This is an enhanced PDF from The Journal of Bone and Joint Surgery

The PDF of the article you requested follows this cover page.

Galeazzi fracture-dislocations
ZD Mikic
J Bone Joint Surg Am. 1975;57:1071-1080.

This information is current as of January 14, 2011

Reprints and Permissions
Publisher Information
Click here to order reprints or request permission to use material from this
article, or locate the article citation on jbjs.org and click on the [Reprints and
Permissions] link.
The Journal of Bone and Joint Surgery
20 Pickering Street, Needham, MA 02492-3157
www.jbjs.org
 EARLY MANAGEMENT OF OPEN JOINT INJURIES 1071

6. DoslisRowski, E. T. , and DuNN. A. W.: Treatment ofOsteomyelitis by D#{233}bridement and Closed Wound Irrigation-Suction. CIin. Orthop.. 43:
215-231. 1965.
7. DRFFt, D. J.: SCHAFFNER. WiL.t.IASI: HiLi.SIAN, J. W.; and KOENIG. M. G.: The Penetration of Penicillin and Other Antimicrohials into Joint
Fluid. Three Case Reports with a Reappraisal of the Literature. J. Bone and Joint Surg.. 49-A: 1415-1421 . Oct. 967.
S. FRANKEI.. C. J.: SPEAR. C. V.: HICKS. J. R.: and Hsu. Y. T.: The Treatment ofPenicillin Resistant Staphylococcus .Aureus Joint Infections with
Intra-articular Broad Spectrum Antibiotics. Surg. Forum, 11: 453-456. 1960.
9. Got i)MAN. VI. A.: JOHNSON, R. K.: and GROSSBERG. N. M.: Artificial Circulation: A New Approach to Chronic OsteotiyeIttts. Orthopedics. 2:
63-65, 1960.
0. HAMFION. 0. P. . JR.: Editorial. Management of Open Fractures and Open Wounds of Joints. J. Trauma, 8: 475-475. 968.
I I . Ku iv. P. J.: MARTIN. W. J.: and COSENTRY, M. B.: Chronic Osteoniyelitis. II. Treatment with Closed Irrigation and Suction. J. Am. Med.
Assn.. 213: l843-l)48, 1970.
2. Kii t v, P. J.: WIt.KOWSKE. C. J.: and WASHINGTON, J. A.. II: Musculoskeletal Infections Due to Serratia marcescens. Clin. Orthop.. 96: 76-83,
1973.
13. Pxi/AKts. M. J.: HAR\EY. J. P.. JR.: and Ivt.ER, DANIEL: The Role of Antibiotics in the Management ofOpen Fractures. J. Bone and Joint
Surg.. 56-A: 532-541. April 1974.
14. RAii. G. F. : GRIFFITH. R. S. : and HIuBi.1, W. M. : The Permeability of Traumatically Inflamed Synovial Membrane to Commonly Used
Antibiotics. J. Bone and Joint Surg.. 48-A: 1534-1539. Dec. 1966.
IS. Ss1trIt-PETIRst:N. M. N.: LARSON, C. B.: and COCHRAN. WILLIASIs: Local Chemotherapy with Primary Closure ofSeptic Wounds by Means of
Drainage and Irrigation Cannulae. J. Bone and Joint Surg.. 27: 562-571, Oct. 1945.

Galeazzi Fracture-Dislocations
BY 2LELIMIR DJ. MIKIC, M.D.*, NOVI SAD, YUGOSLAVIA

Front the Clinieal Hospital. Non Sad

ABSTRACT: Among 125 patients with the Galeazzi- Clinical Material

type fracture-dislocation of the forearm, there were By definition, the Galeazzi fracture-dislocation is a
fourteen children and eighty-six adults with the classic fracture of the shaft of the radius with an associated dislo-
Galeazzi lesion, and twenty-five patients with a special cation of the distal radio-ulnar articulation. The shaft is
type - fracture of both bones and dislocation of the considered to be that part of the radius between the bicipi-
distal radio-ulnar joint. Conservative management tal tuberosity proximally and an area four to five centimeters
was successful only in children. In adults this method from the distal articulating surface of the radius distally.
resulted in failure in 80 per cent ofcases. The results of Accordingly, fractures of the distal end of the radius
operative treatment were much better. The fracture (Colles’ fractures), which are often accompanied by a dis-
fragments of the radius and the dislocation of the location of the ulnar head, and fractures of the radial neck
radio-ulnar joint in this complex injury are very un- and head, which are occasionally associated with a dislo-
stable, especially in the lesion with fractures of the cation of the distal radio-ulnar joint (Essex-Lopresti frac-
radius and ulna, and it appears that rigid internal fixa- tures), are excluded from this series. However, in the
tion is necessary for the dislocation as well as the frac- present series cases in which the shafts of both the radius
ture. With combined fixation over half of the results and the ulna were fractured and the distal radio-ulnar joint
were excellent. was dislocated are included. This kind of injury, despite
its deviation from the classic definition, should be consi-
Fracture of the shaft of the radius associated with a dered a particular type of Galeazzi lesion.
dislocation of the distal radio-ulnar joint is a rare injury, From 1964 through 1974, I treated 125 patients with
first reported in 1 822 by Sir Astley Cooper Judet injuries of the Galeazzi type. Ninety-two of the patients
and Schnek also wrote about the lesion, but the eponym were male (73.6 per cent) and thirty-three, female (26.4
Galeazzi’s fracture-dislocation is based on a series of eigh- per cent). Most were adults between the ages of twenty
teen cases described in 1934 s.i4.I5.t7Ji.2i.21i.:tu.:t2 and fifty (Fig. 1 ). This fracture-dislocation rarely occurs in
A survey of the literature revealed only a few articles children 14.21.22, and we had only one patient in the age
on this specific subject. most of them reporting small group of birth to ten years. The equivalent lesion in chil-
series.
Hughston
(forty-four
To my knowledge,
in
the largest

