3.5 mm LCP (locking compression plate) offers angular stability in osteoporotic bone and less need for precise contouring; preferred in comminuted fractures
Dual plating (volar + radial or dorsal) is rarely needed but can be used for very distal fractures where a single plate has insufficient distal fixation
Bridge plating for comminuted segmental fractures where absolute stability is not achievable; aims for relative stability and indirect reduction
Timing of Surgery
Primary ORIF is recommended within 24-48 hours for closed injuries. Open fractures require emergency debridement and stabilisation at the first available theatre slot. Delayed reconstruction (greater than 3 weeks) is associated with more difficult reduction, higher complication rates, and less predictable DRUJ outcomes.
Galeazzi Fracture — Management Options Compared
Key Evidence
Evidence
Galeazzi fracture-dislocations
Level IV
Mikic ZD
Clinical implication: Established ORIF as the standard for Galeazzi fractures in adults; non-operative treatment should not be used in the adult population.
Results of compression-plating of closed Galeazzi fractures
Level IV
Moore TM, Klein JP, Patzakis MJ, Harvey JP Jr
Clinical implication: Reinforced the two essential tenets: anatomic radial fixation plus mandatory DRUJ assessment; poor outcomes almost always trace back to one of these being compromised.
Galeazzi fracture-dislocation: a new treatment-oriented classification
Level IV
Rettig ME, Raskin KB
Clinical implication: The distance of the radial fracture from the joint is a reliable predictor of DRUJ disruption; fractures within 7.5 cm of the midcarpal joint require ORIF with mandatory DRUJ assessment.
The interosseous membrane of the forearm: structure and its role in Galeazzi fractures
Level IV
Schneiderman G, Meldrum RD, Bloebaum RD, Tarr R, Sarmiento A
Clinical implication: Explains the biomechanical rationale for anatomic radial fixation: restoring length tensions the IOM, which in turn stabilises the DRUJ. The IOM is the mechanical link between the radial fracture and the DRUJ.
The radius has a gentle lateral (radial) bow in the coronal plane and a gentle volar bow in the sagittal plane — both must be restored during plating to avoid malunion
The radial shaft is triangular in cross-section proximally (with distinct volar, dorsal, and lateral surfaces) and becomes more rectangular and broad distally
The pronator tuberosity (insertion of pronator teres) lies on the lateral surface at the junction of the middle and proximal thirds — it is an important landmark for the midshaft
The radial tuberosity (bicipital tuberosity) lies medially, just distal to the radial neck — the proximal boundary of the Henry approach
The distal radius flares into a broad metaphysis that articulates with the scaphoid and lunate facets distally and the sigmoid notch (for the ulnar head) medially
Surgical Landmarks
Radial styloid
Location
Distal radial tip
Relevance
Palpable; origin of brachioradialis tendon; distal extent of Henry approach
Lister tubercle
Location
Dorsal distal radius
Relevance
Dorsal landmark; EPL tendon wraps around it; not encountered in volar approach
Pronator tuberosity
Location
Middle-third lateral radius
Relevance
Pronator teres insertion — marks the transition from proximal to middle third
Radial tuberosity
Location
Proximal medial radius
Relevance
Distal to radial neck; proximal boundary of safe dissection for PIN
Sigmoid notch
Location
Medial distal radius
Relevance
Articulates with ulnar head; DRUJ articular surface
Landmark
Location
Relevance
Radial styloid
Distal radial tip
Palpable; origin of brachioradialis tendon; distal extent of Henry approach
Lister tubercle
Dorsal distal radius
Dorsal landmark; EPL tendon wraps around it; not encountered in volar approach
Pronator tuberosity
Middle-third lateral radius
Pronator teres insertion — marks the transition from proximal to middle third
Radial tuberosity
Proximal medial radius
Distal to radial neck; proximal boundary of safe dissection for PIN
Sigmoid notch
Medial distal radius
Articulates with ulnar head; DRUJ articular surface
The Volar Henry Approach — Surgical Interval
Interval
Interval: between brachioradialis (radially) and flexor carpi radialis (FCR) (ulnarly)
Superficial dissection: skin and subcutaneous fat — protect the superficial radial nerve emerging from beneath brachioradialis in the distal third
Deep dissection: incise the deep fascia over FCR; retract FCR ulnarly and brachioradialis radially; the radial artery is encountered between them — this is the landmark of the Henry interval
Radial artery: lies immediately deep to the interval between brachioradialis and FCR; it is retracted radially WITH brachioradialis to protect it; the venae comitantes travel with it
Approaches by Zone (Distal to Proximal)
Distal third (wrist to pronator quadratus):
The radial artery is the key structure — it runs directly on the volar radius
Pronator quadratus muscle is elevated subperiosteally from the radius from radial to ulnar
The superficial radial nerve emerges from under brachioradialis about 8-10 cm proximal to the radial styloid — protect it
Good access to the distal radial metaphysis and distal shaft
Middle third (pronator quadratus to pronator teres):
The radial artery moves away from the bone in the mid-forearm, lying between brachioradialis and FCR
The flexor digitorum superficialis (FDS) and flexor pollicis longus (FPL) origins from the volar radius are encountered
