GALEAZZI

H.

FRACTURES

P. J. WALSH,

From

Alder

C. A.

Hey

N.

IN CHILDREN
McLAREN,

Childrens

R.

Hospital,

OWEN

Liverpool

We have reviewed 41 children

under 15 years of age with a fracture
of the radius and disruption
of the
inferior radio-ulnarjoint.
Despite the fact that thejoint
injury had not at first been recognised
in 41% of cases
and a variety of treatments
had been used, the final results of conservative
management
were generally
good.
The more distal the radial fracture,
the greater
were the problems
encountered.

Fracture

of

the

shaft

of

the

radius

complicated

by

dislocation
of the inferior
radio-ulnar
joint
(IRUJ)
is a
rare injury (Hughston
1957; Miki#{233}1975; Reckling
1982).
It was originally
described
by Astley
Cooper
in 1 826, and
received
its eponym
from Riccardo
Galeazzi
of Milan
in
1934, when he reported
18 cases to the Lombard
Surgical
Society.
Many
authors
since then have noted
its rarity
in
children
(Hughston
1957;
Reckling
and Peltier
1965;
Miki#{233} 1975;

King

1984),

studied
the incidence,
ment
in this age group.
Although
applied
middle
years
with

and

term

distal

thirds,

fracture

occurring
fractures
IRUJ.

specifically

clinical

manage-

was

originally

at thejunction

the term

radial
of the

have

Galeazzi

has

been

at any
On this

of the

used

over

the

level associated
basis,
we have

fracture-dislocations
within
the distal
third
shaft,
but have excluded
cases with fracture
shaft,
or injury
affecting
the distal
radial

of
of
or

epiphysis.

PATIENTS
We reviewed
years
or
fractured
was

few
and

fractures

to describe
disruption

included
the radial
the ulnar
ulnar

the

to radial

but

diagnosis

AND

either
written

on a true
by the

of 1453 patients

aged

questionnaire

evidence

of

disruption

of the

and

the

We recorded
and mode
injury
was

of injury,
recognised

MCh Orth, Orthopaedic

Hospital,
Eaton
Road,

Registrar
Liverpool

in the radial
It became
of the radial

third
1975).

than
We

that
found
in an
therefore
grouped

within

the

distal

shaft

C. A. N. McLaren,
Robert
Jones
and
England.

FRCS,
FRCS
Ed,
Agnes
Hunt
Hospital,

Orthopaedic
Oswestry,

R. Owen,
FRCS,
Surgery
Royal
Liverpool
3BX,
England.

MCh

of Orthopaedic

Requests

for

730

Hospital,

reprints

1987 British
030l-620X/87/5145

Orth,

should

Professor

Prescott

Street,

be sent

Editorial
Society
$2.00

to

of Bone

P0

Mr

Box

H.
and

Registrar
Salop
SYIO

7AG,

and
147,

Accident

Liverpool

L69

the mode

evident
fractures

third

that
were

adult
those

of the

ly, the groups

were further
giving
four categories
of
and Figs 1 to 4).

the side

nature
of the
the position
of
and

outcome

a much
higher
within
the distal

population
with
the

radius

(Figs

(Miki#{233}
fracture

1 and

subdivided
according
fracture-dislocation

Table I. Level and displacement

fragment
in 41 Galeazzi
fractures

of the distal
in children

Level

of radial

2) and

Within
third

distal

13

Posterior

I3

no

limitation

P. J. Walsh.
Joint

obvious
pronation

of treatment
An excellent
alignment
of function

of
one

was adjudged
using
Miki#{233}s
result had satisfactory
union
and length,
no subluxation,
at the

elbow

or wrist

supination
or pronation.
or more
of the following

subluxation
or supination
THE

of

the

ulnar

OF

BONE

and

A fair
: delayed

head,

of up to 45#{176}
or other
JOURNAL

radial

At junction
of
distal and
middle third

Anterior

The result
(1975) criteria.
with near-perfect

to this,
(Table
I

fracture

Displacement

limitation
showed

Surgery

and

the

those with the fracture

at the junction
of the middle
and
distal
thirds
(Figs
3 and 4). Because
it was felt the
mechanism
of injury
was
different
when
the
distal
fragment
was displaced
anteriorly
rather
than posterior-