cases)
1957
series are those of
(forty-one
Reckling and Cordell
cases) , Wong
in 1968
in 1967
dren is a fracture
of the distal
prognosis
of the radius
ulnar epiphysis: however,
associated
the pathology
of this injury in a child are quite different,
with separation
and
and it
(twenty-three cases) 21, and Maurel in 1970 (twenty-six is therefore excluded from this report. Fifty-eight (46.4
cases) 17 per cent) of the fractures occurred on the right side and
sixty-seven (53.6 per cent) on the left. Forty-nine patients
* Clinical Hospital. Hajduk Veljkova 1, 2 1000 Novi Sad, Yugoslavia. (39.2 per cent) were manual laborers; twenty-four (19.2

VOL. 57-A, NO. 8, DECEMBER 1975

1072 ;. DJ. MIKIC

35 -
number or cases
fracture. In two patients a double fracture of the radius oc-
32 curred. The fracture of the radius usually is composed of
30
only two fragments (eighty-three cases in our series), but
forty-two cases (33.6 per cent) were multifragmentary
25 - fractures. The transverse-type fracture was most frequent
22
(sixty-nine cases). In twenty-one cases the fracture was
20 - 20
oblique and in fourteen, spiral. In eleven cases the type of
fracture could not be classified because of comminution.

15
The subperiosteal fracture with angular displacement only
was noted in ten patients, all less than sixteen years old.
Twenty-seven fractures (2 1 .6 per cent) were open, and in
10
some of them the soft tissue was severely damaged. All of
7 these fractures had marked displacement and the radius
always was shortened. The usual displacement of the dis-
tal radial fragment was to the ulnar side (60 per cent), but
o-5_ 3-b ,t;2o a;,ii ,;-so _-- ,;.bo rbo rs it occurred to the dorsal, volar, and radial sides, and prox-
FIG. 1 imally as well. Only rarely was the displacement in one
Age distribution in 125 cases of Galeazzi fracture-dislocation. direction.
Most of the time (ninety-nine cases, or 79.2 per cent)
per cent), farmers; twenty-three (18.4 per cent), house- the dislocation of the distal radio-ulnar joint was evident
wives; nineteen (15.2 per cent), students; six, office clinically and roentgenographically. However, sometimes
workers; and four, retired. (twenty-two cases, or 20.8 per cent) the ulnar head mi-
tially was only subluxated, and this was more evident din-
Pathology ically than roentgenographically. But in those cases, be-
There is some disagreement on the exact mechanism cause the triangular fibrocartilage was ruptured the joint
that produces the Galeazzi fracture-dislocation. The most was very unstable, and if the early treatment was improper
probable mechanism is a fall on the outstretched hand complete dislocation of the joint occurred later.
combined with extreme pronation of the fore- The distal radio-ulnar joint is stabilized by various
arm 17JI.22.:to.:U The forces are thought to cross the structures (the ulnar collateral ligament, the anterior and
radiocarpal articulation, producing the dislocation and posterior radio-ulnar ligaments, and the pronator quad-
foreshortening of the radial shaft. As the displacement ratus muscle), but the most important stabilizing force is
continues, dislocation of the ulnar head occurs with tear- the triangular fibrocartilage 0.2 1 .22,24.:iii There can be no dis-
ing of the triangular fibrocartilage, which then loses its location of the distal radio-ulnar joint without rupture of
stabilizing influence on the wrist. This occurred in sixty- this strong intra-articular ligament. Therefore, the ques-
eight of our patients (54.4 per cent). Hughston consid- tion of whether the triangular fibrocartilage is ruptured or
ered the usual cause of this injury to be a direct blow to not is the crucial one in determining the presence of a
the dorsoradial aspect of the forearm, but that mechanism Galeazzi lesion. The specific function of the triangular
was responsible for only eight (6.4 per cent) of the injuries fibrocartilage is to limit the rotational movements of the
in this series. In the rest of our cases the mode of injury radius and ulna on one another ii.21.3() Therefore, if the
was not determinable. Twenty-five of our patients (20 per joint was exposed to an exaggerated rotational movement
cent) were injured in traffic accidents, nineteen (15.2 per (hyperpronation or hypersupination), rupture or detach-
cent) while at work on machines, and five in miscellane- ment of the triangular fibrocartilage could occur and a dis-
ous other ways: they were not able to explain how their location of the ulnar head was then possible.
forearms were injured. In any case, rotational stresses on In this regard the avulsion of the ulnar styloid process
the forearm would seem to be essential for dislocation of was equivalent to rupture of the triangular fibrocartilage; it
the distal radio-ulnarjoint. It has been demonstrated clini- was noted in 3 1 .2 per cent (thirty-nine) of our patients. In
cally and experimentally that a tear or detachment of the four cases in the present series the ulnar head was frac-
discus articularis is the first step to dislocation and occurs tured and dislocated. Dislocation of the ulna usually oc-
at the extreme of pronation and extension of the curred distally, dorsally, and medially (diastasis); volar
wrist :i.2t.22.24.:4O dislocation was less frequent.
The fracture occurs most often at the junction of the As mentioned, in twenty-five cases (20 per cent) the
middle and distal thirds of the radius (seventy-one cases, Galeazzi-type lesion was one in which the shafts of both
or 56.8 per cent in our series), and less often in the middle bones were fractured and the inferior radio-ulnarjoint was
third of the radial shaft (thirty-nine cases, or 31.2 per dislocated (Figs. 5-A through 6-D). Although dislocation
cent). The junction of the proximal and middle thirds of the distal radio-ulnar joint with fractures of both bones
(eight cases), the distal third (five cases), and the proximal of the forearm was reported by some authors 13J6J9,28.29

third of the radius (two cases) are infrequent sites of the the meaning and importance of this particular lesion has not