The median nerve and its branches are deeper and ulnar — usually not directly visualised but must be protected from retraction pressure
Pronator teres inserts on the lateral radius at the junction of middle and proximal thirds; it can be released for exposure and later repaired
Proximal third (pronator teres to bicipital tuberosity):
The posterior interosseous nerve (PIN) is the critical structure — it wraps around the radial neck within the supinator muscle
The forearm is supinated to protect the PIN (moves it posteriorly away from the operative field)
The supinator muscle is elevated off the radius carefully — do not dissect within the muscle belly
The recurrent radial artery (a branch off the radial artery) crosses the interval and may need ligation
DRUJ Anatomy
Components
Sigmoid notch of the radius — shallow curved articular surface (approximately 60-90 degrees of arc); articulates with the ulnar head
Ulnar head — dome-shaped distal ulna; articulates with the sigmoid notch and the TFCC
Triangular fibrocartilage complex (TFCC) — the primary stabiliser of the DRUJ, consisting of:
Triangular fibrocartilage proper (articular disc)
Ulnar collateral ligament
Dorsal and volar radioulnar ligaments (deep and superficial limbs)
Extensor carpi ulnaris (ECU) tendon and its subsheath
Ulnolunate and ulnotriquetral ligaments (palmar)
Meniscus homologue
Key Stabilisers
Radioulnar ligaments (dorsal and volar)
Function in DRUJ Stability
Primary stabilisers; tighten in pronation (dorsal) and supination (volar)
TFCC proper
Function in DRUJ Stability
Provides the load-bearing surface for the ulnar carpus
ECU subsheath
Function in DRUJ Stability
Dynamic stabiliser; ECUs contraction tensions the subsheath, compressing the ulnar head into the sigmoid notch
Interosseous membrane (central band)
Function in DRUJ Stability
40-60% of longitudinal stability; tensioned by radial length restoration
Pronator quadratus
Function in DRUJ Stability
Dynamic stabiliser in supination; also compresses DRUJ
Structure
Function in DRUJ Stability
Radioulnar ligaments (dorsal and volar)
Primary stabilisers; tighten in pronation (dorsal) and supination (volar)
TFCC proper
Provides the load-bearing surface for the ulnar carpus
ECU subsheath
Dynamic stabiliser; ECUs contraction tensions the subsheath, compressing the ulnar head into the sigmoid notch
Interosseous membrane (central band)
40-60% of longitudinal stability; tensioned by radial length restoration
Pronator quadratus
Dynamic stabiliser in supination; also compresses DRUJ
Neurovascular Structures at Risk
Radial artery
Location
Between brachioradialis and FCR, applied to radius distally
Risk in Approach
Highest risk in distal third of Henry approach; retract radially with BP; use careful subperiosteal dissection
Superficial radial nerve
Location
Emerges from under brachioradialis 8-10 cm proximal to radial styloid
Risk in Approach
At risk from retraction of brachioradialis; use intermittent, gentle retraction
Posterior interosseous nerve (PIN)
Location
Wraps around radial neck within supinator
Risk in Approach
At risk in proximal third Henry; supinate forearm to move PIN posteriorly; do not dissect within supinator
Median nerve (and its palmar cutaneous branch)
Location
Runs deep to FDS in the mid-forearm
Risk in Approach
At risk from over-zealous retraction of FCR/FDS complex ulnarly; avoid prolonged deep retraction
Lateral antebrachial cutaneous nerve
Location
Terminal branch of musculocutaneous nerve; runs on superficial aspect of FCR
Risk in Approach
Can be injured during superficial dissection or retraction; often overlooked as a cause of post-operative dysaesthesia
Radial nerve (main trunk)
Location
Between brachioradialis and brachialis in the proximal forearm
Risk in Approach
Only at risk in very proximal extension above the supinator — rare in standard Galeazzi approach
Structure
Location
Risk in Approach
Radial artery
Between brachioradialis and FCR, applied to radius distally
Highest risk in distal third of Henry approach; retract radially with BP; use careful subperiosteal dissection
Superficial radial nerve
Emerges from under brachioradialis 8-10 cm proximal to radial styloid
At risk from retraction of brachioradialis; use intermittent, gentle retraction
Posterior interosseous nerve (PIN)
Wraps around radial neck within supinator
At risk in proximal third Henry; supinate forearm to move PIN posteriorly; do not dissect within supinator
Median nerve (and its palmar cutaneous branch)
Runs deep to FDS in the mid-forearm
At risk from over-zealous retraction of FCR/FDS complex ulnarly; avoid prolonged deep retraction
Lateral antebrachial cutaneous nerve
Terminal branch of musculocutaneous nerve; runs on superficial aspect of FCR
Can be injured during superficial dissection or retraction; often overlooked as a cause of post-operative dysaesthesia
Radial nerve (main trunk)
Between brachioradialis and brachialis in the proximal forearm
Only at risk in very proximal extension above the supinator — rare in standard Galeazzi approach
Positioning and Preparation
Patient position: Supine on a standard operating table. The arm is abducted 90 degrees on a hand table or arm board. A tourniquet is applied to the upper arm (250-300 mmHg) after exsanguination — inflate only if needed; many cases can be performed without tourniquet or with a low-pressure tourniquet.
