Fracture of Necessity | ORIF Required | DRUJ Instability | Adult vs Pediatric Difference
GALEAZZI COMPONENTS
Critical Must-Knows
- Fracture of Necessity - virtually always requires ORIF in adults
- DRUJ instability is the key associated injury - always assess
- Anatomic radius reduction usually restores DRUJ stability
- Pediatric Galeazzi often treated conservatively (different than adults)
- Compare to Monteggia: Galeazzi = Distal (DRUJ), Monteggia = Proximal (radial head)
Clinical Pearls
- "G for GRUJ (distal), M for MPRUJ (proximal) - mnemonic for location
- "Supination after fixation usually stabilizes DRUJ
- "Brachioradialis deforming force causes shortening
- "Check ulnar styloid - base fracture indicates DRUJ disruption
Critical Galeazzi Points for Exams
Fracture of Necessity
Called the fracture of necessity because operative treatment is essentially mandatory in adults. Conservative management leads to high failure rates (92% failure).
DRUJ Always Involved
The DRUJ is ALWAYS disrupted. After radius fixation, test DRUJ stability in supination and pronation. Most stable in supination.
Pediatric Difference
Children under 10 can often be treated conservatively with cast. Adults always need surgery. This is a common exam question contrast.
Radius First
Fix the radius fracture first with anatomic reduction and compression plating. This alone often restores DRUJ stability (80%).
At a Glance: Quick Decision Guide
| Scenario | Decision | Key Point |
|---|---|---|
| ORIF radius with plate | Assess DRUJ after fixation | |
| Supination cast 6 weeks | Most common outcome (80%) | |
| Pin DRUJ in supination or repair TFCC | Occurs in 20% | |
| Consider conservative management | Different from adults | |
| Indicates DRUJ disruption | Fix if DRUJ unstable after radius | |
| Urgent debridement then ORIF | Standard open fracture protocol |
GRIPS vs MUGSSGaleazzi vs Monteggia Location
| G | Galeazzi Radius fracture + DRUJ disruption |
| R | Radius Fracture of radius shaft |
| I | Inferior Distal (inferior) radioulnar joint |
| P | Plus Plus DRUJ disruption |
| S | S for distal Points downward like S |
| G | Galeazzi Radius fracture + DRUJ disruption | P | Plus Plus DRUJ disruption |
| R | Radius Fracture of radius shaft | S | S for distal Points downward like S |
| I | Inferior Distal (inferior) radioulnar joint |
Hook:Galeazzi = Radius fracture + Inferior (distal) radioulnar joint disruption!
SUPINATEDRUJ Stability Position
| S | Supination Position of maximum DRUJ stability |
| U | Ulna and radius Come parallel in supination |
| P | Post-fixation Test DRUJ after radius plate |
| I | Immobilize Cast in supination if stable |
| N | Neutral if pinned Or pin if unstable |
| A | Assess Compare to contralateral side |
| T | TFCC May need repair if unstable |
| E | Evaluate fully Check stability in all positions |
| S | Supination Position of maximum DRUJ stability | I | Immobilize Cast in supination if stable | T | TFCC May need repair if unstable |
| U | Ulna and radius Come parallel in supination | N | Neutral if pinned Or pin if unstable | E | Evaluate fully Check stability in all positions |
| P | Post-fixation Test DRUJ after radius plate | A | Assess Compare to contralateral side |
Hook:SUPINATE - DRUJ is most stable in supination position!
RDComponents of Galeazzi Injury
| R | Radius fracture Junction middle-distal third |
| D | DRUJ disruption Dislocation or subluxation |
| R | Radius fracture Junction middle-distal third |
| D | DRUJ disruption Dislocation or subluxation |
Hook:RD - Radius fracture plus DRUJ disruption equals Galeazzi!
BPQDeforming Forces
| B | Brachioradialis Shortens the radius |
| P | Pronator quadratus Pronates distal fragment |
| Q | Quadratus thumb Creates apex dorsal angulation |
| B | Brachioradialis Shortens the radius |
| P | Pronator quadratus Pronates distal fragment |
| Q | Quadratus thumb Creates apex dorsal angulation |
Hook:BPQ muscles cause the classic Galeazzi deformity pattern!
Overview and Introduction
What is a Galeazzi Fracture?
A Galeazzi fracture-dislocation consists of:
- Fracture of the radius shaft (typically junction of middle and distal thirds)
- Disruption of the DRUJ (distal radioulnar joint)
The DRUJ disruption may be:
- True dislocation
- Subluxation
- Ulnar styloid base fracture (Galeazzi equivalent)
Historical Note
First described by Riccardo Galeazzi in 1934. Called the fracture of necessity by Hughston (1957) because operative treatment is necessary for good outcomes in adults.
