Regional Anatomy and Biomechanics

Stability of the forearm, and specifically the DRUJ, is dependent on the presence of dynamic (musculotendinous) and passive (ligamentous) soft tissue stabilizers and, to a lesser extent, osseous anatomy. Bony congruity between the ulnar head and sigmoid notch of the radius contributes only approximately 20% of total DRUJ stability. In the transverse plane, the sigmoid notch is shallow relative to the ulna seat and the radii of their articular seats are disparate; thus, appositional contact is small.^10,11 As a result, motion at the DRUJ is predominantly translational—a combination of sliding and rotation. However, its axis of motion remains adjacent to the center of the ulnar head.

Tolat and associates¹¹ analyzed the osseous characteristics of the sigmoid notch and ulnar head in 50 cadaveric specimens in the coronal and transverse planes with multiple articular surface-based measurements. Three midcoronal DRUJ articular types (types I to III) were confirmed: type I DRUJ (55%)—apposing joint surfaces are parallel to the long axis of the radius and ulna; type II DRUJ (33%)—oblique apposing surfaces at the sigmoid and ulnar articular seats; and type III DRUJ (12%)—“reverse oblique” joint orientation with the DRUJ angular apex formed proximal to the DRUJ. In addition, four axial plane anatomical variants of the sigmoid notch were also noted and included flat face (42%), ski slope (14%), C-type (30%), and S-type (14%) notches. Furthermore, an extra-articular palmar osteocartilaginous lip was found in 80% of specimens and was found to serve as a consistent point of attachment for the volar radioulnar ligament and volar DRUJ capsule. When the TFCC is sectioned in the laboratory or incompetent in the clinical setting, this palmar lip serves as a buttress to palmar dislocation of the ulnar head and, thus, acts as a supplemental stabilizer to the interosseous membrane (IOM). This buttress effect is lost when there is a longitudinal tear in the interosseous membrane or fracture of the palmar rim (i.e., sigmoid notch fracture).

The soft tissue anatomy about the DRUJ is well defined,¹² and its stabilizers include the pronator quadratus, ulnocarpal ligaments, extensor carpi ulnaris subsheath, dorsal and volar radioulnar ligaments, IOM, and DRUJ capsule. The TFCC is considered the primary stabilizer of the DRUJ, and the IOM is a secondary restraint. The ulnar styloid projects 2 to 6 mm and is the site of attachment for the superficial (distal) limbs of the radioulnar ligaments and the extensor carpi ulnaris subsheath. The deep (proximal) fibers of the distal radioulnar ligaments and the ulnocapitate ligament insert into the fovea at the styloid base. Gofton and colleagues¹³ found that the radioulnar ligaments and the triangular fibrocartilage maintain DRUJ kinematics with simulated active forearm motion when more proximal soft tissue stabilizers (i.e., pronator quadratus, IOM, extensor carpi ulnaris subsheath, ulnar collateral ligament) are sacrificed. Furthermore, the radioulnar ligaments may play a greater stabilizing role in DRUJ stability in patients with flat sigmoid notches.¹¹