THE JOURNAL OF BONE AND JOINT SURGERY

 GALEAZZI FRACTURE-DISLOCATIONS 1073

been understood or related to the usual Galeazzi lesion. tal radio-ulnar joint, however, is not always easy. When
From the pathological and therapeutic point of view these the ulnar head is only subluxated (in about 20 per cent of
lesions differ from ordinary fractures of the forearm. The cases), the roentgenographic appearance usually is normal
mode of injury is the same as in the classic type of at first.
Galeazzi lesion - the distal fragment of the radius is dis- In these cases care must be taken with the physical
placed and the bone shortened but the main and criti-
- examination, and roentgenographically attention should
cally differentiating characteristic is the dislocation of the be given to the problem of plus and minus variations of the
distal radio-ulnarjoint. which always is present. The frac- ulna ,27, These normal variations can be mistaken roent-
ture of the ulna which obviously occurs after the disloca- genographically for dislocations.
tion of the radio-ulnar joint, as force continues to be ap- In cases in which the diagnosis is uncertain, arthrog-
plied, is the unique feature of the injury that might be con- raphy of the wrist joint can be helpful in establishing
sidered a differentiating characteristic from typical whether the triangular fibrocartilage is ruptured We :t.t:t

Galeazzi fracture-dislocations. Because of the rupture of started to use this method of diagnosis three years ago and
the triangular fibrocartilage this special Galeazzi have had experience with it in eight cases of suspected
fracture-dislocation is also extremely unstable. Conse- Galeazzi lesions. In five patients the arthrograms were
quently the therapeutic problem and the prognosis with normal, showing that no rupture of the articular disc had
this lesion are similar to those of the classic Galeazzi le- occurred. On the basis of that finding, a Galeazzi injury
sion. was excluded. In three young patients, filling of the wrist
The Galeazzi fracture-dislocation can sometimes be joint with contrast medium indicated a rupture of the disc
associated with an injury to the ulnar nerve In the pres- i2, (Figs. 2-A through 2-D), and in these cases the diagnosis
ent series this happened only once, in a twenty-year-old of Galeazzi fracture was confirmed. The positive arthro-
patient with fractures of both bones which were initially graphic finding (the passage of contrast medium from the
reduced and fixed with Kirschner wires. The distal radio- wrist into the inferior radio-ulnarjoint) cannot be regarded
ulnar joint was reduced closed but later delayed union of as always diagnostic of a disc rupture, because there often
the fracture and redislocation ofthe distal radio-ulnar joint is a perforation in the normal disc. This considerably re-
occurred. After eight months, no recovery of the ulnar duces the clinical value of wrist arthrography, but accord-
nerve was evident. Then the distal end of the ulna was re- ing to my own investigation of 100 fresh cadavera (I 80
sected and the nerve was explored, but no obvious lesion wrist joints), perforation of the triangular fibrocartilage
of the nerve was found, and nerve function did not im- develops from degenerative changes, and its occurrence
prove thereafter. Warren st also reported a case of an depends on the age of the subject. In cadavera of persons
interosseous nerve palsy following a Galeazzi fracture. up to twenty years old no perforation was found, and in the
third decade the perforation occurred only rarely (7.6 per
Diagnosis
cent). However, in cadavera of individuals over thirty
Although the diagnosis of the Galeazzi fracture- years old the incidence of perforation was much higher,
dislocation should not be difficult, it often seems to be and in persons over sixty the perforation occurred in 53.1
misdiagnosed :ti The fracture, of course, is always noted, per cent. Therefore, a positive arthrographic finding of
but the disruption of the distal radio-ulnar joint is often disc rupture may be considered reliable only in persons up
overlooked. Our patients were treated by many surgeons to thirty years old.
and initial documentation in many cases was incomplete;
Treatment and Results
therefore, the frequency of misdiagnosis, although high,
could not be established. The diagnosis ofthis complex in- We will describe the treatment and results in our
jury is quite simple, providing a careful clinical and roent- series with reference to three groups of patients: (1 ) chil-
genographic examination of the distal radio-ulnar joint is dren (up to sixteen years old); (2) adults with the classic
made whenever a fracture of the forearm, and especially Galeazzi fracture-dislocation; and (3) adults with fracture
an isolated fracture of the radius, is encountered. of both bones associated with dislocation of the distal
The clinical appearance is characteristic. There is radio-ulnar joint.
usually an angular, concave deformity on the radial side of The results are classified as excellent, fair. and poor.
the forearm, which seems shortened. The distal radio- An excellent result is one in which there is union, perfect
ulnar joint also is deformed, swollen, and painful. The alignment, no loss of length, no subluxation of the distal
ulnar head may seem to protrude and to be slightly more radio-ulnar joint, no limitation of elbow and wrist func-
mobile than usual. tion, and no limitation of supination or pronation. A fair
Every roentgenographic examination of an isolated result is one in which there is one or more of the following:
fracture of the radius must include the inferior radio-ulnar delayed union, minimum malalignment and shortening of
joint, but because dislocation of the joint can also be as- the radius, subluxation of the ulnar head, excessive scar,
sociated with a fracture of both bones, it is advisable to limitation of pronation-supination up to 45 degrees, and
examine the joint carefully in every case of forearm frac- some degree of restriction of motion of the elbow and
ture. Roentgenographic diagnosis ofdislocation ofthe dis- wrist. An important criterion for a fair result is that subjec-