Image intensifier: Position a C-arm perpendicular to the table from the contralateral side. The hand table must be radioucent at the forearm segment. Confirm adequate AP and lateral views of the distal radius and DRUJ before draping.
Preparation: Prepare the limb from the axilla to the fingers with iodine or chlorhexidine-alcohol. Drape with the hand and forearm exposed to allow intraoperative pronation-supination for DRUJ assessment. The hand is included in the field for rotational assessment.
Anaesthesia: General anaesthesia or regional block (supraclavicular/infraclavicular brachial plexus block). Muscle relaxation facilitates fracture reduction.
Consent: Specifically counsel regarding radial artery injury (less than 1%), PIN neurapraxia (1-3%), superficial radial nerve dysaesthesia (2-5%), infection (less than 1%), compartment syndrome (rare), nonunion (1-3%), malunion (less than 5%), persistent DRUJ instability (5-10%), stiffness, and the possible need for K-wire transfixion or secondary DRUJ surgery.
Step-by-Step Operative Technique
Step 1: Surface Marking and Incision
Palpate the radial styloid distally and the lateral epicondyle proximally. Mark the course of the radial artery (palpate the pulse) and the FCR tendon (ulnar to the radial artery at the wrist crease).
Incision: A longitudinal incision is made over the interval — centred on the radial fracture site. For a typical distal-third Galeazzi fracture, the incision begins 3-4 cm proximal to the wrist crease over the FCR tendon and extends proximally 10-12 cm along the radial border of the forearm. The incision is gently curved so that it lies over the course of the radial artery in the distal forearm.
Clinical Pearl
Technical Tip: 'I palpate the radial artery pulse at the wrist and mark it before inflation of the tourniquet. My skin incision lies just radial to the FCR tendon — this puts me directly over the Henry interval. I make the incision long enough to expose the entire fracture site plus one plate length proximally and distally — inadequate exposure is a common cause of poor reduction.'
Dangers at this step
Incision too far radial — enters the dorsal compartment and misses the correct interval
Incision too short — insufficient exposure for plate application; the fracture cannot be properly reduced when only one end is visible
Not marking the radial artery before tourniquet inflation — the artery is more easily palpated with a pulse present
Step 2: Superficial Dissection
Incise the skin with a number 15 blade. Deepen through subcutaneous fat with electrocautery or scissors. Identify and protect the superficial radial nerve as it emerges from beneath the brachioradialis tendon in the distal forearm — it lies in the subcutaneous plane lateral to the interval.
Incise the deep fascia over the FCR tendon longitudinally. Develop the plane between the FCR (ulnarly) and the brachioradialis (radially). The radial artery and its paired venae comitantes are encountered in this interval — this confirms you are in the correct plane.
Clinical Pearl
Technical Tip: 'I identify the radial artery by looking for its venae comitantes — the paired veins are a more conspicuous landmark than the artery itself, which can be narrow or in spasm. Once identified, I retract the artery radially WITH the brachioradialis tendon. I protect the artery throughout the case with intermittent release of retraction. The superficial radial nerve I identify in the subcutaneous plane and protect — I have seen neurapraxia from a self-retaining retractor left too long.'
Dangers at this step
Radial artery injury when dissecting too radially — keep the dissection centred over FCR
Superficial radial nerve injury — identify it in the subcutaneous plane before placing deep retractors; do not place retractors blindly under brachioradialis
Lacerating the radial artery by not identifying it before incising the deep fascia — once the fascia is open between FCR and BP, look for the artery before proceeding deeper
Step 3: Deep Exposure of the Radius
Retract the radial artery and brachioradialis radially and the FCR and flexor digitorum superficialis (FDS) mass ulnarly. The flexor pollicis longus (FPL) is seen on the volar surface of the radius — it takes origin from the volar radius in the middle third.
For the middle and distal thirds: Elevate the FPL and pronator quadratus (distally) from the volar surface of the radius subperiosteally from radial to ulnar. Use a periosteal elevator starting at the radial border of the bone, sweeping ulnarly. The pronator quadratus is elevated as a single layer from distal to proximal as needed.
For the proximal third (if extending exposure): Supinate the forearm to move the PIN posteriorly. Identify the supinator muscle belly at the proximal radius. Elevate the supinator subperiosteally from the radius — do NOT dissect into the muscle substance (the PIN lies between its two heads). The recurrent radial artery may require ligation.
The fracture site is now exposed. Identify the fracture ends and clear the haematoma. Assess the fracture geometry — simple (transverse, oblique, spiral) versus comminuted — to plan the reduction and plate strategy.
Clinical Pearl
Technical Tip: 'I elevate the FPL and pronator quadratus as a single continuous sheet from radial to ulnar — this preserves a robust layer for later closure over the plate. I suPinate the forearm for any dissection proximal to the pronator teres insertion to protect the PIN. I do not place any retractor deep to the radius on the dorsal side in the proximal forearm — the PIN runs there.'