IRUJ,

2AP,

or not
attendance,

the fracture

15

L12

sex of the patient,

whether
at first

of radius

H. P. J. Walsh,
FRCS,
Alder
Hey
Childrens
England.

notes
these

radiographs.

the age and

of treatment.
proportion

less who
had
presented
with
a diagnosis
of
radius
over a six-year
period.
In 41 cases there

unequivocal

radiograph
or from clinical
at the time
of injury.
Of

patients,
30 were personally
reviewed
and the result in I I
was
obtained
from
review
of the
case
records,
a

METHODS

the radiographs

lateral
doctor

AND

no

result
union,

limitation

of

restriction

of

JOINT

SURGERY

GALEAZZI

FRACTURES

IN CHILDREN

731

IL.V

Fig.
Radiograph
distal
third

Fig.

and diagram
of the forearm

Fig.

to show
a fracture-dislocation
with posterior
displacement

within
the
of the radius.

Fig.

Radiograph
and diagram
to show
a classic
radial
fracture
at the junction
of the middle
anterior
displacement
of the distal
radius.

Galeazzi
and distal

4
injury
thirds.

with
the
There
is

movement
at elbow
or wrist.
A poor result
was one with
one or more
of the following
: patient
dissatisfaction,
pain,
obvious
deformity
of the
forearm,
non-union,
significant
shortening
of the
radius,
limitation
of
pronation
or supination
of more
than
restriction
of elbow
and wrist
function.
Anteroposterior
and true lateral
taken
at
radiographic

the

category
tion

time
of
outcome

of the

of the

and,

radiographs

review.
The
final
was
then
correlated

fracture-dislocation,

injury

45#{176},
or excessive

most

the
importantly,

were

clinical
with

initial

and
the

recogni-

with

the

mode
Age

of treatment.

in

Fig.
The

RESULTS
The age distribution
the majority
being
(34%)
were under

ofthe
patients
is shown
in Figure
5,
from nine to 12 years ofage,
while
14
10. There
were 31 boys and 10 girls.

Twenty-one
others
fell

had fallen
from
running,
playing

skating.

patients
whilst

In 1 7 patients

injury

24 to the left. In 17 cases

not at first recognised.
of the

compared
proximal

seven

been

to the

a fracture

within

used,

had

(35%)

II summarises
In five of the

had

recognised.
had been

with

injury

14 (67%)

with only
fracture.

Table
employed.
plaster

radius,

to the right

(41%),

Of the 21 patients
third

was

a height,
football

fallen
of the

the treatment
I 6 cases
where

the

injury

to the

An acceptable
initial
obtained
in all except

closed
reduction
could
not
reduction
with internal
fixation
True
lateral
post-reduction

while
the
or rollerwrist

and

IRUJ

from

in
was

the distal
a height

20 with

a more

which
had been
a below-elbow
IRUJ

had

been

69-B,

No.

5, NOVEMBER

1987

distribution

of 41

reduction

ofthe

had

unrecognised.

been

IRUJ

Galeazzi

in all four

injuries

in children.

the originaljoint

injury

The outcome
of treatment
was then correlated
with
the
site
of the
fracture
and
the
type
of plaster
immobilisation
used, with results
which
are summarised
in Table
III. Excellent
results
were found
in all patients
with a posteriorly
displaced
distal
radial
fragment
who
were treated
in the traditional
manner
by reduction
and
an above-elbow
plaster
in supination.
This also applied
to this type
of case
immobilised
in neutral
rotation.
Reduction
of the radius
in these
cases
had resulted
in
automatic
reduction
of the IRUJ,
even
when
the joint
injury
had not been
initially
recognised.

reduction
of the radius
two cases.
In these
a
be

achieved
and
was performed.
radiographs
had

open

Table

II.

