Abstract
Background/Purpose
This study explored the need for distal radio-ulnar joint (DRUJ) stabilization and its effects on patients’ functional outcomes.
Methods
A retrospective chart review at level I trauma center was performed to identify all Galeazzi fractures between 2014 and 2022. CPT codes were pulled for any radius fracture, and then X-rays were reviewed to identify the Galeazzi fractures. Once the patient population was identified, chart reviews, including imaging study evaluation, were conducted. Statistics were performed with α=0.05 for the Chi-square tests and t-tests.
Results
Sixty-five Galeazzi fractures were included. Seventeen (26%) patients required DRUJ stabilization. DRUJ widening and ulnar variance were indicators for DRUJ stabilization (p = 0.03, p = 0.006, respectively). Fracture distance from DRUJ was not predictive of need for stabilization (p = 0.405). Current guidelines of ulnar variance > 2 mm and fracture distance <75 mm were not predictive of DRUJ instability (p = 0.09, p = 0.422, respectively). DRUJ widening >6 mm was associated with the need for stabilization (p = 0.0012). Patients who underwent DRUJ stabilization had significantly decreased pronation compared to the non-stabilized patients (p = 0.01), while other range of motion were similar in both groups.
Conclusion
There are likely combinations of factors that predict DRUJ instability, while they are inconclusive factors on their own. DRUJ stabilization may limit pronation but have otherwise comparable functional outcomes.
Introduction
The mechanism, incidence, and management of fractures of the radial shaft with associated dislocation of the distal radio-ulnar joint (DRUJ) was first described in 1934 by Ricardo Galeazzi, thus earning this injury the eponym by which it is known today.1–2 Galeazzi fractures, proposed to be caused by a force to an outstretched hand in the setting of a hyper-pronated forearm, are estimated to make up 3–7% of all forearm fractures. 3 The transmission of energy from the fracture causes disruption of the soft tissue structures, such as the foveal component of the triangular fibrocartilage complex (TFCC) that stabilizes the DRUJ, leading to dislocation. 4 Instability and pain related to this injury complex can lead to a limited range of motion (ROM) in both the forearm and wrist, and therefore can inhibit physical function.
While nonoperative management of these injuries is favorable in the pediatric population, there is a high rate of failure in adults when non-operative management is attempted.2,5 Timely surgical intervention via open reduction and internal fixation of the radial shaft fracture with or without stabilization of the DRUJ is performed routinely to restore wrist and forearm function. Current practice is examination of DRUJ stability under anesthesia, and based on exam findings and surgeon discretion, the DRUJ is managed with routine post-operative splinting with early ROM, splinting of the forearm in a position of stability for 4–6 weeks, or via surgical stabilization of the joint.
Guidelines have proposed that radiographic parameters of >5 mm shortening and fractures within 75 mm of the joint can be indicative of the need for stability of the DRUJ after fixation of the radial shaft. However, these parameters have been shown to be unreliable predictors of DRUJ instability. 6
The goal of the present study is to improve understanding of optimal diagnostic and treatment strategies for Galeazzi fractures, and ultimately enhance both functional and patient-reported outcomes.
Methods
An institutional review board-approved retrospective chart review was performed at an urban level I trauma center. Billing and registry data was queried for data from 01/01/2014 to 12/31/2022. CPT codes (25107, 25320, 25337, 25605) relating to Galeazzi fractures and relevant ICD-9/10 codes (S52.37, S52.3) were used to identify patients. All potential patients’ X-rays were reviewed to confirm the diagnosis and include them in the study. This resulted in 65 patients with Galeazzi fractures.
Individual patient charts were then reviewed for management of the injury, demographic data, and complications. Operative notes, inpatient hospital notes, and outpatient follow-up visit notes were reviewed along with radiographic and CT imaging when available.
X-rays were reviewed by a board-certified fellowship-trained orthopedic hand surgeon. Ulnar variance, DRUJ width, and fracture distance from the joint were measured via anterior–posterior views of plain radiographs of the injuries prior to reduction (Figure 1). DRUJ width was measured from the most medial radial articular edge to the most lateral ulnar head edge. For the distance from joint to oblique fractures, the average of the most proximal and most distal fracture edges was used.
