Galeazzi Fractures

A Galeazzi fracture-dislocation is a fracture of the radial shaft, typically at the junction of the middle and distal thirds, together with disruption of the distal radioulnar joint (DRUJ). Both components must be present for the diagnosis. The DRUJ disruption takes one of three forms:

• True dislocation
• Subluxation
• Ulnar styloid base fracture in place of a true dislocation, the Galeazzi equivalent

Its mirror image at the other end of the forearm, an ulnar shaft fracture with dislocation of the radial head, is the Monteggia fracture; the paediatric form of that injury is covered under Monteggia fractures in children.

Who. Galeazzi injuries make up 3-7% of all forearm fractures and are more common than Monteggia fracture-dislocations. Men outnumber women 3:1, and the peak age is 30-40 years.

Mechanism. A fall on the outstretched hand with the forearm pronated is the most common story. The others:

• Direct blow to the dorsoradial forearm
• Axial load on a hyperpronated wrist
• High-energy trauma, including motor vehicle accidents
• Sporting injury (cycling, contact sports)

Galeazzi versus Monteggia. Distal for Galeazzi, proximal for Monteggia, in both the bone and the joint:

The joint. The ulnar head articulates with the sigmoid notch of the radius, and the radius rotates around the relatively fixed ulna through 180°. The articulation is shallow, with articular surface coverage of approximately 60°, so the joint relies heavily on soft tissue for its stability.

The stabilisers. With so little bony constraint, the soft tissues hold the ulnar head in the notch:

• TFCC (triangular fibrocartilage complex), the primary stabiliser
• Dorsal and volar radioulnar ligaments, the components of the TFCC
• Pronator quadratus
• Interosseous membrane (central band)
• ECU subsheath
• Ulnocarpal ligaments

Why the instability outlasts the fracture. The shallow sigmoid notch provides minimal bony constraint, so the TFCC and the interosseous membrane are what keep the joint reduced. In a Galeazzi fracture the interosseous membrane is disrupted and the TFCC is often torn, which is why DRUJ instability can persist even after the radius has been fixed.

View larger

Deforming forces. The muscles decide where the fragments go. The proximal fragment is pulled proximally by biceps and supinator; its rotation varies with the level of the fracture, and it tends to supinate if the fracture is proximal to pronator teres. The distal fragment is shortened by brachioradialis, the primary deforming force, pronated by pronator quadratus and flexed by the wrist flexors, and the fracture typically angulates apex dorsal.

The result. A shortened radius with apex dorsal angulation and loss of the radial bow, and a DRUJ that is incongruent, with the ulnar head prominent.

The interosseous membrane. The central band is the primary longitudinal stabiliser of the forearm; it runs obliquely from radius to ulna (proximal-distal) and transmits 80% of axial load from the radius to the ulna. It is disrupted in a Galeazzi fracture, which contributes to the radial shortening, may prevent closed reduction, and adds to the persistent DRUJ instability. Keep it in mind when the DRUJ is assessed after fixation.

View larger

Two things are classified: where the radius broke, and how the DRUJ behaves once the radius is fixed. The first predicts the second.

View larger

History. The mechanism is one of those in the Overview, most often the fall on the pronated hand. The symptoms:

• Forearm pain and swelling
• Wrist pain (DRUJ involvement)
• Visible deformity
• Inability to supinate or pronate the forearm
• Weakness of grip

Look. Deformity and swelling of the forearm, and swelling at the wrist, especially dorsally over the DRUJ. A dorsally prominent ulnar head means the DRUJ is dislocated. Check the skin for an open fracture and compare radial length with the opposite side.

Feel. Point tenderness at the radius fracture, tenderness dorsally over the DRUJ, and tenderness over the ulnar styloid, where a base fracture is being sought. Palpate along the interosseous membrane and assess the compartments.

Move. Supination and pronation are limited and painful, and the patient usually cannot rotate the forearm. Wrist motion is limited by pain.