VOL. 57-A. NO. 8. DECEMBER 1975

I 074 z. DJ. MIKIC

cellent result. The end result in two patients was unknown

because they were lost to follow-up. The average time for
fracture healing was four to six weeks.
There were eight-six adult patients with the classic
Galeazzi lesion. Thirty-four of them (39.5 per cent) were
treated with closed reduction and immobilization only,
and fourteen of these could not be evaluated because the
records were incomplete. Of the remaining twenty pa-
tients, sixteen (80 per cent) had end results that were poor.
In most of these cases good position of the fracture frag-
ments and good reduction of the ulnar head were obtained
initially by means of manipulative reduction; but later,
while in a plaster cast, some angulation and slipping of the
FIG. 2-A
radial fragments and subluxation or dislocation of the dis-
A twenty-four-year-old patient with a dislocated fracture of the radius
and suspected dislocation of the distal radio-ulnar joint. tal radio-ulnar joint occurred, resulting in loss of
supination-pronation and loss of wrist and elbow motion.
tively the patient must be satisfied with the end result. The The slippage usually occurred seven to ten days after the
result is rated poor ifthere is one or more ofthe following: reduction.
pain. deformity of the forearm. non-union, remarkable In two patients a second reduction was tried, but
shortening or angulation of the radius, dislocation of the without success. Excellent results were obtained in only
distal radio-ulnar joint. limitation of pronation-supination two patients treated conservatively, and in them the distal
of more than 45 degrees. and excessive restriction of radio-ulnar joint was only subluxated. The healing period
elbow and wrist function. of the conservatively treated fractures was usually two to
The follow-up period in our series was from six three months. Delayed union was noted in one patient and
months to eleven years. with an average of two years and osteoarthritis of the distal radio-ulnar joint with painful
seven months. forearm rotation occurred in five patients.
In the group ofchildren there were fourteen patients, Fifty-two adult patients (60.5 per cent) were operated
of whom twelve were treated conservatively. In all cases on early. They were treated by several surgeons over an
adequate. stable reduction was easily achieved by ma- eleven-year period, and therefore the operative methods
nipulation. probably because most of the fractures were were quite varied. In most cases a closed reduction was at-
subperiosteal. In nine patients the results were excellent, tempted first, and when it failed the operation was done
and only in a fifteen-year-old boy did redislocation of the within a few days. In forty-two patients open reduction
radial fragments (volar angulation) occur. and internal fixation of the radius was performed. In ten
The radius healed in an angulated position but func- patients a closed reduction was done with percutaneous
tion was good and the result was rated fair. Closed reduc- Rush pinning of the radius. The distal radio-ulnar joint
tion failed in only one patient: open reduction was then was always reduced closed except in two cases in which,
done without internal fixation, and a fair result was re- because of fracture of the ulnar head, resection of the dis-
corded after six years of follow-up. In one sixteen-year- tal portion of the ulna was performed. In fourteen patients
old boy percutaneous Rush pinning was done with an ex- the radio-ulnar joint was transfixed with Kirschner wires

FIG. 2-B FIG. 2-C FIG. 2-D

Fig. 2-B: The arthrography of the wrist joint revealed the passage of contrast medium into the inferior radio-ulnarjoint, indicating the rupture of
the triangular fibrocartilage. The extra-articular flow of the contrast medium (ef) showed the seriousness of the injury to the distal radio-ulnar joint.
Fig. 2-C: Closed reduction and percutaneous Rush pinning of the radius and radio-ulnar transfixation were performed.
Fig. 2-D: After seven months the anatomical and functional results were excellent.

THE JOURNAL OF BONE AND JOINT SURGERY

 GALEAZZI FRACTURE-DISLOCATIONS 1075

FIG. 3-A FIG. 3-B FIG. 3-C

Fig. 3-A: Multifragmentary fracture in the middle third ofthe radius in a thirty-one-year-old man. The dislocation ofthe distal radio-ulnarjoint is
shown.
Fig. 3-B: Because the fracture was multifragmentary, a six-hole plate was used. Radio-ulnar transfixation with Kirschner wires was applied to
stabilize the distal radio-ulnarjoint. One month postoperatively the plaster cast and Kirschner wires were removed and physical therapy was initiated:
although the fracture had not healed, it was stabilized sufficiently to begin rehabilitation.
Fig 3-C: Four months after operation the fracture was healed and the patient had a full range of motion.