Imaging example demonstrating the various plain film measurements. FDx represents the fracture distance from the articular surface. UV represents the ulnar variance. DRUJx represents the widening distance of the DRUJ.
Post-operation outcomes, including persistent nerve pain, unstable DRUJ on physical exam, degree of ROM, pain with ROM, and quick DASH scores, were identified via the patient's follow-up clinic notes and occupational therapy notes.
Descriptive and statistical analysis was conducted via Microsoft Excel v16.60. Chi-square test and t-test were used with a significance set at α = 0.05.
Results
Sixty-five Galeazzi fractures were included in the study. Of these patients, 44 (68%) were male, 44 (68%) were Black, and the average age was 35 years old (Table 1). The most common mechanisms of injury were motor vehicle collision (42%), followed by motorcycle accident (17%), and gunshot wound (GSW) (9%). Twenty (31%) of the Galeazzi fractures were open. Twenty-six (40%) of the cases involved the right upper limb, and one patient had bilateral Galeazzi fractures, resulting in 66 fractures. Median nerve symptoms were present in 11 patients (17%).
Patient demographics and management by DRUJ stabilization.
MOI: mechanism of injury; MVC: motor vehicle collision (excluded motorcycles); MCC: motorcycle collision; GSW: gunshot wound.
*Statistically significant p-value (p < 0.05).
This statistic was measured as a subset of patients with insurance.
All patients were treated with surgical fixation of the radius. Two patients were managed with external fixation. Seventeen (26%) of the Galeazzi fractures required DRUJ stabilization based on the surgeon's exam and expertise. This included eight patients splinted in position of stability (47%), eight stabilized with k-wires spanning the DRUJ (47%), and one open TFCC repair with suture anchors (6%).
Prior to reduction and splinting, the average distance from the articular surface of the distal radius to the fracture was 78.30 mm (SD23.4). The average ulnar variance was 8.47 mm (SD7.13), and the average DRUJ widening was 2.92 mm (SD2.85) (Table 1). Seven patients' DRUJ was not measured due to inadequate plain film imaging. When evaluated as a continuous variable, increased DRUJ widening and increased ulnar variance were associated with the need for stabilization (p = 0.03, p = 0.006, respectively). Similarly, DRUJ widening >6 mm (categorical variable) was also associated with the need for stabilization (p = 0.001) (Table 2). However, ulnar variance >2 mm (categorical variable) was not associated with need for stabilization (p = 0.090) (Table 2). The average fracture distance in patients with median nerve symptoms who underwent DRUJ stabilization was 65 mm.
Galeazzi fracture measurements comparing those treated with DRUJ stabilization and those without.
*Statistically significant p-value (p < 0.05).
Some plain film views were inadequate for measuring in these cases, at which point those cases were excluded in this count.
The average fracture distance from the distal radius articular surface was 73.3 mm (SD18.2) in those who required stabilization of DRUJ and 80.1 (SD24.9) in those who did not (p = 0.405). Distance from the DRUJ to the fracture >75 mm was not associated with the need for DRUJ stabilization (Table 2). Mechanism of injury being blunt was not associated with the need for stabilization compared to GSW (p = 0.541). Median nerve symptoms were associated with shorter fracture distances from DRUJ (p = 0.001). The use of external fixation for treatment of fracture was more common in patients requiring DRUJ stabilization (p = 0.016).
There was no mortality, malunion, or nonunion. Two patients developed superficial surgical site infections, which were managed with antibiotics, without the need for repeat operations. One patient had an intra-operative radial artery injury that was immediately repaired, and healed his fracture with no further complications.
One patient was noted to have DRUJ instability on physical exam postoperatively, as determined by the treating physician, but no pain, prompting the patient not to pursue additional surgery. This 52-year-old patient had his DRUJ stabilized with k-wires when surgically treating the Galeazzi fracture. At his 3-month post-op appointment, ROM was as follows: flexion 50°, extension 40°, supination 70°, pronation 55° (Figure 2). There was otherwise no recurrent DRUJ instability, regardless of fixation strategy.