Neurovascular examination. Each nerve, and the circulation:

• Median nerve: sensation in the first web space, thumb opposition
• Ulnar nerve: sensation over the little finger, finger abduction
• Radial nerve: wrist and finger extension, sensation over the dorsal first web space
• Vascular: radial and ulnar pulses, capillary refill

DRUJ stability test. The same test is used in clinic and again on the table after the radius is fixed:

1. Stabilise the radius firmly with one hand
2. Translate the ulna dorsally and volarly with the other hand
3. Assess the amount of translation and compare with the contralateral side
4. Test in supination, neutral and pronation
5. Note the position of maximum stability (usually supination)

Reading the test. Increased translation compared with the opposite side is instability, and pain on testing indicates ligament injury. Dorsal prominence of the ulnar head is a DRUJ dislocation. The joint is usually most stable in supination.

Differential diagnosis. The mimics are separated by which bone is broken and which joint is disrupted.

Radiographs. The forearm series must include both the elbow and the wrist so that associated injuries are not missed, and the wrist gets its own views:

• Full-length forearm radiographs, AP and lateral, including both joints
• Dedicated wrist views, PA and lateral
• Contralateral forearm for comparison if needed

On the AP view. The radius fracture at the middle-distal junction, radial shortening relative to the ulna, and an ulnar styloid base fracture, which suggests DRUJ disruption. The joint itself shows as DRUJ widening: a difference of greater than 2 mm compared with the opposite wrist is abnormal.

On the lateral view. Dorsal subluxation of the ulnar head and loss of the normal DRUJ relationship, with apex dorsal angulation of the radius fracture. Volar displacement of the distal radius is possible.

View larger

View larger

CT. It answers what plain films leave open: detailed sigmoid notch anatomy and the fracture fragments, quantification of DRUJ subluxation, associated fragments such as the ulnar styloid, and articular step-off. The indications:

• DRUJ congruity when plain films are unclear
• Complex intra-articular fracture patterns
• Pre-operative planning for comminuted fractures
• Post-operative assessment if the DRUJ reduction is questioned
• Chronic DRUJ instability

MRI. Rarely needed in the acute setting; it may be useful in delayed or chronic cases, where it shows TFCC tears (central perforations or peripheral detachments), IOM disruption, ligament injuries and cartilage damage. The indications:

• TFCC assessment (tears, quality)
• Chronic DRUJ instability
• Persistent unexplained symptoms after treatment
• IOM assessment in suspected Essex-Lopresti

Algorithm

View larger

Why it is operated on. The Galeazzi is the "fracture of necessity" because operative treatment is mandatory in adults. Conservative treatment fails in most of them: 80% in Mikic's 1975 series of 125 patients, and the great majority in Hughston's. Both figures describe the same conclusion from different cohorts; do not blend them into one number.

The goals and the timing. An anatomic radius and a stable DRUJ. Surgery is typically performed within 24-48 hours, and the steps follow in order:

1. ORIF of the radius with a compression plate (anatomic reduction)
2. Assess DRUJ stability intra-operatively
3. Stabilise the DRUJ if unstable (pin or repair)
4. Immobilise in the position of stability (supination)
5. Early mobilisation protocol

Children. A child under 10 years can often be treated with closed reduction and cast immobilisation in supination: the DRUJ is more likely to reduce and remain stable because of the periosteal sleeve and the remodelling potential. Older children and adolescents, over 10 years, should be treated like adults with ORIF, because remodelling potential decreases. Walsh's series supports this: results of conservative management were generally good in 41 children under 15, with a gradient that echoes the adult one, the more distal the radial fracture the more trouble.

When to cast a child. The indications for conservative treatment:

• Age under 10 years
• Acceptable closed reduction achieved (less than 10° angulation)
• DRUJ stable after reduction
• Compliant child and family
• Close follow-up available

How. Closed reduction under sedation or general anaesthesia, then an above-elbow cast in supination for 6 weeks. Weekly radiographs for the first 2-3 weeks watch for loss of reduction, and if reduction is lost the child proceeds to ORIF. Close monitoring is essential to the success of conservative treatment in a child.