Dangers at this step
PIN injury in proximal dissection — supinate the forearm before elevating supinator; never place a retractor around the dorsal radius proximally (the PIN winds from anterior to posterior around the radial neck within the supinator)
Perforating the interosseous membrane dorsally — dissecting too far dorsal to the radius can injure the posterior interosseous artery and nerve
Inadequate periosteal stripping — insufficient exposure leads to poor reduction and plate malposition
Step 4: Fracture Reduction
Reduce the fracture under direct vision. For simple transverse or short oblique fractures, direct manipulation with bone-holding forceps (Verbrugge or reduction clamps) applied to both fragments.
Restoring length: The most critical step. The radius is shortened by the deforming forces of the pronator quadratus (distal fragment) and the pronator teres and brachioradialis (proximal fragment). Distract the fracture using a small distracter or manual traction. Confirm correct length by:
Fluoroscopic comparison of ulnar variance with the contralateral wrist (the amount of ulnar positive variance reflects radial shortening)
Matching the contour of the radial bow — the gentle lateral bow must be restored
Restoring rotation: The distal fragment pronates relative to the proximal fragment (pull of pronator quadratus). The radial tuberosity faces medially when rotation is correct. On fluoroscopy, the radial styloid should be in the correct rotational orientation relative to the proximal fragment.
Temporary fixation: Hold the reduced fracture with a small fragment reduction clamp or K-wires placed obliquely across the fracture. Confirm reduction on AP and lateral fluoroscopic views — correct length, alignment, and rotation.
Clinical Pearl
Technical Tip: 'I compare intraoperative fluoroscopy of the injured side to the uninjured contralateral forearm if there is any doubt about radial length or bow. The key intraoperative measurement is ulnar variance — if the ulnar head is more than 2 mm positive compared to the contralateral side, my radial reduction is still short. I do not proceed to plating until the variance is within 1 mm of the normal side.'
Dangers at this step
Accepting radial shortening — anything greater than 2 mm of ulnar positive variance after reduction will cause DRUJ symptoms; re-attempt reduction or consider bone grafting for segmental defects
Rotational malreduction — easy to miss on AP and lateral; check the cortical thickness match at the fracture site (a classic sign of correct rotation is matching cortical thickness on both sides of the fracture)
Excessive periosteal stripping of comminuted fragments — maintain soft tissue attachments to preserve vascularity
Step 5: Plate Fixation
Plate selection: A 3.5 mm LC-DCP or LCP is the standard implant. The plate must be long enough to achieve at least six cortices of fixation on each side of the fracture (three bicortical screws proximally and three distally). For very distal fractures, a distal radius L plate or T plate may be needed.
Plate contouring: The volar radius has a gentle sigmoid curve — concave volarly in the proximal half and convex volarly in the distal half. The plate must be contoured to match this bow. A malcontoured plate will either displace the fracture or leave a gap between the plate and bone.
Plate position: Place the plate on the volar (flat) surface of the radius. The plate should sit flat against the bone. For the typical distal-third fracture, the plate is centred over the fracture and placed slightly radial to midline to avoid the FPL tendon.
Screw insertion:
Apply the plate to the reduced fracture and hold with a plate-holding clamp
Insert the first screw eccentrically on one side of the fracture in the dynamic compression slot to compress the fracture (for a simple transverse fracture pattern)
Insert the remaining screws in neutral position
For comminuted fractures, use bridge plating technique with the plate spanning the comminuted zone; no screw placed in the zone of comminution; use locking screws in osteoporotic bone
Final fluoroscopic check: Confirm plate position, screw lengths, fracture reduction, and — most importantly — ulnar variance on the AP view with the DRUJ included.
Clinical Pearl
Technical Tip: 'I prefer a 3.5 mm limited contact dynamic compression plate contoured to the volar radial bow. For a distal-third fracture I use a longer plate — at least 6-7 holes — because three bicortical screws in the distal fragment can be difficult if the fracture is very distal. I check that the most distal screw does not enter the radiocarpal joint or impinge on the sigmoid notch. I use intermittent fluoroscopy during screw insertion to confirm no penetration of the far cortex or joint.'
Dangers at this step
Screw penetration of the radiocarpal joint — the most distal screw must be aimed away from the joint; check on multiple fluoroscopic views
Screw penetration of the DRUJ (sigmoid notch) — screw tips protruding from the medial radius enter the DRUJ and cause erosive changes and pain; aim screws laterally, not medially
Plate malposition — if the plate is too radial, it will be prominent and irritate the tendons; if too ulnar, it can impinge on the pronator quadratus closure
Using a short plate in the distal fragment — three screws in the distal fragment are essential; if the fracture is within 2 cm of the distal articular surface, use a distal radius-specific plate
Step 6: Assess the DRUJ (The Critical Step)
The most important step after radial fixation — do not close the wound until the DRUJ is formally assessed.