The IOM has multiple biomechanical functions: it helps to transmit force from the radius to the ulna, acts to prevent excessive supination, serves as an aponeurosis for insertions of the deep flexors and extensors, and resists radius and ulna diastasis. The complexity of the IOM structure has been studied by several groups.^14–16 In a cadaveric study, Hotchkiss and associates¹⁴ defined a central band of ligamentous tissue that contributed 71% of the longitudinal stiffness of the IOM after radial head excision. Injury to this region may represent the pathoanatomy responsible for proximal migration of the radius after radial head excision. Skahen and coworkers¹⁶ found that the IOM was consistently organized into a central band, one to five accessory bands, a dorsal proximal interosseous band, and membranous portions. Fibers from the central band originate from the radius and run in a distal-ulnar direction at a 20-degree angle to the long axis of the ulna. Peak strain occurs in the central band during pronation, the assumed position of the forearm when a Galeazzi fracture-dislocation is sustained. Other authors^17,18 have demonstrated that the IOM also serves as a coronal (transverse) and sagittal (dorsal-volar) plane stabilizer of the DRUJ, in addition to its described role as a longitudinal restraint. Analyses by Watanabe and colleagues¹⁸ suggest that it is a specific injury to the distal portion of the IOM (distal to the central band) that confers increased dorsal-volar instability at the DRUJ throughout a range of forearm rotation when the TFCC and distal radioulnar ligaments are incompetent; when the midportion of the IOM (including the central band) is sectioned together with the distal IOM, the DRUJ becomes unconstrained. Similarly, in a cadaveric biomechanical model, Gofton and coworkers¹³ demonstrated that the IOM was essential in the maintenance of DRUJ kinematics when distal soft tissue stabilizers are sacrificed (i.e., radioulnar ligaments and triangular fibrocartilage).

True Galeazzi fracture-dislocations have not been reproduced in an ex vivo biomechanical model.^19–21 As a result, although these injuries are assumed to occur in definable stages, the failure sequence of the regional soft tissue restraints after fracture of the radius has not been elucidated. However, the contributions of the TFCC and IOM to the biomechanics of the Galeazzi fracture-dislocation have been studied. Moore and associates,²⁰ in a cadaveric model, produced artificial Galeazzi fractures composed of transverse, uncomminuted radial metadiaphyseal fractures created with a Gigli saw at the distal insertion of the pronator teres followed by sequential sectioning of the TFCC and IOM. Moore and associates²⁰ and Schneiderman and coworkers¹⁵ independently demonstrated that radial shortening greater than 10 mm required complete disruption of both the TFCC as well as the IOM. Intermediate shortening occurred with isolated sectioning of the TFCC or IOM, respectively. The dorsal carpal retinaculum and ulnar collateral ligaments of the wrist were not found to be significant soft tissue constraints.

Classification

Galeazzi fracture-dislocations are relatively rare injuries, constituting 3% to 7%²² of all forearm fractures. In a retrospective review, Ring and colleagues²³ reported that the incidence of isolated radial diaphyseal fractures without DRUJ involvement is greater than that of the true Galeazzi fracture-dislocations. Of the 36 radial shaft fractures, only 9 (25%) occurred in conjunction with DRUJ disruption, whereas 27 (75%) radial diaphyseal fractures occurred in isolation and had no evidence of DRUJ dysfunction at latest follow-up. If both-bone forearm fractures with DRUJ dislocation are included, the incidence is higher. In Mikic’s series of 125 patients with Galeazzi fracture-dislocations,¹ 20% of cases included fractures of both the radius and ulna.

Dameron²⁴ originally subdivided Galeazzi fracture-dislocations into the ulna-volar type (ulna volar to the radiocarpal complex) and the ulna-dorsal type (ulna dorsal to the radiocarpal complex). In a retrospective review of 40 operatively treated Galeazzi fracture-dislocations, Rettig and Raskin⁸ introduced a classification scheme for these injuries with prognostic value with regard to the probability of intraoperative DRUJ instability after ORIF of the radial shaft fracture. Two patterns of fracture-dislocation were identified based on the distance of the radial shaft fracture from the midarticular surface of the distal radius. In 12 of 22 (55%) type I fractures, occurring within the distal third of the radial shaft and within 7.5 cm of the midarticular surface (Fig. 22-1), operative stabilization of the DRUJ was required with percutaneous Kirschner wire (K-wire) fixation secondary to persistent DRUJ instability after ORIF of the radial shaft fracture. Three of these 12 patients underwent concomitant open repair of the TFCC because the DRUJ was found to be irreducible. In contrast, only 1 of 18 (6%) patients with a type II injury, within the middle third of the radial shaft and more than 7.5 cm from the midarticular surface of the distal radius (Fig. 22-2), required percutaneous fixation of an unstable DRUJ (P < .001).