Epidemiology
Incidence:
- 3-7% of all forearm fractures
- Less common than Monteggia fractures
- Male predominance (3:1)
- Peak age 30-40 years
Mechanism:
- Fall on outstretched hand with forearm pronated (most common)
- Direct blow to dorsoradial forearm
- Axial load on hyperpronated wrist
- High-energy trauma (motor vehicle accidents)
Galeazzi vs Monteggia - Key Differences
Comparison of Forearm Fracture-Dislocations
| Feature | Galeazzi | Monteggia |
|---|---|---|
| Radius (distal) | Ulna (proximal) | |
| DRUJ (distal) | Radiocapitellar (proximal) | |
| Ulna from radius (DRUJ) | Radial head | |
| Always ORIF | Usually ORIF | |
| Conservative possible under age 10 | Often conservative |
Anatomy and Pathophysiology
Distal Radioulnar Joint (DRUJ) Anatomy
Bony Articulation:
- Ulnar head articulates with sigmoid notch of radius
- Radius rotates around relatively fixed ulna (180° rotation)
- Shallow articulation - relies heavily on soft tissue stability
- Articular surface coverage approximately 60°
Soft Tissue Stabilizers:
- TFCC (triangular fibrocartilage complex) - primary stabilizer
- Dorsal and volar radioulnar ligaments (components of TFCC)
- Pronator quadratus
- Interosseous membrane (central band)
- ECU subsheath
- Ulnocarpal ligaments
DRUJ Instability Mechanism
The shallow sigmoid notch provides minimal bony constraint to DRUJ stability. The TFCC and IOM are the primary stabilizers. In Galeazzi fractures, the IOM is disrupted, and TFCC is often torn, leading to DRUJ instability that persists even after radius fracture fixation.
Deforming Forces
Proximal Fragment:
- Pulled proximally by biceps and supinator
- Variable rotation depending on fracture level
- Tends to supinate if fracture is proximal to pronator teres
Distal Fragment:
- Shortened by brachioradialis (primary deforming force)
- Pronated by pronator quadratus
- Typically apex dorsal angulation
- Flexed by wrist flexors
Result:
- Radius shortening
- Angular deformity (apex dorsal)
- Loss of radial bow
- DRUJ incongruity with ulnar head prominence
Interosseous Membrane Role
Central Band:
- Primary longitudinal stabilizer of forearm
- Transmits 80% of axial load from radius to ulna
- Disrupted in Galeazzi fractures
- Runs obliquely from radius to ulna (proximal-distal)
Clinical Relevance:
- IOM disruption contributes to radius shortening
- May prevent closed reduction
- Contributes to persistent DRUJ instability
- Must be considered when assessing DRUJ stability after fixation
Classification Systems
Classification by Radial Fracture Location
Location-Based Classification
| Type | Location | Clinical Significance |
|---|---|---|
| Junction middle/distal thirds | Classic Galeazzi pattern, high DRUJ instability (most common) | |
| True mid-shaft radius | Less DRUJ instability but still assess carefully | |
| Proximal third radius | Rare, consider Essex-Lopresti variant with IOM disruption |
Classic Location
The classic Galeazzi fracture occurs at the junction of the middle and distal thirds of the radius. More distal fractures have HIGHER DRUJ instability risk. Fractures in the proximal third should raise suspicion for Essex-Lopresti injury (complete IOM disruption with proximal radius migration).