Planning and PositioningVolar ApproachDorsal ApproachFixationDRUJ Management

Planning. Review the full forearm radiographs including the DRUJ, plan the approach by the fracture location, template the plate size and length, and consent the patient for possible DRUJ stabilisation as well as the radius.

Positioning.

• Supine on the operating table
• Arm on a radiolucent hand table
• Tourniquet on the upper arm, which may be left uninflated if the DRUJ is to be checked without it
• C-arm positioned for AP and lateral views

Volar (Henry) approach. The approach for the distal third, the most common site, and for the classic junction of the middle and distal thirds. The interval is between brachioradialis (radial nerve) and FCR (median nerve); the superficial radial nerve lies on brachioradialis, the radial artery lies under FCR, and the PIN is generally safe because it passes dorsally through supinator. Supinating the forearm brings the volar radius into view.

1. Incision: curvilinear from the biceps tendon to the radial styloid, over FCR
2. Dissection: identify the interval between brachioradialis and FCR
3. Protection: retract brachioradialis laterally, protecting the superficial radial nerve
4. Exposure: incise the deep fascia and supinate the forearm to expose the radius
5. Vascular care: protect the radial artery under FCR

Pronator quadratus. The muscle is incised and elevated off the radius to expose the volar surface for the plate, and at closure it is repaired over the plate to reduce flexor tendon irritation.

View larger

Dorsal (Thompson) approach. For middle third fractures, or where dorsal plating is preferred. The interval is between ECRL/ECRB (radial nerve) and EDC (PIN), and the nerve to protect is the PIN.

1. Incision: longitudinal over the dorsum of the radius
2. Dissection: identify EDC and ECRL/ECRB
3. PIN protection: dissect carefully through supinator, where the PIN emerges
4. Exposure: supinate to bring the radius into the field

PIN Danger with Dorsal Approach

The posterior interosseous nerve (PIN) emerges through the supinator muscle approximately 6cm distal to the radial head. When using the Thompson approach, the supinator must be carefully elevated to protect the PIN. Excessive retraction or dissection can cause PIN palsy. Keep dissection within 9cm of radial head if possible.

Reduction. Length, bow and rotation, in that order:

1. Clean the fracture edges
2. Reduce anatomically with clamps
3. Restore radial length, compared with the length of the ulna
4. Restore the radial bow
5. Correct rotation with the elbow flexed 90°, using the opposite forearm as the template

The plate. A 3.5 mm compression plate, DCP or locking, on the volar or dorsal surface according to the approach, with a minimum of 6 cortices (3 screws) on each side of the fracture. Compress if the pattern allows: a lag screw through a suitable oblique fracture with a neutralisation plate over it, or bridge plating if the fracture is comminuted. Confirm the reduction and the DRUJ congruence on fluoroscopy before closure.

Radial Bow Restoration

The radius has a normal 10-12° radial bow with maximum curvature at the junction of proximal and middle thirds. Failure to restore this bow results in loss of pronation-supination (up to 50% loss). Use contralateral radiographs for comparison. Some surgeons pre-bend plates to match radial bow.

Test it. With the radius fixed, release the tourniquet, or never inflate it, and repeat the translation test described under Clinical Assessment, in supination, neutral and pronation, against the opposite wrist. If the joint will not reduce concentrically, do not pin it: that is the irreducible DRUJ under Classification.

If stable. No additional procedure is needed; plan supination immobilisation post-operatively. Most joints are stable once the radius is anatomic, but location shifts the odds (see Classification).

If unstable. Three options; K-wire fixation is the most common.

K-wire fixation. Reduce the DRUJ manually, position the forearm in supination, and pass two 1.6 mm K-wires from ulna to radius above the joint, not through the articular surface. The wires are left outside the skin for removal at 6 weeks.