FIGURE 22-1 Preoperative posteroanterior (A) and lateral (B) radiographs reveal a fracture of the radial shaft within 7.5 cm of the midarticular surface of the distal radius—type I injury. DRUJ disruption as well as ulnar styloid fracture is appreciated.

FIGURE 22-2 Preoperative posteroanterior (A) and lateral (B) radiographs demonstrating a short oblique fracture of the radial shaft more than 7.5 cm from the midarticular surface of the distal radius—type II injury.

The mechanism of injury includes a high-velocity direct impact with axial loading of an outstretched arm. Axial loading of the forearm combined with hyperpronation of the forearm is the most common mechanism and causes dorsal dislocation of the DRUJ¹; conversely, hypersupination leads to volar dislocation of the ulnar head from the sigmoid notch. We have postulated that for distal radial shaft fractures (type I injuries) within 7.5 cm of the midarticular surface, a high-impact hyperextension mechanism results in a direct continuum of complete injuries through the TFCC and IOM, which predisposes the DRUJ to residual instability and dorsal subluxation despite anatomical radial shaft fracture fixation⁸ (Fig. 22-3A). With fractures through the middle third of the radial shaft (type II injuries) an indirect pronation force is incurred with incomplete disruption to the regional stabilizing soft tissue structures (see Fig. 22-3B). This may account for the high likelihood of DRUJ and ulnar head stability within the sigmoid notch after fixation of more proximally located radial shaft fractures. However, a significant relationship between the magnitude of initial radial shortening and DRUJ stability was not identified. In a retrospective review of 36 patients with radial shaft fractures treated with plate and screw fixation, Ring and coworkers²³ observed a similar trend toward DRUJ stability with proximal and middle third fractures in accord with our findings. In this series, 5 of 8 distal third fractures were associated with DRUJ instability, whereas only 4 of 28 proximal/middle third radius fractures had DRUJ involvement.

FIGURE 22-3 A, Posteroanterior radiograph demonstrating a type I fracture in the distal third of the radial shaft within 7.5 cm of the midarticular surface of the distal radius resulting from a high-impact hyperextension injury. B, Posteroanterior radiograph demonstrating a type II fracture in the middle third of the radial shaft more than 7.5 cm from the midarticular surface of the distal radius resulting from an indirect pronation force. Arrows represent an axial load force in A and a hyperpronation force in B.

Indications and Contraindications

ORIF of radial shaft fractures in the skeletally mature patient is indicated. The DRUJ is treated based on the clinical and radiographic examination after fixation of the radial shaft fracture. Nonoperative management of acute closed Galeazzi fracture-dislocations, in general, results in an unacceptable clinical result.

The timing of surgery is dependent on the soft tissue status and clinical condition of the patient. Contraindications to early ORIF include severe, high-grade open fractures with soft tissue loss and gross contamination. Jones²⁵ reported good or excellent results in 66% (12/18) of patients with grade III open forearm fractures treated with a protocol of immediate extensive primary débridement, open reduction and dynamic compression plate fixation, and serial re-débridements at 24- to 48-hour intervals until wound status allowed for soft tissue reconstruction. Duncan and coworkers²⁶ found statistically significant differences in the rate of satisfactory outcomes between grade I, II, and IIIA open forearm fractures and those seen in grade IIIB and IIIC injuries when immediate (<24 hours) ORIF was performed. Patients with grade IIIB and IIIC open forearm fractures may be managed with initial external fixation, serial débridements, and meticulous wound care, followed by delayed internal fixation. Bone grafting should be planned for open fractures with extensive comminution and/or segmental defects at a minimum of 6 weeks from the time a closed soft tissue envelope is obtained. Multisystem trauma or multiple medical comorbidities are clinical scenarios in which early ORIF may also be contraindicated.