Manipulation

Treatment
and

given

in 41 Galeazzi

Manipulation

fractures

in children

and above-elbow

plaster

been

taken
in only 28 cases,
so an accurate
estimate
of the
frequency
offull
reduction
ofthe
IRUJ
was not possible.
Of the 28 cases with adequate
films, four had inaccurate

VOL.

age

years

below.elbow
16

plaster

Supination

Neutral

Pronation

Internal
fixation

10

H. P. J. WALSH,

732
Table

III.

Result

related

to level

C. A. N. McLAREN,

of fracture

and

------

Level

of fracture
Junction
of
distal and
middle third

Result

Number

Distal
third

Excellent

25

10

15

Fair

13

Poor

Total

41

mode

R. OWEN

of treatment

--

Below-elbow
plaster

Above-elbow
plaster

Internal
fixation

17

21

20

16

23

Table

For
distal
ably

those

end

cases

of the

so that

no

with

radius,
firm

anterior

displacement

treatment
conclusions

had

varied

could

be

associated
recognition
below-elbow
was more

pain

and

fractures

moderate
within

with
a worse
of the joint
immobilisation
initial
disruption.

plaster

considerdrawn.

the four who had inaccurate

reduction
ofthe
had only fair results
with persistent
subluxation
restriction
of wrist
movements
and
one

The

to
Of

IRUJ,
three
and mild
had
a poor

restriction

the

many

authors

distal

third

to the

rarity

in

incidence.
Our study
radial
shaft
fractures

indicates
that less than
5%
in children
are associated

lesser

disruption
degree

adults,
Reckling

ofthe

of damage

is controversial
1982) and

IRUJ,

though

to the joint.

(Hughston
internal
fixation

has

more

given

adequate
radio-ulnar

stability.
ligaments,

This

an

have
even

a
in

1957;
Miki#{233}1975;
is frequently
used.
or fair
plaster
4 to 6
union.

accounts
for the greater
and alignment
in children,
its original
position
with

stability
the pronator

depends
quadratus

on

the
and,

33 cases

above-elbow

with

position

of rotation

local
most

classic

of the

forearm

Excellent

Fair

Poor

or

more

those

distal

fractures

cases

with

with

a history,
a distal

blow to the forearm

were associated
with

forces
The

children
such

an

of sufficient

diagnosis

of

the

posterior

fall often

fracture

being

and

but it appeared
more severe

anterior

should

not

injury

should

wrist

no matter

however,
that
and
Levinsohn
importantly,

velocity

a careful

IRUJ

must

be made

distal

radial

injuries)

or magnitude.

First,

the

in

possibilities

be remembered,

especially

this
always
Thirdly,

clinical

seem

under

(not

Palmer
most

state

of the

easy

in the

anaesthesia

after
reduction
of the fracture.
In the series
we report,
treatment
when
the type of injury
was recognised.

effort
of the

we do agree,

ofthe

anaesthesia
also

(Mino,
perhaps

appraisal

before
and

may

possible
and

of
when

a height.
Secondly,
every
true lateral
radiographs

difficult

is not
1983).

distal
than

fracture-dislocation

be difficult.

how
this

that
trauma

Moore,
Lester
and
failure
to reproduce
to their
inability
to

Galeazzi

the child has fallen

from
must
be made
to obtain

before

and

although

and

of the

an

Pronation

provide

of the

series,

in

displacement
of the radius
there
was no such consistent
history
of the mechanism
of injury
and it seemed
that
different
forces
were involved.
No patient
had a history

IRUJ

In our

to the

displacement,
21 gave such
from a considerable
height.

importantly,
the triangular
interosseous
fibrocartilage.
It
is likely
that once position
is restored
and maintained,
healing
of this structure
occurs
more
effectively
and
rapidly
in children
than
in adults.
The cause ofthe
classic
Galeazzi
injury is probably
a
fall on to the outstretched
hand
with extreme
pronation
forearm.