(Figs. 3-A, 3-B, and 3-C). Of the patients operated on, Kirschner intramedullary pinning of the radius. The heal-
forty-three were followed up. ing period for these fractures was four months, and in two
With the method of Rush pinning, we had satisfactory patients non-union was evident after six months.
results (thirteen excellent, five fair, and one poor). In ten We used K#{252}ntscher nails only twice, with a poor re-
patients with simple transverse fractures the closed reduc- suit in one patient and an unknown result in the other, in
tion and percutaneous Rush pinning of the radius was suc- whom resection of the distal ulna was also performed.
cessfully performed. We were especially pleased with the Two spiral fractures were fixed with wire loops and
results of Rush pinning (open or percutaneous) and radio- the final result was excellent in one; in the other the result
ulnar transfixation (five excellent and two fair results) was originally poor, as the wire cut through the bone.
(Figs. 2-A through 2-D). The healing period after Rush Later, onlay bone-grafting was performed with a satisfac-
pinning in most cases was two to three months. Only once, tory end result.
in a twenty-four-year-old man with an open fracture, did Primary bone-grafting (onlay bone graft fixed with
we encounter non-union, after four months. This patient four screws) was used only once, with a fair result.
initially had a poor result; onlay bone-grafting was per- As mentioned earlier, in all except two patients the
formed and a fair result was achieved. dislocation of the distal radio-ulnar joint was treated con-
Plating of the radius was used in thirteen patients, servatively. Only twice, because of ulnar-head fracture,
with generally satisfactory results (six excellent, four fair, was resection of the distal part of the ulna performed. In
and two poor). Once again results were better when one patient, because of complications with radial fracture,
radio-ulnar transfixation had been done (Figs. 3-A, 3-B, the result was poor, and in the other it was unknown. In
and 3-C). In one patient with a poor result (Figs. 4-A most patients with fair and poor results, ulnar-head sub-
through 4-E), although the osteosynthesis seemed stable, luxation or dislocation recurred. Because of this, a few
malunion of the radius and redislocation of the distal years ago we began to stabilize the joint by percutaneous
radio-ulnar joint occurred. In the other poor result, in temporary radio-ulnar transfixation. After rigid osteosyn-
which the fractured ulnar head was also resected, the fail- thesis ofthe radius the distal radio-ulnarjoint was reduced
ure probably occurred because of technical error. Slight and one or two Kirschner wires were placed percutane-
redislocation and non-union were evident after seven ously through the ulna into the radius slightly above the
months; onlay bone-grafting was done and a fair result was head of the ulna (Figs. 2-A through 3-C), as visualized
obtained. In most instances the healing period was two to with the image intensifier. After four weeks the wires were
three months. removed. This technique was used in fourteen patients
The most unsatisfactory results (none excellent, five with a classic Galeazzi fracture, with an excellent result in
fair, and three poor) occurred in the patients treated with nine patients and a fair result in four. In one patient the

VOL. 57-A, NO. 8, DECEMBER 1975

I076 z. DJ. MIKIC

FIG. 4-A FIG. 4-B FIG. 4-C

Fig. 4-A: The classic Galeazzi fracture-dislocation in a forty-eight-year-old man.
Fig. 4-B: Plating of the radius and closed reduction of the distal radio-ulnarjoint were carried out. Note the good position ofthe radial fragments
and the distal radio-ulnar joint.
Fig. 4-C: A month later the redislocation of the radius and the distal radio-ulnar joint was discovered, but nothing was done to correct it.

result was unknown. Complications were recorded in two formed in twelve patients and eight of them had a good re-
patients with fair results: in one a slight infection de- suit (three poor and one fair).
veloped and in the other, in whom the radius was plated, In Wong’s series :i thirty-four patients were treated
the Kirschner wire which had not been removed after six initially by manipulative reduction followed by immobili-
weeks broke as the patient started physical therapy. zation in plaster. Immobilization in plaster without any at-
A serious infection occurred in two patients treated tempt at reduction was done in four patients. and operation
operatively (one closed and one open fracture). Osteoar- was performed initially in six. A successful result was
thritis of the distal radio-ulnar joint occurred in three pa- achieved in only three of the thirty-four patients (9 per
tients (two poor and one fair result). cent) treated conservatively. Of the ten patients treated by
In the third group there were twenty-four patients open reduction and internal fixation, either initially or sub-
with fracture of both bones and associated dislocation of sequently. a successful result was achieved in three (30 per
the distal ratho-ulnar joint. Four patients were treated cent).
conservatively with unsatisfactory results. The others Our experience with the treatment of the Galeazzi
were operated on early in various ways. with unsatisfac- fracture-dislocation in adults has been similar. We agree
tory results in 45 per cent. Excellent results were obtained with Hughston, who said: ‘We believe ‘ that the high per-
in only three patients, in whom radio-ulnar transfixation centage of unsatisfactory end results in the treatment of
was done in addition to rigid osteosynthesis of both bones this fracture is due to most physicians’ lack ofknowledge of
(Figs. 5-A through 5-D). In most cases of fair and poor the forces active when the customary reduction and irn-
results there was redislocation of the distal radio-ulnar mobilization is applied in the treatment of these fractures.
joint (Figs. 6-A through 6-D), and this resulted in restric- The rareness of this fracture and, therefore, our unfamil-
tion of pronation-supination. In two patients painful os- iarity with it, accounts for our lack of knowledge of its
teoarthritis of the joint was also noted. Delayed union oc- complex aspects’ ‘

curred in six patients and non-union, in four. Six patients

had infection (one closed and five open fractures).

Discussion

Galeazzi
Hughston
fractures,
, in reporting
noted that
the
thirty-eight
results
had
of
been
forty-one
treated
by closed means and three by open reduction. Of his
thirty-eight patients treated conservatively, thirty-five
(92 per cent) had an unsatisfactory result and only three (8
per cent) were satisfactory. Of the three treated initially
by open reduction, two attained a satisfactory result and
the third resulted
In Reckling
were treated initially
in failure.
and Cordell’s
by closed
series
reduction
, eight patients
and plaster-cast
Figs.
healed
4-D and 4-E:
in a dislocated position.
Fi#{236}.4-D

Roentgenograms
The distal
made
FIG. 4-E

a year
radio-ulnarjoint
later. The radius
remained dis-
located and osteoarthritic changes developed. with pseudarthrosis of
immobilization only. and there was not a single good re-
the ulnar styloid process. The patient had painful and restricted rotation
sult (five fair and three poor). Open reduction was per- of the forearm. The result was rated poor.

