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Technique: ORIF of a Galeazzi radius fracture using locking plate

    Overview

    Learn the Open Reduction and Internal Fixation of a Galeazzi radius fracture using Synthes LCP locking plate surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Open Reduction and Internal Fixation of a Galeazzi radius fracture using Synthes LCP locking plate surgical procedure.
    A Galeazzi fracture is a fracture of the middle to distal third of the radius and either a dislocation or subluxation of the distal radio-ulnar joint (DRUJ). The usual mechanism is high energy and thought to involve axial force through a hyper-pronated forearm. Galeazzi fractures are rare and only account for 3-7% of forearm shaft fractures.
    In 1822, Sir Astley Cooper first described the injury however, the fracture pattern was named after an Italian Riccardo Galeazzi after his presentation of 18 cases in 1934.
    The forearm is a complex area of anatomy and represents a complicated interaction of 6 joints:
    Radio-carpal joint
    Ulnar-carpal joint
    Distal radio-ulnar joint
    Radio-capitellar joint
    Ulnar-trochlear joint
    Proximal radio-ulnar joint
    Any injury to either the radius or the ulna or both will cause an associated disruption of some of these joints. It is therefore paramount that an anatomic reduction is achieved to prevent any loss of function.

    The Synthes Locking Compression Plate (LCP) has uniformly spaced combination (combi) holes. The plate can be applied in any of the following modes:
    Compression
    Bridging
    Neutralisation
    Buttress
    Tension band
    The combi holes can accommodate standard cortical / cancellous screws and locking screws. The combi holes are aligned as a “mirror image” relative to the middle of the plate. This places the threaded hole section (for locking screws) closer to the fracture and the dynamic compression unit (DCU) side of the hole is furthest away from the fracture. This means that with eccentric cortical or cancellous screw placement, compression is achieved at the fracture site.
    As the plates allow the insertion of locking screws, this converts the construct into a fixed angle device and you do not need to rely on plate/bone compression to maintain the stability of the construct.

    Indications

    INDICATIONS
    In adults, all Galeazzi fractures should be treated surgically with an anatomical reduction and stabilisation of the radius. Usually this reduces the distal radio-ulnar joint.
    SYMPTOMS & EXAMINATION
    A forearm fracture is usually very painful and this type of fracture often results in a clinically deformed limb. There will be swelling and sometimes bruising. Rarely a forearm compartment syndrome may develop.
    An examination need not palpate the fracture site, as this will be unnecessarily painful for the patient and won’t yield much useful information. A hand examination is however essential. You must thoroughly examine and document the findings. The autonomous zones for the peripheral nerves are:
    Radial (dorsal 1st webspace)
    Median (index finger pulp)
    Ulnar (little finger pulp)
    To examine the motor component of each nerve, first ask the patient to place the hand palm downwards:
    Extend the wrist (radial nerve)
    Extend the fingers (PIN: posterior interosseous nerve – terminal branch of the radial nerve)
    Abduct the fingers (ulnar nerve)
    Turn the hand palm upwards
    Abduct the thumb (median nerve)
    Form an ‘OK’ sign (AIN: anterior interosseous nerve – terminal branch of the median nerve). This injury can cause an isolated injury to the AIN.
    If there is significant displacement this may compromise the limb’s neurovascular status, threaten the skin or predispose to developing a compartment syndrome, all of which make it is essential to reduce the deformity urgently.
    IMAGING
    Plain film imaging is usually sufficient to make the diagnosis – a postero-anterior (PA – usually the forearm is placed palm down on the x-ray plate) and lateral (Lat) radiograph. Radiographic signs suggesting an injury to the DRUJ include:
    Widening of the DRUJ
    Displacement of the radius relative the ulna (note that some texts refer to displacement of the ulna, this is incorrect, as the ulna is intact and hasn’t moved).
    Fracture of the ulna styloid base
    >5mm of radial shortening
    Moore et al. determined that radial shortening of more than 5mm occurs only with disruption of the TFCC or interosseous membrane. Shortening of more than 10mm results in disruption of both the TFCC and interosseous membrane.
    CT scans or MRI scans are usually not required pre-operatively. However, if there is concern that the DRUJ may not be reduced or there is a triangular fibrocartilage complex (TFCC) injury that could not be ruled out peri-operatively, then further imaging may be required. A CT scan is best for looking at the DRUJ congruence and an MRI with contrast is best to determine if the TFCC has been injured.
    Moore TM, Lester DK, Sarmiento A. The stabilising effect of soft-tissue constraints in artificial Galeazzi fractures. Clin Orthop Relat Res. 1985; 194: 189-94.
    ALTERNATIVE OPERATIVE TREATMENT
    The radius fracture should be reduced anatomically and treated with open reduction internal fixation (ORIF). The DRUJ is where there is a range of opinion on the best management options.
    If the DRUJ is unstable then options include:
    A sugar-tong forearm cast with the hand in supination.
    DRUJ stabilisation with temporary K-wires.
    Open or arthroscopic TFCC repair
    If there is an ulnar styloid fracture, this should be treated with open reduction internal fixation to stabilise the DRUJ.
    NON-OPERATIVE MANAGEMENT
    Non-operative management of forearm fractures is not recommended, particularly in this pattern of injury because the forearm axis of rotation (centre of the radial head to the centre of the distal ulna) has been disrupted. This means that there will be a consequent loss of forearm rotation which can lead to significant disability. It should only be considered if surgical treatment is not possible.
    CONTRAINDICATIONS
    If there is a compartment syndrome, then it must be decompressed first before definitive treatment. A temporary external fixator may be used to provide immediate stabilisation while the soft tissue injury and compartment pressures improve.