Clinical Assessment
History Taking
Mechanism of Injury:
- Fall on outstretched hand (FOOSH) - most common
- Forearm typically in pronation at time of impact
- Direct blow to dorsal forearm
- Sporting injury (cycling, contact sports)
- Motor vehicle accident (high energy)
Symptoms:
- Forearm pain and swelling
- Wrist pain (DRUJ involvement)
- Visible deformity
- Inability to supinate or pronate forearm
- Weakness of grip
Physical Examination
Inspection:
- Forearm deformity and swelling
- Wrist swelling (especially dorsal - DRUJ area)
- Prominent ulnar head dorsally (DRUJ dislocation)
- Skin integrity - check for open fracture
- Radial shortening compared to opposite side
Palpation:
- Point tenderness at radius fracture site
- DRUJ tenderness dorsally
- Ulnar styloid - check for base fracture
- Interosseous membrane tenderness
- Compartment assessment
Range of Motion:
- Limited and painful supination/pronation
- Usually cannot rotate forearm
- Wrist motion limited by pain
Neurovascular Examination:
- Median nerve: Sensation first web space, thumb opposition
- Ulnar nerve: Sensation little finger, finger abduction
- Radial nerve: Wrist/finger extension, sensation dorsal first web space
- Vascular: Radial and ulnar pulses, capillary refill
DRUJ Stability Testing
Examination Technique:
- Stabilize radius firmly with one hand
- Translate ulna dorsally and volarly with other hand
- Assess amount of translation and compare to contralateral side
- Test in supination, neutral, and pronation positions
- Note position of maximum stability (usually supination)
Interpretation:
- Increased translation compared to opposite side = instability
- Pain with testing indicates ligament injury
- Dorsal prominence of ulnar head = DRUJ dislocation
- Usually most stable in supination
Differential Diagnosis
Distinguishing Galeazzi from Its Mimics
| Diagnosis | Distinguishing Features | Key Discriminator |
|---|---|---|
| Distal-third radius shaft fracture PLUS DRUJ disruption | DRUJ widening/dorsal ulnar prominence with an isolated radius fracture | |
| Radius fracture with a congruent, stable DRUJ on imaging and exam | Normal DRUJ - the defining absence | |
| Proximal ULNA fracture PLUS radial head dislocation | Pathology is proximal (radiocapitellar), not distal (DRUJ) | |
| Fractures of both radius and ulna shafts | Ulna is also fractured; DRUJ usually intact | |
| Radial head fracture, complete IOM disruption and DRUJ dissociation | Proximal radial migration; tenderness along the whole IOM and elbow | |
| Metaphyseal distal radius fracture; DRUJ may be involved via ulnar styloid | Fracture is metaphyseal/intra-articular, not diaphyseal shaft | |
| DRUJ disruption without a radial shaft fracture | No diaphyseal radius fracture present |
Investigations
Radiographic Assessment
Essential X-ray Views:
- Full-length forearm radiographs (AP and lateral)
- MUST include both elbow and wrist joints
- Dedicated wrist views (PA and lateral)
- Contralateral forearm for comparison if needed
Key Radiographic Findings:
AP View:
- Radius fracture at middle-distal junction (typical)
- DRUJ widening (greater than 2mm asymmetry)
- Increased space between radius and ulna at DRUJ
- Ulnar styloid base fracture (suggests DRUJ disruption)
- Radial shortening relative to ulna
Lateral View:
- Dorsal subluxation of ulnar head
- Apex dorsal angulation of radius fracture
- Loss of normal DRUJ relationship
- Distal radius volar displacement possible
DRUJ Assessment on X-ray
On the AP view, look for DRUJ widening - greater than 2mm difference compared to opposite wrist is abnormal. On the lateral view, look for dorsal prominence of the ulnar head. Always obtain full forearm X-rays including both joints to avoid missing associated injuries.
CT Scanning
Indications for CT:
- Assess DRUJ congruity when plain films unclear
- Complex intra-articular fracture patterns
- Pre-operative planning for comminuted fractures
- Post-operative assessment if DRUJ reduction questioned
- Chronic DRUJ instability evaluation
Information Provided:
- Detailed sigmoid notch anatomy and fracture fragments
- Quantification of DRUJ subluxation
- Associated fracture fragments (ulnar styloid)
- Articular step-off assessment
MRI Scanning
Role in Galeazzi Fractures:
- Rarely needed in acute setting
- May be useful in delayed or chronic cases
Indications:
- TFCC assessment (tears, quality)
- Chronic DRUJ instability evaluation
- Persistent unexplained symptoms post-treatment
- IOM assessment in suspected Essex-Lopresti
Findings:
- TFCC tears (central perforations or peripheral detachments)
- IOM disruption
- Ligament injuries
- Cartilage damage
Management Algorithm
Treatment Decision Tree
Management Based on Patient and Injury Factors
| Scenario | Treatment | Key Points |
|---|---|---|
| ORIF radius with plate | Fracture of necessity - always operative | |
| Consider closed reduction and cast | Conservative possible if reduction acceptable | |
| ORIF radius with plate | Treat as adult | |
| Supination cast 6 weeks | Most common outcome (80%) | |
| Pin DRUJ or repair TFCC | Occurs in 20% of cases | |
| Urgent debridement then ORIF | Standard open fracture protocol |
Surgical Technique
ORIF of Radius Fracture
Pre-operative Planning:
- Review full forearm X-rays including DRUJ
- Plan approach based on fracture location
- Template plate size and length
- Consent for possible DRUJ stabilization
Patient Positioning:
- Supine on operating table
- Arm on radiolucent hand table
- Tourniquet on upper arm (may not inflate if checking DRUJ stability without tourniquet)
- C-arm positioned for AP and lateral views
Careful pre-operative planning facilitates smooth surgical execution.