TFCC repair. For a clear TFCC tear: open repair through a dorsal incision, with the sutures anchored to the fovea or the ulnar styloid.

Ulnar styloid fixation. For a large base fragment (greater than 2 mm): tension band wire or small screws, which restores the TFCC attachment.

Intraoperative DRUJ Check is Mandatory

ALWAYS check DRUJ stability after radial fixation under direct vision, NOT just on fluoroscopy. Position changes during imaging may give false impression of stability. Check actively by translating ulna while stabilising radius. If any doubt about stability, immobilise in supination or consider pinning.

What the films should show afterwards. A radius restored to length, bow and rotation under a plate, and a concentrically reduced DRUJ.

View larger

View larger

View larger

Compartment syndrome. The volar and dorsal forearm compartments are at risk, and the first 48 hours after surgery are the time to watch. The diagnosis is clinical, pain out of proportion and pain on passive stretch, and the treatment is urgent fasciotomy.

Nerve and vessel injury. Each approach has its own nerve at risk, and nerve function is examined and documented after surgery:

• Superficial radial nerve: at risk with the volar approach, lying on brachioradialis
• PIN: at risk with the dorsal approach, emerging through supinator
• Median nerve: rare, but possible with the volar approach
• Posterior interosseous artery: can bleed with the dorsal approach

Wound problems. Infection carries a 1-2% risk; dehiscence and haematoma are the others.

Acute DRUJ instability. The most common early problem. It may only become apparent after the cast comes off, and it needs assessment and possibly secondary stabilisation.

Persistent DRUJ instability. The most common late complication, in 10-15%, caused by inadequate initial stabilisation, a missed TFCC tear or a malunion. The patient reports pain, weakness, clicking and a sensation of instability. Treatment follows the reconstructive ladder in the pearl below; a chronic ulnar styloid nonunion is fixed.

Malunion. Inadequate reduction or loss of fixation leaves a shortened radius, angular deformity and loss of the bow, which produce DRUJ incongruity, loss of rotation and pain. A symptomatic malunion is treated with a corrective osteotomy.

Nonunion. Rare with rigid plate fixation, less than 2%; inadequate fixation, infection and smoking are the risk factors, and the treatment is revision ORIF with bone graft.

Loss of motion. Loss of supination and pronation is the most common residual deficit, from DRUJ problems, malunion or soft-tissue contracture. Early motion and an anatomic reduction are what prevent it; avoid prolonged rigid immobilisation beyond 6 weeks.

Other late complications. Rarer, and mostly the generic ones:

• Heterotopic ossification (rare)
• Radioulnar synostosis (very rare)
• Post-traumatic arthritis (DRUJ or radiocarpal)
• Hardware prominence or irritation
• Chronic regional pain syndrome (CRPS)

The position. The forearm is immobilised in supination, where the radius and ulna come parallel. Supination tightens the volar radioulnar ligament and brings the radius over the ulna into the reduced position, taking the stress off the healing TFCC; in pronation the volar ligaments are lax and the DRUJ subluxates dorsally. Cadaveric studies show maximum DRUJ stability in supination.

If the DRUJ was pinned. An above-elbow cast in supination for 4-6 weeks, with the K-wires removed at 6 weeks in clinic, no anaesthetic needed, then protected motion for a further 2-4 weeks: 8-10 weeks of immobilisation in total.

If the TFCC was repaired. An above-elbow cast for 4 weeks, then a below-elbow cast for 2 more, then protected range-of-motion exercises and hand therapy: 6-8 weeks in total.