Clinical examination:
With the radius stabilised, grasp the ulnar head between thumb and index finger
Translate the ulnar head volarly and dorsally — compare to the contralateral side
Assess stability through full pronation-supination arc
The DRUJ is most unstable in pronation (dorsal instability) and most stable in supination
Fluoroscopic assessment:
AP view: check ulnar variance (should be within 1 mm of contralateral); check DRUJ space (should be symmetric and less than 2 mm)
Lateral view: the ulnar head should be centred within the sigmoid notch; dorsal or volar subluxation is abnormal
Three possible outcomes:
A — DRUJ Reduced AND Stable (through full pronation-supination)
No further surgical action required
Below-elbow cast or splint in neutral rotation for 6 weeks
DRUJ is stabilised indirectly by the restored radial length and interosseous membrane tension
B — DRUJ Reducible BUT Unstable (reduces spontaneously with supination but subluxates with stress or pronation)
Transfix the DRUJ with two 1.6 mm K-wires placed from the ulnar side, across the DRUJ, into the radius
The forearm is positioned in full supination during wire insertion (the position of maximum DRUJ stability)
Cut the K-wires subcutaneously (buried beneath the skin) or leave them outside with sterile dressings
Above-elbow cast in supination for 6-8 weeks
Remove K-wires at 6-8 weeks, begin forearm rotation rehabilitation
C — DRUJ Irreducible (the ulnar head cannot be manually reduced or seated in the sigmoid notch)
Incise the DRUJ capsule through a separate dorsal incision or extend the existing approach
Most common cause: interposition of the ECU tendon, the dorsal capsule, or a torn TFCC fragment
Relieve the interposed structure, reduce the ulnar head, and confirm stable reduction
K-wire transfixion as above
Repair the TFCC if possible (rarely required in the acute setting — the capsule usually heals)
Above-elbow cast in supination for 8 weeks
Clinical Pearl
Technical Tip: 'After plating the radius, I supinate and pronate the forearm and watch the DRUJ under fluoroscopy. If the ulnar head tracks smoothly and remains congruent in both positions, I stress it — if it subluxates more than 50% in pronation, it is unstable and I pin it. I place two 1.6 mm K-wires percutaneously from the ulnar side, directed across the DRUJ into the radius, with the forearm in full supination. I confirm on AP and lateral that the DRUJ is anatomically reduced before cutting the wires.'
Dangers at this step
Skipping DRUJ assessment — the most common error in Galeazzi fracture management; the DRUJ may appear reduced fluoroscopically but be unstable clinically; always stress it manually
Pinning the DRUJ in neutral or pronation — the DRUJ must be pinned in SUPINATION (the position of maximum stability); pinning in pronation will result in recurrent dorsal instability
Leaving a K-wire protruding outside the skin — high infection risk; bury wires subcutaneously or use sterile dressings with regular pin-site care
Missing irreducible DRUJ — if the ulnar head does not reduce easily, do not force it; open the DRUJ and look for interposed soft tissue (ECU, capsule, TFCC fragment)
Step 7: Wound Closure
Irrigate the wound copiously. Release the tourniquet if used and achieve haemostasis (bipolar electrocautery).
Deep closure: The pronator quadratus and FPL should be reapproximated over the plate if possible. This provides a muscle bed between the plate and the superficial flexor tendons and median nerve, reducing the risk of tendon irritation. Suture the muscle layer with 2-0 or 3-0 absorbable sutures (Vicryl). If the pronator cannot be closed without tension, leave it — do not suture under tension.
Superficial closure: Close the deep fascia loosely (to prevent compartment syndrome) with interrupted absorbable sutures. Close the subcutaneous layer with 3-0 absorbable sutures. Close the skin with 3-0 nylon (interrupted or subcuticular) or staples.
Dressing: Non-adherent dressing, bulky cotton wool and crepe bandage. If the DRUJ was pinned, apply an above-elbow backslab in supination. If the DRUJ was stable, apply a below-elbow backslab in neutral.