Complications
Early Complications (0-6 weeks)
Compartment Syndrome:
- Forearm compartments at risk (volar and dorsal)
- Monitor closely in first 48 hours post-operatively
- Clinical diagnosis: Pain out of proportion, pain with passive stretch
- Treatment: Urgent fasciotomy if diagnosed
Neurovascular Injury:
- Superficial radial nerve: At risk with volar approach (lies on brachioradialis)
- PIN: At risk with dorsal approach (emerges through supinator)
- Median nerve: Rare but possible with volar approach
- Posterior interosseous artery: Can bleed with dorsal approach
Wound Complications:
- Infection (1-2% risk)
- Wound dehiscence
- Hematoma
Acute DRUJ Instability:
- Most common early problem
- May become apparent after cast removal
- Requires assessment and possible secondary stabilization
Late Complications (After 6 weeks)
Persistent DRUJ Instability:
- Most common late complication (10-15%)
- Causes: Inadequate initial stabilization, missed TFCC tear, malunion
- Presentation: Pain, weakness, clicking, instability sensation
- Treatment: TFCC reconstruction, ulnar styloid ORIF if chronic nonunion
- Salvage: Darrach procedure or Sauve-Kapandji if severe
Malunion:
- Causes: Inadequate reduction, loss of fixation
- Manifestations: Shortened radius, angular deformity, loss of bow
- Consequences: DRUJ incongruity, loss of rotation, pain
- Treatment: Corrective osteotomy if symptomatic
Nonunion:
- Rare with rigid plate fixation (less than 2%)
- Risk factors: Inadequate fixation, infection, smoking
- Treatment: Revision ORIF with bone graft
Loss of Motion:
- Supination/pronation loss (most common residual deficit)
- Causes: DRUJ problems, malunion, soft tissue contracture
- Prevention: Early motion protocol, anatomic reduction
Other Late Complications:
- Heterotopic ossification (rare)
- Radioulnar synostosis (very rare)
- Post-traumatic arthritis (DRUJ or radiocarpal)
- Hardware prominence or irritation
- Chronic regional pain syndrome (CRPS)
Complication Prevention Strategies
For DRUJ Instability:
- Ensure anatomic radius length restoration
- Test DRUJ stability intraoperatively under direct vision
- Immobilize in supination for 6 weeks
- Pin if unstable (do not ignore instability)
For Malunion:
- Anatomic reduction of radius fracture
- Restore radial bow (10-12°)
- Adequate plate fixation (3 screws minimum each side)
- Assess reduction fluoroscopically before closure
For Stiffness:
- Early finger and elbow motion (immediate)
- Wrist motion after 6 weeks once healed
- Avoid prolonged rigid immobilization beyond 6 weeks
- Supervised hand therapy
For Nerve Injury:
- Careful surgical dissection
- Identify and protect nerves (superficial radial nerve, PIN)
- Avoid excessive retraction
- Post-operative nerve examination and documentation
Postoperative Care and Rehabilitation
Rehabilitation Protocol Timeline
Galeazzi Fracture Rehabilitation Protocol
Above-elbow cast or splint in supination (if DRUJ stable) or sugar-tong splint. Elevation of limb. Finger ROM exercises encouraged. Wound checks at 2 weeks. Maintain shoulder and elbow mobility.
Convert to below-elbow cast if DRUJ stable (elbow ROM allowed). Continue finger exercises. K-wires remain in place if DRUJ pinned. Radiographs at 6 weeks to assess healing.
Remove cast and K-wires. Begin active wrist ROM exercises. Active pronation-supination exercises started. Gentle strengthening if union confirmed. Hand therapy referral.
Progressive strengthening program. Return to sport when ROM and strength recovered (usually 3-4 months). Hardware removal if symptomatic (typically 12+ months). Full recovery expected by 6 months.
If DRUJ Stable Post-Fixation (80% of cases)
Immobilization Protocol:
- Week 0-2: Above-elbow splint in supination with elbow 90°
- Week 2-6: Convert to below-elbow cast in neutral or slight supination
- Week 6: Remove cast, begin wrist ROM
Position Rationale:
- Supination tightens dorsal DRUJ ligaments
- Brings radius over ulna into reduced position
- Minimizes stress on healing TFCC
Early Motion Protocol:
- Immediate: Finger ROM (all joints), grip strengthening
- Week 2: Elbow ROM exercises
- Week 6: Wrist flexion/extension, forearm rotation
- Week 8: Strengthening exercises
Expected outcome is excellent with full ROM recovery in 95% of cases.