THE JOURNAL OF BONE AND JOINT SURGERY

 GALEAZZI FRACTURE-DISLOCATIONS 1077

L
25

,1..

FIG. 5-A

A
stretched
ofboth
thirty-seven-year-old
left hand.
bones,
Initial
the fracture
woman
roentgenograms
ofthe
fell

styloid
from a bicycle
show the fracture
process ofthe
onto
ofthe
her out-
shafts
ulna, and disloca-
1
FIG. 5-C
lion of the distal radio-ulnar joint.
After two months the Kirschner wire was removed and physical
therapy was begun. although the fractures were not healed. The stable
fixation of the fractures allowed this.

FIG. 5-B
Open reduction and plating of the radius and Rush pinning of the ulna
were performed. As the distal radio-ulnarjoint was unstable, radio-ulnar
transfixation with a Kirschner wire was done.

FIG. 5-D
When the lesion occurs in a child, the situation is dif-
An excellent anatomical and functional result after three years.
ferent. This injury is quite rare in childhood, and the frac-
ture then is usually subperiosteal with angular displace- the reduction must be adequate and must be checked
ment. It can be reduced, and the dislocation of the distal throughout the period of immobilization. The immobiliza-
radio-ulnar joint can also be reduced without difficulty. tion should consist of an above-the-elbow plaster cast with
The reduction of both the fracture and the dislocation usu- the forearm in supination, because of the muscle forces
ally is stable, and therefore the results of treatment are which act in the distal radio-ulnarjoint
quite favorable Obviously
. . this fracture-dislocation in The Galeazzi syndrome in adults has been recognized
children should be managed conservatively Of course, and described as a very unstable fracture-disloca-

VOL. 57-A, NO. S. DECEMBER 1975

I078 1. DJ. MIKIC

FIG. 6-A

A forty-tour-year-old man. injured in a traftic accident. Both bones

were fractured and the distal radio-ulnar joint was dislocated.

Roentgenograms made seven months after operation show the frac-

tures healed in satisfactory position, but redislocation of the distal
radio-ulnar joint occurred. The result was rated poor.

FiG. 6-B

Open reduction and Rush pinning of both hones was performed: the
pin in the ulna is obviously too short.

tion 8,21,30, There are many factors responsible for the

FIG. 6-D
instability K, However, rupture of the triangular fibro-
The pins were removed and the distal end of the ulna was resected.
cartilage seems to be the main cause of the frequent re-
The function of the forearm improved subsequently. and the end result
dislocations of the joint and the poor results which was rated fair.

THE JOURNAL OF BONE AND JOINT SURGERY

 GALEAZZI FRACTURE-DISLOCATIONS 1079

ensue. The radius and ulna are nearly parallel and they plaster immobilization. Some displacement of the frag-
have complex mechanical relationships to one another. ments ordinarily leads to delayed union and subluxation of
Any disproportion in length results in a disturbance of one the distal radio-ulnar joint, with consequent unfavorable
of the radio-ulnar joints t,:to, Accordingly, any displaced results. Although the K#{252}ntscher nail is strong enough, it is
and foreshortened fracture of the radius or ulna must be straight and too rigid. and hence unsuitable for use in a
associated with a dislocation of the distal or proximal curved bone like the radius. Plating of the fracture of the
radio-ulnar joint or with a fracture of the other bone radius is most suitable in cases of multifragmentary frac-
From the standpoint of the restoration of normal radio- tures, and if correctly done will provide rigid internal
ulnar joint function and normal pronation-supination, re- fixation of the bone and stable reduction of the distal
establishment of the equal lengths of the bones is essen- radio-ulnar joint in most cases. In addition, the firm os-
tial. Therefore, if the fracture is displaced, the fragments teosynthesis makes early rehabilitation possible without
must be anatomically reduced and must be maintained waiting for the fracture to heal (Figs. 3-B and 3-C). In a
throughout the healing period. Moreover, an unstable dis- multifragmentary fracture a six-hole plate (Fig. 3-B) is
tal radio-ulnarjoint should also be reduced and fixed in op- preferable, in my opinion, because it stabilizes the frag-
timum position. Obviously Galeazzi injuries in adults are ments better and prevents angulation (Fig. 4-B).
very difficult to treat successfully by conservative means, The stability ofthe distal radio-ulnarjoint is a special
and it is quite understandable that the results of the closed problem. In many cases in the present series. subluxation
reduction and immobilization are uniformly or dislocation recurred. This is understandable in cases in
unsatisfactory 5.17.21.30.32, which the reduction and fixation of the radial fracture was
The results in patients treated operatively are obvi- not adequate, but it was also encountered in several cases
ously better than in those treated conservatively, but they in which the osteosynthesis seemed solid (Figs. 4-B and
are still not always satisfactory, and there are too few ex- 4-C). Because of many factors (strong muscle action, the
cellent results. It is true that some of the fractures in our weight of the hand, absorption at the fracture site) there
series were complicated (open fractures with severe soft- always seems to be a tendency toward redislocation of the
tissue damage and comminuted fractures) and difficult to distal radio-ulnar joint. Even rigid osteosynthesis of the
treat, but the main reason for bad results seems to have radius does not guarantee stable reduction of the ulnar
been the inadequate surgical procedures that were per- head in all cases. One must keep this in mind if this com-
formed in many cases. plex injury is to be treated properly. Because of these fac-
The radius is a curved bone. Its concavity faces the tors, when open reduction and internal fixation of the
ulna. The medullary canal of the radius is funnel-shaped in radius have been performed the distal radio-ulnar joint
the distal third, and curved and narrow in the middle should always be tested for stability and in cases where it
third Because
. of this anatomical configuration, the is unstable obviously something must be done. Hughston
radius is somewhat unsuitable for intramedullary fixation. suggested immediate resection of the distal portion of the
When a radial fracture is reduced the arc on the ulnar side ulna, but there are too few cases in his series to evaluate
must be maintained, because any deviation changes the the value ofthis procedure as initial treatment. In my opin-
length of the bone, involves the interosseous membrane, ion, this is too aggressive, and it may be better in such
affects the distal radio-ulnarjoint, and produces some re- cases (and perhaps in all cases) to temporarily fix the
striction of pronation-supination. Therefore, the pin for an radio-ulnar joint with one or two Kirschner wires. With
intramedullary fixation of a radial fracture must be strong this maneuver the ends of the ruptured triangular
enough, and at the same time must follow the arc so that fibrocartilage are approximated and can heal in optimum
anatomical reduction of the radial fragments will obtain position.
with optimum alignment. In my opinion, the best device Fractures of both bones of the forearm, with an as-
for such a purpose is the Rush pin, which is sufficiently sociated dislocation of the distal radio-ulnar joint, is a
flexible to follow and maintain the radial curve, and at the much more difficult injury to manage than the classic
same time strong enough to secure good fixation of the Galeazzi lesion. Conclusions should not be firmly drawn
fragments. In most cases, this also will allow stable reduc- on the basis of a relatively small number of cases treated in
tion of the distal radio-ulnar joint. According to my re- different ways, but it does seem that open reduction and
suits, Rush pinning (open or percutaneous) was a satisfac- rigid internal fixation of both bones is the first absolute
tory method for treating the simple two-fragment fracture necessity. As redislocation of the distal radio-ulnarjoint is
and especially the double fracture of the radius. very likely to occur it was present
- in all of my patients
Kirschner wires are too weak to stabilize the radial frag- with unsatisfactory results - I believe that additional
ments against the deforming forces which operate during temporary radio-ulnar fixation also is necessary.