Therapy goals. Full recovery typically takes 3-6 months, and the targets the therapist works towards:

• Full pronation-supination (80° each way)
• Wrist flexion and extension of at least 60°
• Grip strength 90% of the opposite side
• Pain-free wrist and forearm function
• Return to pre-injury activities

Red flags during recovery. Watch for:

• Persistent DRUJ instability or clicking
• Progressive loss of motion after initial gains
• New neurological symptoms (weakness, numbness)
• Signs of compartment syndrome (severe pain, tense forearm)
• Wound complications (redness, drainage, dehiscence)
• Failure to progress with therapy

Follow-up. The standard schedule:

• 2 weeks: wound check and radiograph to ensure no loss of reduction
• 6 weeks: remove cast and K-wires, radiograph to assess union, begin wrist ROM
• 12 weeks: radiograph, assess ROM and strength
• 6 months: final assessment, return to full activities

Discharge. The fracture united, with bridging callus on 3 cortices; a DRUJ that is clinically stable; range of motion at least 80% of the opposite side; pain minimal or absent; and a patient satisfied with the function.

What the sources report. Conservative treatment in adults fails, and the verified figure for that is Mikic's, quoted under Management. Operative treatment is clearly superior: Mikic reports over half excellent with combined fixation, and that is the honest operative figure. Beware the widely repeated "92% success" for ORIF: it mirrors Hughston's 92% failure figure for conservative treatment and has no primary source. Operative treatment is the standard because conservative treatment fails, not because a precise success percentage has been established.

Favourable factors. In the patient and in the treatment:

• Younger age (under 50 years), or a child under 10 treated conservatively
• No smoking, good compliance with rehabilitation, no significant comorbidities
• Anatomic radius reduction achieved and the DRUJ stable after radius fixation
• Early surgery (under 1 week) with rigid plate fixation
• Early mobilisation protocol followed

Unfavourable factors. In the injury and in what went wrong:

• High-energy mechanism, open fracture or significant soft-tissue injury
• Comminuted fracture pattern or associated injuries
• Residual radius malreduction or loss of the radial bow
• Persistent DRUJ instability
• Delay to surgery (over 2 weeks) or inadequate fixation

Motion and strength. 95% achieve at least 80% of the opposite side's pronation-supination, wrist flexion and extension are usually full or near-full, and elbow motion should be full. Grip strength recovers to 85-95% of the opposite side, with full strength taking 4-6 months.

Return to activities. Graded by demand:

• Light activities: 6-8 weeks
• Heavy labour: 3-4 months
• Contact sports: 4-6 months
• Full unrestricted activity: 6 months

Residual symptoms. 10-15% have mild residual DRUJ discomfort, 5-10% a permanent minor loss of rotation, and fewer than 5% significant disability.

Global Epidemiology

Galeazzi fracture-dislocations are uncommon, classically quoted as roughly 3-7% of forearm fractures and far less frequent than isolated diaphyseal or distal radius fractures. They sit within the young-adult, higher-energy diaphyseal forearm fracture group described in the reference population-based epidemiology of adult fractures (Court-Brown & Caesar, Injury 2006; PMID 16814787). Typical mechanisms worldwide are a fall on the outstretched, pronated hand, a direct dorsoradial blow, road-traffic and sporting trauma, with a male predominance and a peak in the second-to-fourth decades.

Registry Evidence

National joint and fracture registries (NJR, AJRR, AOANJRR, the Swedish/SHAR and Norwegian registries) are arthroplasty-focused and do not capture Galeazzi-specific outcomes, so registry-level survival data are not available for this injury. The best available evidence remains operative case series reporting good-to-excellent results in the large majority of anatomically reduced adults, with residual DRUJ problems as the dominant late issue (see Evidence Base).

Global Practice Variation

• High-resource settings: routine plate ORIF on a radiolucent hand table with intra-operative fluoroscopy and formal DRUJ testing; hand-therapy-led rehabilitation.
• Limited-resource settings: the same biomechanical priorities apply, but elastic intramedullary nailing or external fixation may be used where plating implants or image intensifiers are scarce; anatomic radial length and DRUJ reduction remain the non-negotiable goals.
• Universal medicolegal point: the dominant pitfall worldwide is a missed DRUJ injury - every forearm radiograph must include the wrist, and DRUJ stability after radial fixation must be documented.