Patrick is a 15-year-old boy who presents to the Emergency Department with a painful left arm. He tells you he fell off his bicycle, putting out his left hand out to break the fall. On examination, his left forearm is deformed at the wrist. There are no open wounds and no signs of compartment syndrome. The limb is neurovascularly intact.
He has declined analgesia in triage but you convince him to take paracetamol and ibuprofen prior to his x-ray. You order a lateral and AP film of his left forearm including the wrist and elbow.
Galeazzi fracture-dislocations consist of a fracture of the radius with dislocation of the distal radio-ulnar joint. The fracture usually affects the distal third of the radius.
Galeazzi injuries are very rare in children (more commonly seen in the adult population). The mechanism of injury is usually due to a fall on an outstretched hand with forearm rotation.
Examination findings
Examine the forearm, wrist and elbow joint.
Inspection and palpation: swelling, tenderness and likely deformity of the distal forearm and wrist. Check for any open wounds.
Range of movement: Maybe reduced at the wrist joint.
Check for signs of neurovascular compromise or compartment syndrome. Ulnar nerve injury is uncommon.
Investigations
True AP and lateral X-rays of the forearm including the wrist and elbow (including distal humerus).
The key point here is if a distal to mid-shaft radial fracture is seen on X-ray, have a good look for signs of distal radioulnar joint disruption.
Classification
Galeazzi fractures are classified according to the direction of ulna displacement.
Galeazzi-equivalent fracture
A Galeazzi-equivalent fracture may occur in children. This characterised by both
- fracture of the distal radius
- fracture of the growth plate of the ulna (separation of the ulnar physis), as opposed to dislocation of the distal radio-ulnar joint, DRUJ.
Treatment
All Galeazzi fracture-dislocations should be referred to orthopaedics on-call as a surgical intervention may be required for unstable or irreducible fractures. The usual approach in children is conservative management with closed reduction and immobilisation in an above-elbow cast. They should be followed up in the fracture clinic in 7 days. Complications include malunion, compartment syndrome and nerve injury but these are more common in adults and if the diagnosis is delayed. Children tend to have good outcomes with closed reduction and casting, even if the diagnosis is initially missed.
You are congratulated by the ED consultant for identifying Patrick’s Galeazzi fracture-dislocation. You call the Orthopaedic surgeons. It is a stable fracture and he has a successful closed reduction performed under procedural sedation in ED. An above-elbow back slab is applied. A few hours later, Patrick is ready to go home as he has recovered from the sedation. On their way out, his mother asks you if he will recover fully. You explain that he will be followed-up in the fracture clinic in 7 days but that his outcome should be good as the fracture was identified early and the post-reduction x-ray shows good alignment. On your next day off, you decide to make a table of the differences between Monteggia and Galeazzi fracture-dislocations to aid your memory.
[wpsm_comparison_table id=”10″ class=””]
*One way of remembering that both Monteggia and Galeazzi require review by orthopaedic surgeons is to remember that both fracture types are named after Italian surgeons!
Top tips
- If you identify a distal to mid-shaft radial fracture, look for signs of distal radioulnar joint disruption or ulna physis disruption.
- A useful mnemonic to remember the key differences between Monteggia and Galeazzi fracture-dislocations is MUGR (Monteggia fractured Ulna, Galeazzi fractured Radius)
Selected references
Eberl, R., Singer, G., Schalamon, J., Petnehazy, T. and Hoellwarth, M.E., 2008. Galeazzi lesions in children and adolescents: treatment and outcome. Clinical orthopaedics and related research, 466(7), pp.1705-1709.
Johnson NP, Smolensky A. Galeazzi Fractures. [Updated 2019 May 2]. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470188/
