Ortho Hors D'oeuvres (Answer):
To review, this is a 57 year-old male with right arm pain after fall.
Questions and Answers: 1) What is the injury identified on radiographs?
This patient has an obvious transverse fracture through the distal radius with radial displacement and some shortening. It is impossible to tell if the distal fragment is dorsally or volarly displaced, or if the volar inclination of the distal radius articulation surface is preserved because we do not have a lateral x-ray.
2) What are the next steps in diagnosis?
The patient must receive a lateral x-ray, as is shown below:
In this radiograph, the patient's fracture of the distal radial shaft is again visualized; it is now apparent that there is signficant volar angulation of the distal fragment. Additionally, the dorsal displacement and dislocation of the distal ulna is now appparent.
Films of fractured bones must follow several requirements:
1) At least 2 views must be obtained to correctly diagnose displacement, dislocation, or joint involvement.
2) The Joint above and below the fracture must be visualized.
This patient went on to receive films of the right elbow, which were normal.
This fracture pattern is called a galeazzi fracture: a fracture of the middle to distal third of the radius associated with dislocation and/or instability of the distal radioulnar joint (DRUJ). Although in this patient the distal ulnar dislocation is fairly obvious, some patients may have automatically self-reduced their distal ulnar dislocation, so it is important to palpate the DRUJ to assess for tenderness. Patients with Galleazi fractures may also have limited forearm protonation or supination or a prominent ulnar head, in addition to the more obvious angular deformity on the radial side of the wrist.
3) What are the next steps in management?
It is important to differentiate Galleazi fractures from a simple distal radius fracture such as a Colles or Barton fracture. Unlike Colles or Barton, which can sometimes be appropriately reduced and healed with splinting, Galleazi fractures frequently fail nonoperative management due to angulation and slipping of the radial fragments accompanied by subluxation or dislocation of the DRUJ, resulting in severe limitation of rotation of the forearm. Patients with suspected or diagnosed Galleazi fractures should be placed in a sugar-tong splint and orthopedics should be consulted for possible ORIF within 24 hours. obtain orthopedic follow-up in less than 24 hours for operative planning. Children with these fracture patterns can often be managed nonoperatively but that decision should be made in conjunction with your consulting orthopedic physician.
References:
Giannoulis, Fillippos, and Dean Sotereanos. "Galeazzi Fractures and Dislocations." Hand Clinics 23(2007)153-163.
Thanks to Eric Silman for the images.