Initial Evaluation and Management

Physical examination demonstrates forearm deformity. Prominence of the ulnar head may be present, especially with dorsal DRUJ dislocation, and significant skin tenting may be present. Deforming forces of the radial shaft fracture include the pronator quadratus insertion on the volar surface of the distal fragment, the brachioradialis, and the extrinsic thumb abductor and extensors.⁴ A thorough neurovascular examination of the upper extremity should be performed and the status of the forearm compartments should be documented. Circumferential inspection of the skin is also performed to identify an open injury. Given the magnitude of energy required to produce this injury, a thorough secondary survey should be performed to rule out any additional musculoskeletal injuries. Prerequisite radiographs include those of the ipsilateral elbow, forearm, and wrist. Radiographic markers of DRUJ disruption are assessed and include fracture through the fovea of the ulnar styloid, DRUJ widening on the anteroposterior view, more than 5 mm of radial shortening, and dorsal subluxation/dislocation of the DRUJ on a true lateral view of the wrist. The importance of radiographic imaging of the ipsilateral elbow and wrist is highlighted by numerous reports of the presence of coincident ipsilateral upper extremity trauma.^9,23,27–32 In a series by Ring and coworkers,²³ 10 of 36 radial diaphyseal fractures were sustained together with ipsilateral upper extremity trauma, including diaphyseal humerus fracture (2), proximal humerus fracture (1), elbow dislocation (1), and scaphoid fracture (1). Strehle and Gerber⁹ identified additional upper extremity fractures in 21% of their cases. Contralateral wrist radiographs may be obtained if radiographs are equivocal on the injured side. Although advanced imaging modalities are available,^33–35 they are rarely obtained preoperatively for true Galeazzi fracture-dislocations. Fester and colleagues³⁶ have recommended the use of both ultrasonography and magnetic resonance imaging when there is clinical suspicion of injury to the IOM because both modalities have impressive testing characteristics (sensitivity, specificity, and positive and negative predictive values).

In the emergency department and with appropriate pain control or sedation, restoration of gross alignment and radial length may be attempted utilizing digital traction applied through finger traps. A well-padded long-arm plaster splint is applied, and the forearm is splinted in supination if the DRUJ is clinically reducible. The patient may require admission for observation and serial neurovascular checks if there is concern for compartment swelling.

Surgical Technique

The patient is positioned supine on the operating room table. The involved upper extremity is positioned in supination on a standard armboard. A nonsterile tourniquet is applied to the upper arm area. After adequate anesthetic has been achieved (usually with regional anesthesia), the entire upper extremity is prepped and draped in a standard manner. Consideration should be given to preparing the ipsilateral iliac crest for harvesting of autogenous bone graft if preoperative radiographs reveal comminution at the radial shaft fracture site. The contralateral DRUJ should be examined preoperatively for intraoperative comparison to the injured wrist.

A volar (Henry) approach to the radial shaft is performed utilizing the flexor carpi radialis/radial artery interval. After retraction of the flexor carpi radialis tendon, the subtendinous space of Parona is developed to expose the pronator quadratus. Traumatic disruption of the pronator quadratus sustained with the injury may be appreciated. The distal extent of the exposure—the radiocarpal joint—is marked by the origin of the extrinsic volar wrist ligaments and fully identified after elevation of the pronator quadratus from the metaphysis of the radius. The pronator quadratus is progressively subperiosteally elevated in a distal-to-proximal as well as radial-to-ulnar fashion. Exposure of the sigmoid notch is possible with this approach and may be helpful if a concomitant comminuted ulnar head fracture is present. The proximal limit of the exposure is dictated by the location of the radial shaft fracture. More proximal exposure of the radial shaft fracture may require release of the flexor pollicis longus origin and pronator teres insertion.