    Setup

    The patient is supine with an arm table.
    Intravenous antibiotics are administered.
    A tourniquet is applied and inflated to 250mmHg. I do not exanguinate the limb using either an Esmarch bandage or Rhys Davies exsanguinator. I simply elevate and gently squeeze to allow the veins to collapse but still contain some blood, so that I can see them and then haemostases them if required.
    I prefer to sit in the axilla position with the C-arm approaching from 45 degrees cranial (because of the arm table leg).

    Operation
    A PA forearm radiograph demonstrating a radius fracture between the middle and distal third. There is a subluxation of the distal radio-ulnar joint (DRUJ) with relative shortening of the radius in comparison to the ulna. There is also a subtle ulnar styloid tip fracture.
    A lateral radiograph demonstrating volar subluxation of the radius in relation to the intact ulna. Note some texts would describe this as a dorsal ulna displacement, this is incorrect, as the ulna is uninjured and represents the origin. The radius fracture is oblique with an apex posterior displacement.
    Pre-washing the injured limb with soap and water removes any superficial dirt and degreases the skin. The skin naturally produces oils that are immiscible with the surgical antiseptic. A pre-wash therefore removes the oils and allows the antiseptic to penetrate deeper into the skin pores.
    Skin antisepsis is performed using alcoholic (70%) chlorhexidine (0.5%). I routinely do a double prep using a darker pink stained solution first. I then wash off the first prep with a pale solution of chlorhexidine. I like to use the difference in the depth of colours to ensure that I have painted the whole limb and not missed any areas. The second prep removes most of the pink stain, so that the limb doesn’t look cellulitic.
    The fracture level is identified using the C-arm. It is quite easy to be too proximal / distal on the forearm and not centred at the level of the fracture. This means that the wound then has to be extended to allow adequate access. Extending the wound, instead of going down layer-by-layer, can lead to an inadvertent injury to the neurovascular structures.
    The surface landmarks for the modified Henry’s approach to the forearm are the scaphoid tubercle and the radial (lateral) border of the biceps tendon insertion. It is along this line that the incision is made at an appropriate level.Trainee’s often get confused remembering which side of the biceps tendon. The radial tuberosity is on the ulnar side of the radius and the biceps tendon inserts on the ulnar side of the radius. Therefore to be over the radius, you need to be on the radial side of the biceps tendon. It’s not essential to measure the incision however, you’ll know how many holes’ plate you intend to use (e.g. 7 holes) and the implant box will specify its’ length. This simple trick allows the incision to be the appropriate length.
    The skin incision is made with great care, as there are usually superficial veins which often bleed profusely.After haemostasis, the subcutaneous fat can be cleared off the fascia. With a cautious approach, the lateral antebrachial cutaneous nerve (or lateral cutaneous nerve of the forearm – running between marks A and B), a branch of the musculocutaneous nerve can be identified and protected. Injury to this nerve often causes loss of sensation to the forearm and a troublesome neuroma as it is superficial.
    Once through the fat the deep fascia is incised and the dissection is performed in the inter-nervous plane between the brachioradialis muscle (radial nerve) on the radial side and on the ulnar side is the flexor carpi radialis (median nerve).The brachioradialis muscle is seen (A) and the plane to develop is an inter-nervous plane between the brachioradialis muscle (radial nerve) on the radial side and on the ulnar side is the flexor carpi radialis (median nerve). Slightly deeper the radial artery is ulnar and the superficial radial nerve is radial and on the underside of the brachioradialis muscle.
    The forearm anatomy is made up two groups of muscles that originate from the medial and lateral epicondyle of the elbow. On the medial side, the common flexor origin muscles are (going from radial to ulnar): Pronator Teres (PT) Flexor Carpi Radialis (FCR) Palmaris Longus (PL) Flexor Digitorum Superficialis (FDS) Flexor Carpi Ulnaris (FCU) On the lateral side, the mobile wad muscles are: Brachioradialis (BR) Extensor Carpi Radialis Longus (ECRL) Extensor Carpi Radialis Brevis (ECRB)
    The approach is between the brachioradialis (on the radial aspect – innervated by the radial nerve) and the flexor carpi radialis (on the ulnar aspect – innervated by the median nerve).This reveals the superficial radial nerve (SRN) on the underside of the brachioradialis muscle (marked A). Lying deep to these two muscles is the radial artery accompanied by its’ venae comitantes (marked B).
    The radial artery has branches that supply the brachioradialis muscle which are identified, cauterised and divided to allow the artery to be mobilised and moved ulnar ward.Below the artery and attaching to the radius are the insertional fibres of the pronator teres (PT). These are partially released to expose the bone. Often the fracture itself has done some the dissection and this needs to be incorporated into the approach.