treated

the proximal
injuries.
Interestingly
Sarmiento
(1985)
attributed
their
Galeazzi
fractures
experimentally

of all
with

may

Treatment,

Of the 41 cases in our series,

36 had excellent
results
after
simple
manipulation
and
immobilisation.
The
average
healing
time
was
weeks
and
there
were
no cases
of delayed
Periosteal
continuity
probably
ease in restoring
radial
length
while
the IRUJ
often
regains

cases

Neutral

In

of Galeazzi

fracture-dislocations

obvious

none

23

Supination

ofa direct
fractures

children,

in

Result

were

outcome
because
of poorer
injury,
a higher
incidence
of
and possibly
because
there

allude

Result

related

injuries

of

DISCUSSION
Although

IV.

of the

influence
of the position
of rotation
in an above-elbow
plaster
on the result
is summarised
in Table
IV.
Of the 1 7 cases
in which
there
was initial
failure
recognise
thejoint
injury,
seven had excellent
results.

outcome
with
movement.
In general,

- - -------

Treatment

good initial
was obtained,

reduction

there

of both

was

was varied
In a few
the radius

subsequent

even
cases,
and

the

loss

of

position
at thejoint.
This was due either
to the ill-advised
use of a below-elbow
plaster
or to the
use of an
inappropriate
position
in an above-elbow
plaster.
We
would
advise
that
once
the radial
fracture
has been
reduced,
relocation
of the joint
should
also be checked
then

the forearm
THE

should
JOURNAL

be immobilised
OF BONE

AND

in an aboveJOINT

SURGERY

GALEAZZI

elbow

plaster

in

such

a position

as

to

FRACTURES

minimise

733

IN CHILDREN

re-

REFERENCES

displacement.
Cooper

In choosing
this position
it is necessary
to consider
the main deforming
forces
acting
on the distal
fragment,
namely

the

muscles.
angulated
held
our

supinated
results

satisfactory
and stable
the

in the plaster
substantiate
in a neutral

and

or pronated

plaster

is used

to prevent

originally
should
be

these
forces;
However,

position

can

give

rotation

of

forearm.

69-B,

No.

5, NOVEMBER

C. J. E. Monk
and Mr J. C. Dorgan
of
Hospital,
Mr J. F. Taylor
of Alder
Hey
P. H. Corkery
of Ysbyty
Glan
Clwyd
for
patients
for this study.
We would
also like
typing
the paper.

1987

Fracture
J Bone

and

onfractures

o/ the joints.

RE. Galeazzi
fracture-dislocation.
In : Rockwood
CA
KE,
King
RE, eds. Fractures
in children.
Philadelphia
Lippincott
Company,
1984 :356- 62.

Mikic

ZD.
Galeazzi
fracture-dislocations.
1975:57-A :1071 -80.

Mino

DE, Palmer
AK, Levinsohn
computerised
tomography
dislocation
of
the
distal
1983 :8 :23-31.

Moore

TM,
Lester
DK, Sanniento
tissue
constraints
in artificial
1985:194:189-94.

Reckling
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FW. Unstable
and Galeazzi

5th

of the
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: 249-64.

King

IRUJ
is reduced
and an above-

subsequent

Sir A. A treatise
on dislocations
London:
Longman,
1826.

Hughston
JC.
management.

brachioradialis

to counteract
this
analysis.

results
provided
that
the
at the time of immobilisation

We would
like to thank
Mr
Royal
Liverpool
Childrens
Childrens
Hospital
and Mr
permitting
us to review
their
to thank
Mrs I. L. Giff for

VOL.

quadratus

Thus,
whether
the
fracture
was
posteriorly
or anteriorly,
the forearm

immobilisation

elbow

pronator

ed.

in

Joint

Jr. Wilkins
etc:
JB
Surg

EM. The role of radiography

the diagnosis
of subluxation
radioulnar
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J
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lesions).
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Reckling
FW,
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[Am]
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in

[Am]
and
and
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of softOrthop

(Monteg:857-63.
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