References
I. ALBERT. S. M.: WOHL. M. A.: and RECHTMAN. A. M.: Treatment of the Disrupted Radio-Ulnar Joint. J. Bone and Joint Surg.. 45-A:
1373-1381. Oct. 1963.
2. BOHLER. J.: Gelenknahe Frakturen des Unterarmes. Der Chirurg. 40: 198-203, 1969.
3. COLEMAN. H. M.: Injuries ofthe Articular Disc atthe Wrist. J. Bone and Joint Surg.. 42-B: 522-529. Aug. 1960.

VOL. 57-A, NO. 8, DECEMBER 1975

1080 z. DJ. MIKIC

4. DE MOURGUE5, G.: SCHNEPP, J.: RICARD. R.: and CHABAL. J.: Fractures isol#{233}es
de Ia diaphyse radiale. Lyon chir., 57: 421-423. 1961.
5. DE RACKER, CH.: La fracture isol#{233}e
de Ia diaphyse radiale avec ou sans luxation du cubitus. Lyon chir., 50: 230-236. 1955.
6. GALEAZZI, R.: Di una particolare sindrome traumatica dello scheletro dell’avambraccio. Atti mem. Soc. Lomb. chir., 2: 12, 1934.
7. GALEAI1I. R. : Uber em besonderes Syndrom bei Verletzungen im Bereich der Unterarmknochen. Arch. f. orthop. UnfaIl-Chir. , 35: 557-562.
1935.
8. H1GHSTON, J. C.: Fracture of the Distal Radial Shaft. Mistakes in Management. J. Bone and Joint Surg.. 39-A: 249-264, April 1957.
9. HLGHSTON, J. C.: Fractures ot the Forearm. Anatomical Considerations. J. Bone and Joint Surg.. 44-A: 1664-1667. Dec. 1962.
10. HULTEN. OI.iE: Uber anatomische Variationen der Handgelenkknochen. Em Beitrag zur Kenntnis der Genese zwei verschiedener
Mondheinser#{225}nderungen. Acta Radiol.. 9: 155-168. 1928.
I I. JUDET. H.: Trait#{233}des fractures des membres. Paris, Expansion Scientifique Fran#{231}aise, 1913.
12. KESSLER, 1.. and SI1.BERMAN. Z.: An Experimental Study otthe Radiocarpal Joint by Arthrography. Surg.. Gynec. and Obstet., 112: 33-40,
1961.
13. KNIGHT, R. A.. and PuRvis.
D.: Fractures G. ofBoth Bones ofthe Forearm in Adults. J. Bone and Joint Surg.. 31-A: 755-764, Oct. 1949.
14. KORZH. A. A.: BONDARENKO. N. S.: and VASILEvSKIi, N. N.: Ob osnovnykh printisipakh lechenila perelomov kostei verknei konechnosti u
detei. Ortop.. travmat. protez.. 30: 9-16. Aug. 1969.
I 5. KovAiKoviTs. I. : M0IN AR, I. : and KRASINAI, I. : Zur operativen Behandlung des Galeazzi- und Monteggia-Syndroms. Der Chirurg. 42: 88-90.
1971.
16. LANG, FRIr/: Das distale Radio-ulnargelenk. Seine bedeutung in der Unfallmedizin. Hefte Unfallheilk., 36: 1-85. 942.
17. MAUREI . E.: Fracture du radius avec luxation de Ia radio-cubitale inf#{233}rieure (Fractures de Galeazzi). These. Toulouse, 1970.
18. PERIziINi. V., and BACCHEI.1.A, C.: Considerazioni su due rare fratture di avambraccio. Minerva ortop.. 16: 544-547. 1965.
19. RAM’oicil, A.. and PIETROGRANDE, V.: Lesioni traumatiche della articolazione radio-ulnare distale. Ortop. traumat.. 17: 311-330. 1949.
20. RAY, R. D. : JOHNSON. R. J. : and JAMESON, R. M. : Rotation of the Forearm. An Experimental Study of Pronation and Supination. J. Bone and
Joint Surg. , 33-A: 993-996. Oct. 1951.
2 I . RECKLING. F. W. . and C0RDEI.t., L. D. : Unstable Fracture-Dislocations of the Forearm. The Monteggia and Galeazzi Lesions. Arch. Surg. . 96:
999-1007, 1968.
22. RECKLING, F. W. , and PELTIER, L. F.: Riccardo Fracture.Galeazzi
Surgery. and Galeazzi’s
58: 453-459. Aug. 1965.
23. RIENAL. G.; GAY, R.; MARTINEZ, CH.; MANSAT, Lesions CH.; and
de I’articulation radio-cubitale
MANSAT, inf#{233}rieure dans
M.: les traumat-
ismes de Ia’avant-bras et du poignet. Int#{233}r#{233}t
de l’arthrographie. Rev. chir. orthop., 57 (Supplement 1): 253-260. 1971.