    The bone is carefully exposed as the displaced segments may distort the anatomy and put some of the structures at risk.
    A lobster claw (crocodile) clamp is used to manipulate the bone and deliver the bone ends into the wound for cleaning prior to reduction.
    Using 2 lobster claws (crocodile) clamps, both bone segments can be manipulated to achieve a reduction.When there is only one bone fractured, the reduction is much harder. Often the assistant will try to be helpful and apply traction but it usually doesn’t work. I find that by creating an angular deformity by delivering both bones into the wound, this creates the required distraction at the fracture site (which are normally overlapping). The rotation is corrected by joy sticking the fragments with the lobster claws and then once aligned, it can be keyed together and then pushed back down into the wound, restoring the length and alignment.
    Once reduced the fracture reduction is held with a pointy reduction forceps.I prefer to use the pointy reduction forceps for two reasons: The points ‘grip’ the bone and allow both of the fragments to be manipulated. The pointy reduction forceps are ‘thinner’ than the lobster claw and allow a lag screw to be positioned closer to the fracture.
    A lag screw is first drilled with the 3.5mm drill and the angle of the drill is perpendicular to the plane of the fracture.It is only advanced through the first / near cortex and not across the fracture site. I like to insert the 2.5mm drill guide into the 3.5mm hole that you have just drilled. This naturally aligns the drill guide with the hole and ensures that the next hole to be drilled through the far cortex is correctly centred in relation to the first hole and is concentric.
    The lag screw length is measured with the depth gauge.Prior to measuring, the near cortex hole can be prepared with the countersink to ensure that the screw head sits flush with bone and avoids any point loading which can cause a fracture.
    The far cortex hole for the lag screw is tapped using the one turn forward and a quarter turn backward technique (to allow the swarf and debris to clear from the cutting thread).
    The screw is inserted and carefully tightened so that the fracture is held and compressed.If the screw is overtightened, the near cortex will fracture with lines running in line with the drilled hole and towards the original fracture.
    The lag screw should be strong enough to hold the fracture reduced when the reduction clamp is removed.The lag screw is however susceptible to shear and rotational forces, so the limb must be handled carefully when checking the fracture reduction with fluoroscopy.
    Depending on the shape of the bone, the LCP plate is contoured to allow a satisfactory fit and provide some far cortex compression (if required).The Synthes Locking Compression Plate (LCP) has uniformly spaced combination (combi) holes. The plate can be applied in any of the following modes: Compression Bridging Neutralisation Buttress Tension band The combi holes can accommodate standard cortical / cancellous screws and locking screws. The combi holes are a mirror image relative to the middle of the plate. This places the threaded hole section (for locking screws) closer to the fracture and the dynamic compression unit (DCU) side of the hole is furthest away from the fracture. This means that with eccentric cortical / cancellous screw placement, then compression is achieved at the fracture site. As the plates allow the insertion of locking screws, this converts the construct into a fixed angle device and you do not need to rely on plate/bone compression to maintain the stability of the construct. The small fragment LCP plates will accept the following screw sizes: 3.5mm cortical screws 4.0mm cancellous screws 3.5mm locking screws
    Ideally a plate holding forceps would be used. However, the depth of the wound and the angle which the plate holding forceps are applied, makes it impractical to use. The first plate hole is drilled by determining the correct distance from the fracture and then using the 2.5mm drill bit to feel either side of the bone. Only when you are confident that the drill bit is centred on the bone, can you begin to drill. The drill guide is used to steady the drill bit and precisely hold it in the correct place. In this case, I’m using a 7 hole plate. The combi holes have the threaded locking screw portion closest to the middle of the plate. If the plate holes are number 1 – 7 with 1 being proximal and 4 being over the fracture / lag screw, it’s my preference to insert the 3.5mm cortical screws into plate holes 3 & 5 respectively. This places the screw further away from the fracture / lag screw, so that you don’t unintentionally either hit the lag screw or have poor screw grip from being within the fracture.
    The technique of inserting a screw is repeated (minus the countersink stage) i.e. drill, (countersink), measure, tap, screw insertion.Prior to definitive tightening the proximal end of the plate is checked to ensure that it is also centred on the bone. A second screw is drilled and inserted proximally (it doesn’t matter whether you fix proximally or distally first).