Alternatively, a dorsal (Thompson) approach to the proximal radius may be performed for type II fractures. The interval between the extensor carpi radialis brevis and extensor digitorum communis is developed. The posterior interosseous nerve is then identified and protected as it emerges from the supinator, which is then elevated in a subperiosteal fashion toward its origin. If distal exposure is needed, the abductor pollicis longus and extensor pollicis brevis are reflected subperiosteally. After fracture reduction, dorsal plate fixation is performed.

The fracture site is identified and the extent of comminution is evaluated. Fracture site débridement is performed. Manual reduction of the radial shaft fracture is performed, and provisional reduction is maintained with bone reduction clamps. A 3.5-mm AO dynamic compression plate or low-contact dynamic compression plate may be applied to the volar surface and temporarily held with bone reduction clamps. Locked plating techniques may be utilized if there is significant comminution and/or osteoporosis. If the radial shaft fracture is located at the metadiaphyseal junction or within the distal radius metaphysis, consideration may be given to the use of a long volar fixed-angle plate and screw construct. Plate length, anatomical reduction, and restoration of radial length and bow are each evaluated and confirmed with intraoperative fluoroscopy. The chosen implant is then secured to the radial shaft with fully threaded cortical screws and the bone reduction clamps are then removed. Certain fracture patterns may be amendable to supplemental small or mini-fragment cortical lag screws to achieve interfragmentary compression (i.e., butterfly fragments) (Fig. 22-4).

FIGURE 22-4 Preoperative posteroanterior (A) and lateral (B) forearm radiographs are consistent with a type I Galeazzi fracture-dislocation. Postoperative posteroanterior (C), oblique (D), and lateral (E) radiographs demonstrate anatomical reduction after volar plate fixation of the radius fracture. Lag screw fixation of the butterfly fragment was performed outside the plate construct.

The location and extent of comminution and cortical bone loss are noted on fluoroscopy. Release of the radial septum from the dorsoradial aspect of the radial shaft affords access for bone grafting of the fracture site, often eliminating the need to perform a separate dorsal incision. Cortical fragments devoid of soft tissue attachments should be removed because they represent a potential nidus for infection. Options for bone graft are multiple and include autogenous iliac crest and the ipsilateral distal radius, as well as a host of osteoconductive and/or osteoinductive commercially available products.

After anatomical reduction and fixation of the radial shaft fracture, the DRUJ is evaluated clinically with the forearm in supination for both stability and reducibility. Because it is possible to force the DRUJ into a reduced position despite soft tissue or bone interposition, accurate lateral radiographs without undue force are evaluated. Dorsally directed manual stress is applied to the DRUJ in an attempt to dorsally translate the ulnar head out from the sigmoid notch. If the DRUJ is stable to stress, an above-elbow splint is applied with the forearm in supination (Fig. 22-5). In Galeazzi fracture-dislocations without associated fracture of the ulna styloid, the triangular ligament is disrupted. Cast immobilization in supination allows for reapproximation and healing of the triangular ligament at the site of avulsion to ensure long-term DRUJ stability.

FIGURE 22-5 Preoperative posteroanterior (A) and lateral (B) forearm radiographs demonstrating a type II Galeazzi fracture-dislocation. A cortical butterfly fragment is seen. C and D, Postoperative radiographs demonstrate restoration of radial bow and length. ORIF was performed through a dorsal approach. Supplemental DRUJ fixation was not required.

If the ulnar head is unstable but reducible within the sigmoid notch in supination and there is no associated basilar ulnar styloid avulsion fracture fragment, then percutaneous transfixion of the DRUJ is performed. With the forearm in supination and the ulnar head held reduced within the sigmoid notch, two 0.062-inch (1.6 mm) K-wires are percutaneously placed from the ulna through the radius transversely approximately 1 cm proximal to the sigmoid notch to stabilize the DRUJ in supination (Fig. 22-6). The surgeon should be suspicious for and predict residual DRUJ instability after ORIF of the radial shaft fracture in type I injury patterns.⁸

FIGURE 22-6 Posteroanterior (A) and lateral (B) forearm trauma radiographs demonstrate a type I injury pattern with a distal third radial shaft fracture and dorsal dislocation of the ulnar head. C to E, Postoperative radiographs reveal congruent DRUJ reduction after K-wire transfixion, which was required to maintain the ulnar head reduced within the sigmoid notch after radial shaft fracture fixation.