Comparison of the range of motion of patients 6-weeks post-operation for Galeazzi fracture by DRUJ stabilization.
Post-operative regime was dictated by the surgeon. 47% of patients had documented post-operative orders for occupational therapy. Patients who did not undergo DRUJ stabilization had wrist ROM evaluated in follow-up clinic appointments as early as 2 weeks post-op, while those with DRUJ stabilization had the earliest wrist ROM evaluated at 1 month post-op. The average time from surgery to first ROM evaluation was 26 days. Grip strength evaluation was delayed, on average, first evaluated at three months post-op. For non-stabilized DRUJs, grip strength was on average first evaluated at three months post-op (87 days), ranging from 56 to 155 days. For stabilized DRUJs, grip strength was on average first evaluated at three months post-op (95 days), ranging from 63 to 121 days. Patients were followed for an average of seven appointments post-operative, ranging from 0 to 24 appointments. Loss to follow-up was 60%, albeit attendance to scheduled appointments having both mean and mode of 100%.
Discussion
There remains contention concerning whether the DRUJ requires stabilization in Galeazzi fractures, and if so, how. Patient sex, age, and race were determined to be non-contributory factors determining the need for stabilization of the patient population. The injury presentation instead has been theorized to be predictive of DRUJ management.
DRUJ widening has previously been described as an indicator for its surgical treatment in Galeazzi fractures. Mirghasemi et al. reported that DRUJ widening of at least 6 mm should be stabilized. 7 Our study confirmed this, and although the pre-surgical DRUJ measurements were not used to guide treatment, patients with DRUJ widening of at least 6 mm were more likely to undergo stabilization of the DRUJ. However, only 66% of patients with widening over 6 mm required stabilization, suggesting it is not an absolute or sole indicator of instability. Work by Takemoto et al. suggested a 2 mm ulnar variance to be the cut-off for DRUJ stabilization, which was inconsistent with the data presented above. However, increased ulnar variance was found to be an indicator of DRUJ stabilization. 8 This could be due to anatomical variation between patients, as native ulnar variance can vary within the general population. Physical examination of instability was prioritized over measurements on imaging. Thus, the combination of DRUJ widening with ulnar variance could be used to objectively predict the need for stabilization of Galeazzi fractures via imaging instead of physical examination.
Qazi et al. suggested that a fracture distance less than 75 mm from the DRUJ in Galeazzi fractures is predictive of its instability. 9 This is based on Rettig et al.'s work, which evaluated Galeazzi fractures based on proximal, mid-shaft, and distal third of the radius fractures, leading to the 75 mm cut-off. They did not mention ulnar variance throughout their study, although they did examine the mobility of the ulnar head to determine stabilization. However, this study's data is inconsistent with their findings, as the results suggest the distance from DRUJ to the fracture has no influence on the need for stabilization. The patients’ fracture distances to DRUJ ranged from 30 to 154 mm, with the average in the stabilized DRUJ patients being similar to the non-stabilized patients’ average. This demonstrates the variety in injury patterns across Galeazzi fractures in general, but notes that they do not indicate DRUJ instability. It was believed that the closer the fracture to the DRUJ, the more likely the force propagated through this joint, injuring it. Instead, it is likely the combination of all the forces within the mechanism of injury, and not a single distance dictates the instability. We found that the fracture distance alone is insufficient in predicting DRUJ stability. A larger sample size of different mechanisms of injuries might better explain the inconsistencies between studies looking at fracture distance and DRUJ instability.