    Check fluoroscopically that the reduction, length, alignment and rotation have all been preserved and the plate is correctly positioned once one screw has been inserted proximally and one distally through the plate.
    It is essential that the reduction and fixation are checked using orthogonal views. It is important to carefully interpret your radiographs or you could inadvertently have the wrong screw length. This radiograph isn’t a true lateral with the radius and ulna perfectly overlapping each other. The screws in the radius are bi-cortical.
    Locking screws are now inserted into the plate using the screw-in threaded drill guide.This ensures that the drilled hole is correctly aligned with the plate, so that the locking screw head thread can correctly engage with plate and not become cross threaded. The screw-in threaded drill guide is shown screwed into plate hole 2 (marked A). Locking screws are beneficial as they convert the plate into a fixed angle device. This changes its’ mode of failure and also increases the constructs rigidity and ability to resist the deforming forces placed upon it.
    Once satisfied with the fixation, the wound is irrigated to remove any bone swarf and haematoma prior to closure.In some cases, depending on the orientation of the fracture to the plate, it may be possible to insert the lag screw through the plate.
    After fixation the next step in the procedure is to assess the distal radio-ulnar joint (DRUJ) stability, initially in the mid-pronation / mid-supination position.Often you’ll hear surgeons state that they would assess the contralateral uninjured limb before prepping to perform the procedure. In practice, most surgeons would forget to do this. However, it is good practice to do it. I recommend assessing the DRUJ translation in the mid-pronation / mid-supination position as shown here.
    The forearm is fully pronated and the DRUJ translation and stability re-tested.If the ligaments are competent, then the amount of translation should decrease and the joint feels tighter.
    The forearm is then fully supinated and the DRUJ assessment repeated.Again the amount of translation should decrease compared to the mid-pronation / mid-supination position and the joint feels tighter. On balance, I feel the dynamic difference in joint translation going from mid-pronation / mid-supination to fully pronated / supinated gives a better idea of joint stability than an isolated estimate of the amount of joint translation.
    After direct clinical testing the wrist should also be assessed radiographically to ensure that the DRUJ is correctly reduced in both the AP and lateral planes.The radius and ulna should be the correct height in relation to each other. There should be no widening of the DRUJ. There should be some overlap of the radius and ulna at the sigmoid notch.
    If the DRUJ is not reduced or is not stable, then the following steps should be taken. Ensure that the fracture is anatomically reduced and rigidly stabilised. If the bones are the correct shape and length, then it might be an issue with the joint. If the ulnar styloid is fractured, this should be fixed. Assess the joint to see if it is reducible. If it is not, then it may be that there is some soft tissue interposition e.g. an entrapped extensor tendon or sometimes the TFCC or a fracture fragment, this needs to be removed to allow the joint to be congruent. If the reduction is impossible, then the approach to the DRUJ is through a dorsal incision. Whatever is blocking the reduction is removed and the TFCC, ligaments and capsule are repaired. If the joint is reducible but unstable, then options available are: Sugar tong plaster in the reduced position / most stable (usually supination). Two transverse K-wires to immobilise the radius on to the ulna and prevent any pronation / supination. Open / arthroscopic stabilisation of the TFCC.
    The wounds are closed. Only a deep dermal and subcuticular suture are inserted, as there is the risk of a forearm compartment syndrome if the fascia is closed.
    A backslab is applied to allow the soft tissues to recover. In this case, I was satisfied that the DRUJ was reduced and stable on testing. If there is an ulna styloid fracture or TFCC injury that has been fixed, then it would be possible to use a splint but most surgeons would use some form of immobilisation to protect the repair and allow the soft tissue injury to recover.
    The backslab is applied until the next clinic appointment where it is changed to a below elbow cast.Despite the DRUJ being reduced and stable, I still feel that the soft tissues need 4-6 weeks of immobilisation to allow them to recover. I decided against a sugar tong plaster, as the DRUJ was stable.
    This is an AP radiograph of the forearm and demonstrates that the radius has been anatomically reconstructed and the joints of the forearm are congruent.
    The lateral radiograph demonstrates that the bones and joints are anatomically restored. Forearm fractures should be stabilised with at least 6 cortices of fixation both proximal and distal to the fracture.
    Post Operative