Post-Reduction Checklist (Before Leaving Theatre)
Radial length
Check
Ulnar variance within 1 mm of contralateral
Action if Not Satisfied
Re-reduce radius; consider bone grafting if bone loss
Radial rotation
Check
Cortical match at fracture site
Action if Not Satisfied
Rotate distal fragment back into correct alignment
Plate position
Check
Plate flat on volar radius; screws not intra-articular
Action if Not Satisfied
Revise plate position or screw trajectory
DRUJ stability
Check
Stable through full pronation-supination
Action if Not Satisfied
Pin DRUJ if unstable; open DRUJ if irreducible
Neurological examination
Check
Document radial/median/ulnar nerve function before leaving theatre
Action if Not Satisfied
Note and document any deficit
Compartment exam
Check
Forearm compartments soft
Action if Not Satisfied
Measure compartment pressures if concern
Tourniquet time
Check
Less than 2 hours
Action if Not Satisfied
Document; consider staged procedure if longer needed
Item
Check
Action if Not Satisfied
Radial length
Ulnar variance within 1 mm of contralateral
Re-reduce radius; consider bone grafting if bone loss
Radial rotation
Cortical match at fracture site
Rotate distal fragment back into correct alignment
Plate position
Plate flat on volar radius; screws not intra-articular
Revise plate position or screw trajectory
DRUJ stability
Stable through full pronation-supination
Pin DRUJ if unstable; open DRUJ if irreducible
Neurological examination
Document radial/median/ulnar nerve function before leaving theatre
Note and document any deficit
Compartment exam
Forearm compartments soft
Measure compartment pressures if concern
Tourniquet time
Less than 2 hours
Document; consider staged procedure if longer needed
Complications of Galeazzi Fracture ORIF — Recognition, Prevention, Management
Post-operative Protocol
Immobilisation
If DRUJ stable after ORIF:
Below-elbow cast or removable splint in neutral rotation
Duration: 6 weeks
Active finger and elbow motion from day 1
Active wrist motion and forearm rotation begin after cast removal at 6 weeks
Progressive strengthening at 8-10 weeks
If DRUJ pinned:
Above-elbow cast in supination
Duration: 6-8 weeks (until K-wire removal)
Active finger, elbow, and shoulder motion from day 1
K-wire removal at 6-8 weeks under local anaesthetic
After K-wire removal: begin active forearm rotation and wrist motion in therapy
Progressive strengthening at 10-12 weeks
Rehabilitation Protocol
1 — Immobilisation
Timing
Week 0-6
Activity
Active finger motion (full fist to full extension, hourly). Elbow and shoulder ROM. Oedema control (elevation). Wound care. If DRUJ pinned: do not pronate-supinate
2 — Early motion
Timing
Week 6-8 (stable) or week 6-8 after K-wire removal (pinned)
Activity
Active wrist flexion-extension and forearm pronation-supination. Passive stretching with therapy. Scar management
Progressive resistance. Sport-specific training. Heavy lifting permitted when radiographs confirm union and strength is greater than 80% of contralateral
Phase
Timing
Activity
1 — Immobilisation
Week 0-6
Active finger motion (full fist to full extension, hourly). Elbow and shoulder ROM. Oedema control (elevation). Wound care. If DRUJ pinned: do not pronate-supinate
2 — Early motion
Week 6-8 (stable) or week 6-8 after K-wire removal (pinned)
Active wrist flexion-extension and forearm pronation-supination. Passive stretching with therapy. Scar management
Progressive resistance. Sport-specific training. Heavy lifting permitted when radiographs confirm union and strength is greater than 80% of contralateral
Return to Activity
Office work: 2-4 weeks (if dominant arm, may be longer)
Light manual work: 8-12 weeks
Heavy manual work / sport: 12-16 weeks (radiographic union confirmed)
Driving: 4-6 weeks (if dominant arm affected; longer if immobilised above elbow)
Contact sports: 16-20 weeks
Hardware Removal
Not routinely required
Indications: symptomatic hardware (prominent plate, tendon irritation, cold sensitivity), request for removal in young high-demand patients, or if the plate is impinging on the DRUJ (very distal plates)
Timing: minimum 12-18 months after surgery (after fracture union and remodelling is complete)
Special Case: Galeazzi-Equivalent Fractures
Definition
A both-bone forearm fracture (radius and ulna) that ALSO involves DRUJ disruption. The ulnar fracture distracts attention from the DRUJ, which is frequently missed in initial assessment and treatment.
Incidence
Approximately 5-10% of both-bone forearm fractures have associated DRUJ disruption
More common in high-energy mechanisms
The risk increases with the degree of radial shortening
Diagnosis
Examine the DRUJ in EVERY forearm fracture — not just isolated radial shaft fractures
Radiographic clues: ulnar styloid base fracture, ulnar positive variance greater than 2 mm, DRUJ space asymmetry, ulnar head dislocation on lateral view
Post-reduction fluoroscopy of the DRUJ after both bones are fixed
Management
Fix both the radius and ulnar shaft by standard plate fixation
After fixation of both bones, reassess the DRUJ exactly as for a standard Galeazzi
The DRUJ is more likely to be stable after both-bone fixation because the interosseous membrane is partially tensioned by the ulnar reconstruction
However, DRUJ assessment is still mandatory — do not assume stability
Special Case: Galeazzi in Osteoporotic Bone
Challenges
Screw purchase is poor in osteoporotic bone
Standard 3.5 mm screws may not achieve adequate fixation
Plate loosening and loss of reduction are risks
Modified Technique
Use a 3.5 mm LCP with locking screws — the fixed-angle construct provides angular stability and is less dependent on screw-bone interface quality
Use longer plates (8-10 holes) to distribute load
Consider bicortical screw placement through the far cortex (more pull-out strength than unicortical locking)
Avoid over-compression of the fracture (risk of comminution in weak bone)
Consider a supplemental cast for 4 weeks in addition to internal fixation
Special Case: Delayed Presentation (Greater Than 3 Weeks)
Challenges
Soft tissue contracture makes reduction more difficult
Early callus may need to be resected
The DRUJ may be chronically dislocated
Approach
Plan for a more extensile exposure
Release callus and interposed soft tissue from the fracture site
The DRUJ may require open reduction with capsular release
TFCC repair is considered in the acute-delayed window (less than 6 weeks)
Above-elbow cast in supination for 8 weeks after surgery
Outcome is less predictable — higher rate of stiffness and DRUJ symptoms
Special Case: Paediatric Galeazzi Fracture
Differences from Adult Injury
The paediatric periosteum is thick and may maintain DRUJ reduction even with significant radial displacement
The DRUJ disruption in children is often a physeal injury of the distal ulna (Salter-Harris) rather than a TFCC disruption
Spontaneous DRUJ stabilisation after radial reduction is more common in children
The threshold for non-operative management is lower — many paediatric Galeazzi fractures (particularly in children younger than 12) can be managed with closed reduction and casting if the DRUJ is reduced and the radial fracture is acceptable (less than 10 degrees angulation, less than 50% displacement)
Surgical Indications in Children
Open fracture
Irreducible DRUJ
Failed closed reduction (loss of radial alignment in cast)
Adolescent approaching skeletal maturity (the paediatric advantage diminishes with age)
Clinical Decision Scenarios
Practise clinical reasoning and management decisions out loud
Viva scenarioStandard
Clinical prompt
“A 32-year-old man sustains a closed Galeazzi fracture of the right forearm after a fall from scaffolding. You have performed open reduction and internal fixation of the radial shaft through a volar Henry approach. The radius is plated with a 3.5 mm LC-DCP and the reduction looks anatomic on fluoroscopy. Talk me through your assessment of the DRUJ and the management options depending on what you find.”