If DRUJ Required Stabilization (20% of cases)
If K-wire Fixation Performed:
- Above-elbow cast in supination for 4-6 weeks
- K-wire removal at 6 weeks (in clinic, no anesthesia needed)
- Protected motion for additional 2-4 weeks
- Total immobilization 8-10 weeks
If TFCC Repair Performed:
- Above-elbow cast for 4 weeks
- Below-elbow cast for additional 2 weeks
- Protected ROM exercises then hand therapy
- Total immobilization 6-8 weeks
Supination Position Rationale
When DRUJ is unstable, immobilize in supination. This position tightens the dorsal radioulnar ligaments and brings the radius over the ulna into reduced position. Pronation will cause the DRUJ to subluxate dorsally due to laxity of volar ligaments. This is based on cadaveric studies showing maximum DRUJ stability in supination.
Physiotherapy Protocol
Therapy Goals
- Full pronation-supination ROM (80° each)
- Wrist flexion/extension 60° minimum
- Grip strength 90% of opposite side
- Pain-free wrist and forearm function
- Return to pre-injury activities
- Typical full recovery: 3-6 months
Red Flags During Recovery
- 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 Schedule
Standard Follow-up:
- 2 weeks: Wound check, X-ray (ensure no loss of reduction)
- 6 weeks: Remove cast/K-wires, X-ray (assess union), begin wrist ROM
- 12 weeks: X-ray, assess ROM and strength
- 6 months: Final assessment, return to full activities
Discharge Criteria:
- Fracture united (bridging callus on 3 cortices)
- DRUJ stable clinically
- ROM at least 80% of opposite side
- Pain minimal or absent
- Patient satisfied with function
Outcomes and Prognosis
Treatment Outcomes by Method
Outcome Data by Treatment Approach
| Treatment Method | Success Rate | Clinical Notes |
|---|---|---|
| 92% | Standard approach, excellent outcomes expected | |
| 85% | For unstable DRUJ after fixation, good outcomes | |
| 8% | High failure rate - do not use in adults | |
| 85% | Acceptable option in young children |
Prognostic Factors
Favorable Prognostic Factors:
Patient Factors
- Younger age (under 50 years)
- Child under 10 years (if conservative)
- No smoking
- Good compliance with rehabilitation
- No significant comorbidities
Treatment Factors
- Anatomic radius reduction achieved
- DRUJ stable after radius fixation
- Early surgery (under 1 week)
- Rigid plate fixation
- Early mobilization protocol followed
Unfavorable Prognostic Factors:
Injury Factors
- High-energy mechanism
- Open fracture
- Significant soft tissue injury
- Comminuted fracture pattern
- Associated injuries
Treatment Complications
- Residual radius malreduction
- Persistent DRUJ instability
- Delay to surgery (over 2 weeks)
- Inadequate fixation
- Loss of radial bow
Expected Outcomes
ROM Recovery:
- 95% achieve at least 80% of opposite side pronation-supination
- Wrist flexion/extension usually full or near-full
- Elbow ROM should be full
Strength Recovery:
- Grip strength recovers to 85-95% of opposite side
- Time to full strength: 4-6 months
Return to Activities:
- Light activities: 6-8 weeks
- Heavy labor: 3-4 months
- Contact sports: 4-6 months
- Full unrestricted activity: 6 months
Residual Symptoms:
- 10-15% have mild residual DRUJ discomfort
- 5-10% have permanent minor loss of rotation
- Less than 5% have significant disability
Evidence Base
The 'Fracture of Necessity' Concept (Landmark)
- Classic case series of distal radial shaft fractures (Galeazzi pattern) documenting that closed/conservative management in adults frequently failed with loss of reduction and DRUJ malalignment
- Established that anatomic reduction and internal fixation of the radius is required for a good outcome in the adult Galeazzi injury
- The associated term 'fracture of necessity' reflects that operative fixation is essentially mandatory in the adult
Treatment-Oriented Classification & DRUJ Instability (Landmark)
- Forty Galeazzi fracture-dislocations treated with ORIF of the radial shaft; fracture location predicted DRUJ instability
- Type I (distal third, within 7.5 cm of the mid-articular distal radius): DRUJ unstable after radial ORIF in 12 of 22 cases (more than half)
- Type II (middle third, more than 7.5 cm from the mid-articular surface): only 1 of 18 was unstable after radial fixation
- Persistent intra-operative DRUJ instability was managed with K-wire transfixion (10 patients) or TFCC repair (3 patients)
DRUJ Bony Incongruity & Soft-Tissue Stability
- The sigmoid notch is shallow with a radius of curvature about 50% greater than the ulnar head, so bony architecture gives minimal inherent DRUJ stability (citing af Ekenstam & Hagert, Scand J Plast Reconstr Surg 1985)
- The TFCC, principally the dorsal and volar radioulnar ligaments, is the major soft-tissue stabiliser of the DRUJ