Open reduction of the DRUJ may be necessary if the ulnar head remains unstable and irreducible after reduction and internal fixation of the radial shaft fracture. Soft tissue interposition usually prevents anatomical reduction of the ulnar head into the sigmoid notch. Several regional soft tissue structures have been implicated as blocks to DRUJ reduction in Galeazzi fracture-dislocations. Interposition of the extensor retinaculum, DRUJ capsule, extensor carpi ulnaris, extensor digitorum communis to the ring and little fingers, and the extensor digiti minimi have been separately reported^37–43 as causes of an irreducible DRUJ in these complex injuries.

For open reduction of the DRUJ, a dorsal approach to the distal ulna between the fifth and sixth extensor compartments is utilized. The dorsal sensory branch of the ulnar nerve is protected. The extensor retinaculum is elevated from the dorsal DRUJ capsule. A dorsal DRUJ capsulotomy is then completed. However, a traumatic capsulotomy may be present and the ulna head may be buttonholed through the dorsal capsule with dorsal DRUJ dislocations. The DRUJ is inspected for loose bodies and traumatic chondromalacia and then débrided. The TFCC is evaluated. In all three cases of type I injuries requiring open reduction of the DRUJ in our series,⁸ the triangular fibrocartilage was observed avulsed from its insertion into the base of the ulnar styloid (Palmer class 1B)⁴⁴ and interposed within the DRUJ. In these cases, the insertion site was prepared for reattachment through drill holes (one patient) or bone suture-anchors (two patients).

Ulnar styloid repair may supplement soft tissue repair/reconstruction and is indicated if a displaced, large ulnar styloid fracture through its base is present. With a displaced ulnar styloid fracture through the fovea, the DRUJ can be unstable as the TFCC is attached to this fragment. Ulnar styloid fractures can be repaired with a 24- or 26-gauge stainless steel figure-of-eight tension band construct or K-wires. Of the nine Galeazzi fracture-dislocations presented by Ring and coworkers,²³ four were associated with displaced fractures through the base of the ulna styloid and underwent ORIF of the ulna styloid. Kikuchi and Nakamura⁴⁵ reported a case of a Galeazzi fracture-dislocation with an irreducible DRUJ secondary to entrapment of an avulsion fracture of the ulna fovea with its preserved attachments to the dorsal portion of the triangular ligament. After reattachment of the foveal fragment to its donor site and K-wire fixation of the ulnar styloid, DRUJ stability was achieved.

Salvage procedures for severe distal ulna fractures sustained with a Galeazzi injury include the Darrach procedure with subperiosteal distal ulnar head excision just proximal to the sigmoid notch with extensor carpi ulnaris tenodesis, the Bowers hemi-resection-interpositional arthroplasty, or some modification of these techniques. In the acute setting, selection of a salvage procedure is dependent on patient-specific characteristics.

Before wound closure, final orthogonal fluoroscopic images are obtained to confirm anatomical reduction of the radial shaft, distal ulna, and DRUJ. The pronator quadratus is positioned over the volar plate and may be reattached along its distal and radial border if it has been elevated as a continuous sleeve and the bony trauma has not disrupted it too extensively. The subcutaneous and skin layers are closed. If a dorsal approach to the distal ulna and DRUJ was utilized, the dorsal capsule is imbricated and the extensor retinaculum repaired. A sterile dressing is applied. A well-padded plaster long-arm splint in supination is applied.

At the initial postoperative office visit, the long-arm plaster splint is changed to an above-elbow cast with the forearm in supination for 6 weeks. The transverse K-wires are removed at 6 weeks. At this time, progressive physical therapy is initiated.