Practical approach
After radius fixation in a Galeazzi fracture, the DRUJ must be assessed before wound closure — this is the most critical step in the operation and the most commonly skipped one. I perform a systematic assessment in three steps:\n\n**Step 1: Clinical examination.** With the radius stabilised by the plate, I grasp the ulnar head between my thumb and index finger. I translate it volarly and dorsally and compare the translation to the contralateral uninjured wrist. I then examine the DRUJ through full passive pronation and supination. The DRUJ is normally most stable in supination and most unstable in pronation.\n\n**Step 2: Fluoroscopic assessment.** I take an AP of the wrist to check ulnar variance — it should be symmetric to the contralateral side, which provides a reference. A lateral view confirms whether the ulnar head is centred in the sigmoid notch. I stress the DRUJ in pronation under live fluoroscopy.\n\n**Step 3: Decision making.** There are three possible outcomes:\n\n**A — DRUJ reduced and stable through full ROM.** This occurs in approximately 40-50% of cases after anatomic radial fixation. The restored radial length tensions the interosseous membrane, which stabilises the DRUJ indirectly. No further surgical action is required. I apply a below-elbow cast or removable splint in neutral rotation for 6 weeks.\n\n**B — DRUJ reducible but unstable.** The ulnar head seats properly with supination but subluxates with stress. This patient needs DRUJ stabilisation. I percutaneously insert two 1.6 mm K-wires from the ulnar side, across the DRUJ into the radius, with the forearm held in full supination (the position of maximum DRUJ congruency). I confirm anatomic reduction on AP and lateral. I then apply an above-elbow cast in supination for 6-8 weeks. The K-wires are removed at 6-8 weeks in clinic.\n\n**C — DRUJ irreducible.** The ulnar head cannot be seated. This indicates interposed soft tissue — most commonly the ECU tendon, the DRUJ capsule, or a torn TFCC fragment. I explore the DRUJ through a separate dorsal incision (or extend the approach), relieve the interposition, reduce the DRUJ, and pin it as above. I consider TFCC repair if there is a large peripheral tear.\n\n**Key teaching point**: The most common error is to fix the radius and forget the DRUJ. The second most common error is to see the DRUJ reduced fluoroscopically but not stress it clinically — a reduced DRUJ is not necessarily a stable one.
Viva scenarioStandard
Clinical prompt
“Describe the volar Henry approach to the radius. What are the key danger zones at each level, and how do you protect the posterior interosseous nerve during proximal exposure?”