- Restoration of the radioulnar ligaments best re-establishes the normal DRUJ constraints and kinematics
Paediatric Galeazzi Fractures - Conservative Management
- Reviewed 41 children under 15 years with a radius fracture plus disruption of the inferior (distal) radio-ulnar joint
- Despite the DRUJ injury being initially unrecognised in 41% of cases and varied treatments, final results of conservative management were generally good
- The more distal the radial fracture, the greater the problems encountered
Ulnar Styloid Base Fractures and DRUJ Instability
- Retrospective review of 166 distal radius fractures correlating ulnar styloid fractures with DRUJ instability
- Every distal radius fracture complicated by DRUJ instability was accompanied by an ulnar styloid fracture
- An ulnar styloid base fracture and significant styloid displacement each increased the risk of DRUJ instability
Global Epidemiology of Forearm/Radius Fractures
- Population-based analysis of 5953 adult fractures from a single orthopaedic trauma unit, defining the distribution curves of all adult fractures
- Radial/forearm diaphyseal fractures (which include the Galeazzi pattern) follow a predominantly younger, higher-energy distribution
- Provides the reference epidemiological framework cited worldwide for adult fracture demographics by age and sex
Clinical Decision Scenarios
Use these scenarios to practise clinical reasoning and management decisions
Classic Adult Galeazzi Fracture
"A 35-year-old man presents to the emergency department after falling from his bicycle onto his outstretched hand. X-rays show a fracture of the radius at the junction of the middle and distal thirds with DRUJ widening visible on the AP view. How do you manage this patient?"
This is a classic Galeazzi fracture-dislocation consisting of a radius shaft fracture with DRUJ disruption. This is called the 'fracture of necessity' because operative treatment is mandatory in adults - conservative treatment has a 92% failure rate while surgical treatment achieves 92% success.
Initial Assessment: I would perform a thorough neurovascular examination checking median, ulnar, and radial nerve function, as well as radial and ulnar pulses. I would examine the DRUJ for instability and check for an ulnar styloid fracture which indicates DRUJ disruption severity.
Surgical Plan - ORIF of Radius: My surgical approach would be ORIF of the radius through a volar Henry approach. This uses the interval between brachioradialis (radial nerve) and FCR (median nerve). I would use a 3.5mm compression plate with at least 6 cortices of fixation (3 screws minimum) on each side of the fracture. The key is achieving anatomic reduction - restoring radial length by comparing to the ulna, restoring the radial bow (10-12 degrees), and correcting rotation by comparing to the opposite forearm.
DRUJ Assessment: After completing radius fixation, I would assess DRUJ stability by stabilizing the radius with one hand and testing ulnar translation dorsally and volarly with the other hand. I would test in supination, neutral, and pronation positions and compare to the opposite wrist. In most cases (approximately 80%), the DRUJ becomes stable once the radius is anatomically reduced.
Post-operative Management: If DRUJ is stable, I would immobilize in an above-elbow cast or splint in supination for 2 weeks, then convert to below-elbow cast for 4 more weeks (total 6 weeks). At 6 weeks I would remove the cast and begin wrist ROM exercises with hand therapy. If DRUJ is unstable, I would pin the DRUJ in reduced position with K-wires in supination or consider TFCC repair if a clear tear is identified.
Expected Outcome: With anatomic reduction and appropriate DRUJ management, I would expect 92% good to excellent results with full or near-full recovery of pronation-supination and return to normal activities by 3-4 months.
Pediatric Galeazzi - Conservative vs Operative
"An 8-year-old girl fell on the playground. X-rays show a greenstick fracture of the distal radius with DRUJ widening. Her mother asks if surgery is needed. How do you counsel them and what is your treatment plan?"
This is a Galeazzi equivalent injury in a child under 10 years old. Importantly, treatment in children differs significantly from adults, and I would explain this to the family.
Counseling the Family: I would explain that while adults with this injury always require surgery, children's bones heal differently and have excellent remodeling potential. In children under 10, we can often achieve good outcomes with casting alone, avoiding surgery and its risks. The success rate with conservative management in young children is approximately 85%, compared to only 8% in adults.