    The patient is encouraged to move the fingers and thumb through a full range of motion to prevent any stiffness.
    The wound is reviewed at 2 weeks and any sutures removed (or trimmed flush with the skin if absorbable).
    A check radiograph is taken to ensure that the DRUJ is still reduced and the fracture reduction is maintained.
    A new cast is applied to allow the soft tissues to recover.
    Further follow up is arranged for 4 weeks later (6 weeks after the surgery).
    It is not uncommon for patient’s to complain of altered sensation in the territory of the Superficial Radial Nerve (SRN). If the sensation is present but altered, then you can be reassured that the nerve is in continuity. Prior to wound closer, it is also recommended to have a final inspection of the nerve to ensure it is intact.

    Recommended Reading


    Hughston JC. Fracture of the distal radius shaft: mistakes in management. J Bone Joint Surg Am. 1957; 39: 249-64.
    Hughston reported 92% unsatisfactory results in 38 patients treated without internal fixation

    Wong PC. Galeazzi fracture-dislocations in Singapore 1960-64: incidence and results of treatment. Singapore Med J. 1967; 8: 186-93.
    Wong reported a successful result in only 9% of 34 patients treated with simple immobilisation

    Mikic ZD. Galeazzi fracture-dislocations. J Bone Joint Surg Am. 1975; 57: 1071-80.
    Mikic found an 80% failure rate for conservative treatment.

    Pickering GT, Nagata H, Giddins GEB. In-vivo three-dimensional measurement of distal radioulnar joint translation in normal and clinically unstable populations. J Hand Surg Eur. 2016; 41(5): 521-6.
    Pickering et al. used a testing jig to assess the translation of the DRUJ of 50 patients with clinical DRUJ instability and compared it to a normal cohort. They found that the mean translation of the DRUJ with the hand in neutral and the forearm in neutral was 6.5mm for both right and left wrists. In the clinically unstable group the mean translation was 14.6mm. This demonstrates that DRUJ instability is a measurable phenomenon and also there is no overlap between the stable and unstable groups.

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