24. ROSE-INNES. A. P. : Anterior Dislocation of the Ulna at the Inferior Radio-Ulnar Joint. Case Reports, with a Discussion of the Anatomy of
Rotation of the Forearm. J. Bone and Joint Surg., 42-B: 515-521, Aug. 1960.
25. SCHNEK, FRITZ: Die Bedeutung der Subluxation im distalen Radioulnargelenk f#{252}r
die Behandlung des Speichenbruches. Deutsche Zeltschr. t.
Chir., 216: 351-356, 1929.
26. SK0BIIN, A. P.. and ZHILA. Ic. S.: Lechenia zastarelykh povrezhdenii Montedzha i Galeatstsi. Ortop., travmat. protez., 32: 49-53, April
I 971.
27. STEINHAUSER, J. , and MERHOF, G. : R#{246}entgenstudien an Handgelenken zur sogenannten Minusvariante der Elle (Hult#{233}n). Zeitschr. f. Orthop..
107: 11-24. 1969.
28. STUCK. W. G.. and THOMPSON. M. S.: Treatment of Fractures of the Forearm with Intramedullary Pins. Am. J. Surg.. 77: 12-18. 1949.
29. VESELY. D. G.: The Distal Radio-Ulnar Joint. Clin. Orthop., 51: 75-91 . 1967.
30. VOLZ, R. G.: The Galeazzi Fracture. In Proceedings of the Western Orthopaedic Association. J. Bone and Joint Surg. . 51-A: 816-817, June
1969.
3 1. WARREN. J. D.: Anterior Interosseous Nerve Palsy as a Complication ofForearm Fractures. J. Bone and Joint Surg. . 45-B: 51 1 -512. Aug. 1963.
32. WONG, P. C. N.: Galeazzi Fracture-Dislocations in Singapore 1960-1964. Incidence and Results ofTreatment. Singapore Med. J., 8: 186-193,
1967.

Recurrent Dislocation of the Elbow

BY MAJOR GARY C. HASSMANN*, MEDICAL CORPS, UNITED STATES ARMY, FREDERICK BRUNN, M.D.I’,

AND CHARLES S. NEER II, M.D.I’, NEW YORK, N.Y.

ABSTRACT: Recurrent dislocation of the elbow re- between 1955 and 1974: to review the pertinent literature:
suited from laxity of the lateral capsule and collateral to re-emphasize that the critical lesion is laxity of the lat-
ligament in four patients. An intra-articular lesion was eral ligaments and capsule and that treatment should be di-
usually also present. Elbow arthrotomy for removal of rected to this lesion: to emphasize that internal derange-
loose bodies and repair of the lateral capsuloligamen- ment and loose bodies may be present in the joint and re-
tous structures are thought to offer an excellent prog- quire treatment; and finally. to offer recommendations for
nosis for satisfactory relief from symptoms of recur- the initial management of posterior elbow dislocation for
rent dislocation. More complicated techniques, such as the prevention of repeated dislocations.
bone blocks or tendon transfers, are believed to be less
Review of the Literature
effective and unnecessary.
Several theories of the pathogenesis and suggestions
Recurrent dislocation of the elbow is so rare that few for the surgical treatment of recurrent elbow dislocation
surgeons learn of the nature of the lesion and its surgical have been presented (Table I). For example, King and
management by experience. The purpose of the present Reichenheim both concluded that ‘ ‘trochlear notch
investigation is to report on four recurrent dislocations of insufficiency’ ‘ was the primary mechanism. Both sug-
the elbow treated at the New York Orthopaedic Hospital gested a form of dynamic muscular stabilization of the
humero-ulnar joint: Reichenheim transplanted the biceps
* Orthopaedic Department. Darnell Arms Hospital. Fort Hood,
Texas 76544.
to the coronoid process, while King transplanted the
1- 622 West 168th Street. New York. N.Y. 10032. biceps through the coronoid. Much, and then Wainwright,

THE JOURNAL OF BONE AND JOINT SURGERY