Mechanism of injury was not found to be indicative of DRUJ instability. GSWs, which do not instill the same force through the DRUJ as a fall, had similar DRUJ widening, ulnar variance, fracture distance from wrist, and need for DRUJ stabilization as those with more classic injury mechanisms. Atesok et al. reported that Galeazzi fractures are primarily caused by forced axial loading with torsion of the forearm. 10 Although this conceptually is understandable, it does not explain how GSWs also cause Galeazzi fractures. The 11% of gunshot-inflicted Galeazzi fractures with similar rates of need for DRUJ stabilization demonstrates that these are not rare incidences to be overlooked. Ertl and Beckett recently stated that the mechanism of injury for Galeazzi fractures remains irreproducible in laboratory settings. 11 Larger studies focusing on the mechanisms of injuries and forces involved in these injuries may offer better insight into the overall understanding of them and thus how to predict their severity and need for DRUJ stabilization.
Preoperative median nerve symptoms were found in 17% of patients, of which the majority did not require DRUJ stabilization. This is counterintuitive, as it was initially believed that the higher energy trauma would disrupt the DRUJ and be associated with median nerve injury. However, these results are consistent with the rare reporting of Galeazzi fractures involving nerve injuries. While nerve injury is uncommon with these injuries, Roettges and Turker reported that anterior interosseus nerve (a branch off the median nerve) palsy is more common than ulnar nerve injury. 12 The data above showed that median nerve symptoms are associated more closely with the fracture distance than the DRUJ instability. The average fracture distance in patients with median nerve symptoms who underwent DRUJ stabilization was longer than that of patients with nerve symptoms without stabilization. This can likely be attributed to the proximity of the injury to the carpal tunnel.
Ultimately, the goal is to determine which patients benefit from DRUJ stabilization. There was no difference in ROM for wrist flexion, wrist extension, and supination between patients who underwent DRUJ stabilization and those who did not (Table 3). However, patients who underwent DRUJ stabilization did develop a significant decrease in pronation ROM when compared to the non-DRUJ stabilized group (Table 3). This could be due to more scar tissue developed around the additional instrumentation near the DRUJ, or perhaps the patients who required stabilization of the DRUJ had more severe injuries and would have had poorer ROM outcomes regardless of the stabilization. We had a relatively short follow-up in this series, and it may be that with a longer follow-up the pronation would improve. There is a need for further study to investigate if the type of stabilization (e.g. k-wires vs splinting vs direct fixation) affects the pronation loss. Whether the limited pronation truly affects the patient's functional status at work and for activities of daily living should also be evaluated.
Range of motion measurements 6 weeks post-operation for Galeazzi fracture by DRUJ stabilization. Occasionally, a range of motion measurement was recorded as “within normal limits,” which was excluded in the quantifiable data.
The main limitation of this study was the nature of the retrospective chart review, particularly in cases with inadequate imaging views. Additionally, surgeon assessment and preference were used to determine DRUJ stability. This introduced bias regarding the actual need for fixation, which can be difficult to determine. This emphasizes the current reliance on examination over imaging studies, despite their subjective nature that can be unreliable. 13 Thus, there is a need for an objective means of predicting the need for DRUJ stabilization in Galeazzi fractures. Unlike Korompilias et al.'s residual DRUJ instability post-operative management with k-wires rate of 42%, the data reported above resulted in a single residual DRUJ instability post-surgical intervention. 14 This one patient had also had their DRUJ instability managed via k-wires. He was fully functional and did not require further treatment, albeit with the persistent instability on examination. All patients in this study who did not require DRUJ stabilization had no instability on their follow-up examinations. Several patients had only short-term follow-up, preventing the collection of long-term data to evaluate healing and functional outcomes. While 26% of patients underwent DRUJ stabilization, there were small numbers of the different sub-types of stabilizations (e.g. k-wires vs splinting vs foveal repair), preventing comparison of these options.
Predictors for DRUJ stabilization in Galeazzi fractures remain elusive, although DRUJ widening remains the main factor. Although subjective, physical examination continues to be an important aspect of determining the need for stabilization. However, more emphasis on the evaluation of the ulnar variance as opposed to the fracture distance should be considered for objective measurements to predict stabilization in Galeazzi fractures. Differences between methods for stabilization have yet to be adequately compared. Similarly, the relevance of the mechanism of injury involved in Galeazzi fractures is unclear. Outcomes for patients with stabilization are similar to those without, with the exception of pronation ROM.
Footnotes
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data availability
Data is available upon request.