Complications

Complications after operative treatment of Galeazzi fracture-dislocations are not uncommon, and several authors have reported a complication rate of 32% to 39%.^9,22 Complications include nonunion, malunion, infection, refracture after hardware removal, and persistent DRUJ pain and instability.

Symptomatic post-traumatic DRUJ instability may be due to ligamentous incompetence, bony deformity, or both. Clinical manifestations include pain and limited forearm rotation. The efficacy of conservative management of DRUJ instability with functional bracing is unclear, but bracing has been shown to reduce translational motion at the DRUJ experimentally in a cadaveric study.⁴⁶ The role of arthroscopic TFCC repair in the setting of chronic DRUJ instability is evolving. In the absence of DRUJ arthritis and significant incongruity, various ligamentous reconstructive procedures of the DRUJ may be considered when the TFCC is irreparable. Ulnar shortening may be considered for symptomatic ulnocarpal impaction and early DRUJ arthritis. Several salvage procedures are available, including the Darrach resection in the low-demand patient, the Sauvé-Kapandji procedure, hemi-resection arthroplasty, and implant arthroplasty. Procedure selection is dependent on individual patient characteristics, radiographic findings, and surgeon preference.

Results of Treatment

With advances in techniques for achieving rigid osteosynthesis and soft tissue reconstruction, ORIF has become the standard of care to optimize outcomes after forearm fractures associated with DRUJ disruption. Although the literature is limited to a relatively small number of retrospective reviews with modest cohort sizes, the data strongly indicate that operative management^6–9 yields results superior to those after closed treatment.^1,2,4,5

We have previously reported excellent clinical results according to Mikic’s criteria¹ in 38 of 40 patients with acute closed Galeazzi fracture-dislocations who were treated with a uniform surgical algorithm.⁸ Only 2 patients had a poor result, and both had sustained a type I fracture-dislocation. Both subsequently required DRUJ reconstruction at an average of 9 months after the initial injury because of pain and limited supination. At 1-year follow-up, Mohan and associates⁷ obtained good results in 80% (40/50) of cases treated with ORIF. Two patients subsequently underwent excision of the ulnar head secondary to limited supination and pronation. When anatomical alignment of the radius is achieved and congruent reduction of the DRUJ is maintained, full DRUJ function can be expected.⁹ Kraus and Horne⁴⁷ reported a satisfactory outcome according to Hughston’s criteria in 25 of 27 (93%) patients at 32 months postoperatively.

Conclusion

Galeazzi fracture-dislocations represent high-energy injuries involving the distal radial meta-diaphyseal region and the soft tissue stabilizers of the DRUJ, the TFCC, and the IOM. A high index of suspicion must be maintained for DRUJ disruption, especially with more distally located radial shaft fractures. Anatomical reduction and fixation of the radius does not reliably ensure stability of the DRUJ in every case. After fixation of the radial shaft fracture, DRUJ stability must be evaluated clinically and radiographically. Type I injuries represent a more severe soft tissue injury pattern to the regional stabilizers, which predisposes the DRUJ to residual instability and subluxation despite anatomical radial shaft fracture fixation. In contrast, DRUJ stability is more commonly found after fracture fixation of type II injuries. This may be due to incomplete soft tissue disruption and/or force transmission along the more substantial midportion of the IOM. Although percutaneous transfixion of the DRUJ is often possible, a low threshold for open reduction of the DRUJ and soft tissue or styloid repair should be maintained when an anatomical reduction is unobtainable with closed techniques. Anatomical fixation of the radial shaft fracture, thorough intraoperative assessment of DRUJ stability, and maintenance of a congruent reduction of the ulnar head within the sigmoid notch optimize the probability of uncomplicated fracture union and excellent functional results. Painful persistent, chronic DRUJ instability is a challenging clinical problem and may require a salvage procedure of the distal ulna.