Treatment Plan: My approach would be closed reduction under sedation or general anesthesia in the operating room. After achieving reduction, I would assess the DRUJ clinically for stability. If the radius is well reduced (less than 10 degrees angulation acceptable) and the DRUJ is stable, I would apply an above-elbow cast in supination with the elbow at 90 degrees for 6 weeks.
Follow-up Protocol: Weekly X-rays for the first 2-3 weeks are essential to monitor for loss of reduction. If reduction is maintained and DRUJ remains stable, I would continue with conservative treatment. If reduction is lost or DRUJ becomes unstable, I would proceed to ORIF as in adults.
Age Considerations: I would explain that this conservative approach is appropriate for children under 10. For older children and adolescents (over 10 years), remodeling potential decreases significantly and I would treat them like adults with ORIF.
Expected Outcome: With successful conservative management, I would expect excellent outcomes with full recovery and normal growth. The greenstick fracture pattern with intact periosteum actually helps maintain reduction and stability.
Persistent DRUJ Instability After Radius Fixation
"You have just completed ORIF of a Galeazzi fracture with anatomic reduction confirmed on fluoroscopy. However, when you test the DRUJ with the tourniquet down, it is grossly unstable in all positions of rotation. What is your approach and what are your options?"
Persistent DRUJ instability after anatomic radius fixation occurs in approximately 20% of Galeazzi fractures and requires additional intervention. This situation demands careful decision-making to prevent chronic DRUJ problems.
Confirm Anatomic Radius Reduction: First, I would carefully re-confirm that the radius reduction is truly anatomic. I would check radial length by comparing to the ulna on fluoroscopy, verify the radial bow is restored (10-12 degrees), and confirm rotation is correct by comparing to the opposite forearm. I would also compare to the opposite side fluoroscopically. Even small malreductions can cause DRUJ instability.
Assess for Ulnar Styloid Fracture: I would look for an ulnar styloid base fracture on the fluoroscopy images. A large displaced base fracture (over 2mm) indicates TFCC avulsion and significant soft tissue disruption. This may need separate fixation.
Treatment Options - My Approach:
First Choice - K-wire Fixation: If the radius is confirmed anatomically reduced, my preferred option would be to pin the DRUJ in reduced position. I would manually reduce the DRUJ and position the forearm in supination. I would then insert two 1.6mm K-wires from the ulna to the radius, crossing the DRUJ but staying above the joint surface (not through the articular cartilage). The wires would be left outside the skin for easy removal. These would stay for 6 weeks then be removed in clinic.
Second Option - Ulnar Styloid Fixation: If there is a large displaced ulnar styloid base fracture, I would fix it with either tension band wiring or small screws (1.5mm or 2.0mm). This restores the TFCC attachment point and may provide enough stability.
Third Option - TFCC Repair: If there is a substantial visible TFCC tear or if the previous options fail to provide stability, I would consider direct TFCC repair through a small dorsal incision. I would use suture anchors to repair the TFCC to the fovea or ulnar styloid base. However, this is more commonly performed as a secondary procedure if instability persists.
Post-operative Management: With K-wires in place, I would immobilize in an above-elbow cast in supination for 6 weeks. The wires would be removed at 6 weeks in clinic without anesthesia, then I would continue with below-elbow cast for 2 more weeks before starting ROM.
Expected Outcome: With additional DRUJ stabilization, the prognosis remains good with approximately 85% achieving good to excellent outcomes, though slightly lower than cases where DRUJ is initially stable.
MCQ Practice Points
Definition Question
Q: What are the two essential components of a Galeazzi fracture-dislocation?
A: Fracture of the radius shaft (typically at junction of middle and distal thirds) PLUS DRUJ disruption (dislocation or subluxation of the distal radioulnar joint). Both components must be present for the diagnosis.
Treatment Question
Q: Why is the Galeazzi fracture called the "fracture of necessity"?
A: Because operative treatment is necessary in adults for good outcomes. Conservative management has a 92% failure rate in adults, while surgical treatment (ORIF with plate) achieves 92% success rate. This term was coined by Hughston in 1957.
Stability Question
Q: In what position is the DRUJ most stable, and why is this clinically important for Galeazzi fractures?
A: The DRUJ is most stable in supination because this position tightens the volar radioulnar ligament and brings the radius over the ulna. After Galeazzi repair, the forearm is immobilized in supination to maximize DRUJ stability during healing. This is based on biomechanical studies.