Practical approach
The volar Henry approach is the standard surgical approach for the radial shaft. It uses the interval between brachioradialis (radially) and flexor carpi radialis (FCR, ulnarly). I divide the approach into three zones based on the level of dissection.\n\n**Surface landmarks**: I palpate the radial styloid distally and the lateral epicondyle proximally. I mark the course of the radial artery at the wrist (palpable pulse before tourniquet inflation) and the FCR tendon, which lies just radial to the palmaris longus at the wrist crease. The skin incision is centred over FCR distally and curves along the radial border proximally.\n\n**Distal third (wrist to pronator quadratus)** — The key danger here is the RADIAL ARTERY. It runs between brachioradialis and FCR directly on the volar radius. After incising the deep fascia over FCR, I develop the interval by retracting FCR ulnarly and look for the radial artery — it is the defining structure of the interval. The artery is retracted radially WITH brachioradialis throughout the case. The SUPERFICIAL RADIAL NERVE emerges from beneath brachioradialis about 8-10 cm proximal to the radial styloid — I identify it in the subcutaneous plane and protect it from retraction injury. I elevate the pronator quadratus and FPL subperiosteally from radial to ulnar as a single layer.\n\n**Middle third (pronator quadratus to pronator teres)** — The radial artery moves away from the bone here, lying more volar between the muscle bellies. The FPL origin from the volar radius and the pronator teres insertion on the lateral radius at its junction with the middle third are encountered. The median nerve and its branches lie ulnar to this plane and are protected by staying on bone.\n\n**Proximal third (pronator teres to bicipital tuberosity)** — This is the zone of greatest risk for the POSTERIOR INTEROSSEOUS NERVE. The PIN is the deep branch of the radial nerve. It pierces the supinator muscle, winding from anterior to posterior around the radial neck, lying within the supinator substance approximately 6-8 cm proximal to the radiocapitellar joint. I take three specific precautions:\n\n1. **Supinate the forearm** — supination moves the PIN posterior and lateral, away from the volar radius and the surgical field\n2. **Stay subperiosteal** — I elevate the supinator from the radius using a periosteal elevator, keeping the instrument on bone. I do NOT dissect into the supinator muscle belly, where the nerve lies\n3. **No dorsal retractors** — I never place a retractor around the dorsal aspect of the proximal radius, as this would put pressure on the PIN where it emerges from the supinator dorsally\n\nAn additional structure in the proximal third is the RECURRENT RADIAL ARTERY (leash of Henry), which crosses the interval and may require ligation with 3-0 ties or bipolar electrocautery.\n\nIn summary: distal third — protect the radial artery; middle third — stay on bone; proximal third — supinate and stay subperiosteal to protect the PIN.
Viva scenarioAdvanced
Clinical prompt
“A 28-year-old woman presents 10 weeks after ORIF of a Galeazzi fracture performed at another hospital. The radius was plated through a volar Henry approach and the operative report notes 'DRUJ was reduced and stable.' She now complains of persistent ulnar-sided wrist pain, a clunk with forearm rotation, and grip weakness. Her ulnar variance is +4 mm on the injured side versus +1 mm on the contralateral. The DRUJ is subluxated dorsally on stress views. How do you manage this patient?”
Practical approach
This patient has symptomatic chronic DRUJ instability due to radial malunion — her ulnar variance of +4 mm indicates the radius healed in a shortened position, the interosseous membrane is lax, and the DRUJ is incongruent. At 10 weeks, the radius is likely united, and the window for acute DRUJ management has passed.\n\n**Initial assessment**: I would obtain:\n- Bilateral CT of both forearms in pronation and supination to quantify DRUJ subluxation, assess the sigmoid notch morphology, and confirm radial malunion (which is already indicated by the +4 mm variance)\n- The CT will also show whether there is any DRUJ arthritis developing (the most important prognostic factor)\n\n**Treatment plan (three-tiered approach)**:\n\n**First — address the radial malunion**: The +4 mm ulnar positive variance is the root cause. I plan a radial corrective osteotomy: I expose the radius through the previous Henry approach, osteotomise at the original fracture site (or at the level of the malunion), distract to restore correct ulnar variance (matched to the contralateral side), and re-fix with a 3.5 mm LCP (locking plate provides better angular stability in a revision setting). I consider iliac crest bone graft autograft or allograft tricalcium phosphate wedges if there is a gap after distraction.\n\n**Second — reassess the DRUJ after osteotomy**: Once the radius is restored to correct length and rotation, I stress the DRUJ intraoperatively. In many cases of secondary DRUJ instability from malunion, restoring radial length alone re-tensions the interosseous membrane and improves stability. If the DRUJ is now stable through full ROM, I proceed with below-elbow cast in neutral for 6 weeks. If still unstable, I proceed to DRUJ reconstruction.\n\n**Third — DRUJ reconstruction if still unstable**: Options depend on the state of the TFCC and the DRUJ articular surfaces:\n- If the TFCC is repairable and the DRUJ is congruent without arthritis: open TFCC repair with capsular plication\n- If the TFCC is irreparable but the DRUJ is not arthritic: DRUJ ligament reconstruction using a palmaris longus or gracilis tendon graft (Adams-Berger technique — reconstructs the volar and dorsal radioulnar ligaments through bone tunnels in the radius and ulna)\n- If there is ulnar abutment syndrome (positive ulnar variance causing ulnar impaction on the lunate): combine ulnar shortening osteotomy with the above\n- If DRUJ arthritis has already developed: salvage procedures — Sauve-Kapandji (radioulnar arthrodesis with ulnar pseudarthrosis) or Darrach resection (distal ulnar excision) in lower-demand patients\n\n**Prognosis**: Chronic DRUJ instability after malunion is a complex revision problem. The outcome is less predictable than primary treatment. Patients should be counselled that some loss of forearm rotation and grip strength is likely even with optimal reconstruction. The key to avoiding this situation is primary prevention — careful intraoperative assessment of DRUJ stability and accepting nothing less than anatomic radial reduction with correct ulnar variance at the index procedure.
Exam day cheat sheet
Galeazzi Fracture ORIF — Exam Day Summary
References
Evidence
Galeazzi fracture-dislocations
Level IV
Mikic ZD
Clinical implication: ORIF became the standard of care for Galeazzi fractures in adults based on this landmark series.