Comparison Question
Q: How does a Galeazzi fracture differ from a Monteggia fracture in terms of anatomic location?
A:
- Galeazzi = Radius fracture (distal) + DRUJ disruption (distal joint)
- Monteggia = Ulna fracture (proximal) + Radial head dislocation (proximal joint)
Mnemonic: G for GRUJ (distal), M for MPRUJ (proximal)
Pediatric Question
Q: How does treatment of Galeazzi fractures differ between children and adults?
A:
- Adults: Always require ORIF with plate fixation (92% failure with conservative treatment)
- Children under 10: Can often be treated conservatively with closed reduction and cast in supination (85% success rate)
- Children over 10: Should be treated like adults with ORIF
This age-based difference is due to remodeling potential in young children.
Complications Question
Q: What is the most common complication after Galeazzi fracture treatment and how can it be prevented?
A: Persistent DRUJ instability is the most common complication (10-15% of cases). Prevention strategies include:
- Achieving anatomic radius reduction (restoring length and bow)
- Testing DRUJ stability intraoperatively after radius fixation
- Immobilizing in supination for 6 weeks
- Pinning DRUJ if unstable (do not ignore instability)
Guidelines, Registries & Global Practice
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.
Guideline & Authority Positions (Side by Side)
| Authority | Position on Adult Galeazzi | Evidence Level |
|---|---|---|
| Diaphyseal radius fracture with DRUJ injury: anatomic ORIF with a 3.5 mm compression/locking plate; restore length, bow and rotation; assess and stabilise the DRUJ | Expert consensus / Level IV-V | |
| Operative fixation is standard for displaced adult forearm-shaft fractures; non-operative care reserved for selected paediatric injuries | Level IV-V consensus | |
| Open injuries: urgent debridement and combined ortho-plastic care; definitive ORIF once soft tissues allow | Standard of care / guideline | |
| Concordant: 'fracture of necessity' - adult Galeazzi requires ORIF with intra-operative DRUJ assessment | Expert consensus | |
| Closed reduction and casting reasonable in younger children with acceptable alignment and a reduced DRUJ; operative fixation for older children/adolescents and irreducible/unstable patterns | Level IV |
Why no single-country framing
There is no high-level RCT or dedicated society guideline specific to Galeazzi fractures - the evidence base is case series and expert consensus (Level IV-V). Across AO, AAOS/OTA, BOA and European teaching the recommendation is uniform: anatomic radial ORIF plus intra-operative DRUJ assessment in adults. Differences are in emphasis (e.g. BOAST open-fracture pathways), not in principle.
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.
GALEAZZI FRACTURE EXAM CHEAT SHEET
Clinical summary
Definition
- •Radius fracture (middle-distal junction)
- •PLUS DRUJ disruption (always present)
- •Fracture of necessity = always ORIF in adults
- •3-7% of forearm fractures, peak age 30-40
Galeazzi vs Monteggia
- •Galeazzi: Radius + DRUJ (distal)
- •Monteggia: Ulna + radial head (proximal)
- •G for GRUJ (distal), M for MPRUJ (proximal)
- •Both usually need ORIF in adults
Surgical Approach
- •ORIF radius FIRST (volar Henry approach)
- •3.5mm plate, 6+ cortices each side
- •Restore length, bow (10-12°), rotation
- •Test DRUJ stability after fixation
- •80% stable, 20% need additional procedure
DRUJ Management
- •Test in supination, neutral, pronation
- •Compare to opposite wrist (key!)
- •Most stable in supination position
- •If unstable: pin in supination 6 weeks
- •Alternative: TFCC repair, styloid fixation
Immobilization
- •Above-elbow cast in SUPINATION
- •Supination tightens DRUJ ligaments
- •6 weeks total immobilization
- •K-wires removed at 6 weeks if used
- •Begin wrist ROM after cast removal
Pediatric Difference
- •Under 10 years: Conservative OK (85% success)
- •Closed reduction + cast in supination
- •Weekly X-rays to monitor reduction
- •Over 10 years: Treat like adults (ORIF)
- •Remodeling potential key factor
Key Evidence & Outcomes
- •Conservative in adults: 92% FAILURE
- •ORIF in adults: 92% SUCCESS
- •Anatomic radius reduction → DRUJ stability
- •Hughston 1957: 'Fracture of necessity'
- •Complications: DRUJ instability (10-15%)
Exam Traps to Avoid
- •Don't attempt conservative in adults
- •Don't forget to assess DRUJ intraop
- •Don't immobilize in pronation
- •Don't ignore ulnar styloid base fracture
- •Don't treat all children with surgery