summary Galeazzi Fractures are rare injuries in the pediatric population and consist of distal radius fractures at the distal metaphyseal-diaphyseal junction with concomitant disruption of the distal radioulnar joint. Diagnosis is made with plain radiographs. Treatment is generally closed reduction and casting for the majority of fractures. Surgical management is indicated for irreducible DRUJ due to interposed tendon or periosteum. Epidemiology Incidence relatively rare injury (3% of distal radius fractures associated with DRUJ disruption) less frequent than in adults often missed injury pattern (up to 41%) when radial fracture is < 7.5 cm from the articular surface, 55% chance of DRUJ instability (6% chance if > 7.5 cm) Demographics peak incidence 9 to 13 years old Etiology Pathophysiology DRUJ disruption disruption of the DRUJ in a pediatric patient can consist of DRUJ dislocation a displaced ulnar physeal injury (Galeazzi-equivalent) most common pathoanatomy axial loading in combination with extremes of forearm rotation (pronation or supination) pronation produces an apex dorsal radial fracture with the distal ulna displaced dorsally supination produces an apex volar radial fracture with the distal ulna displaced volarly Associated injuries nerve injuries are rare Anatomy DRUJ osteology possesses poor bony conformity in order to allow some translation with rotatory movements ligamentous ligament structures are critical in stabilizing the radius as it rotates about the ulna during pronation and supination triangular fibrocartilage complex (TFCC) is a critical component to DRUJ stability biomechanics the joint is most stable at the extremes of rotation Classification Walsh classification Type I Dorsal displacement of the radius Due to supination force Type II Volar displacement of the radius Due to pronation force Presentation Symptoms wrist and forearm pain radial deformity limitation of wrist motion ulnar head prominence or deformity can sometimes be seen Physical exam pain with movement or palpation of the wrist DRUJ instability may be appreciated by local tenderness and instability to testing of the DRUJ compare to contralateral side careful examination for nerve injury Imaging Radiographs required views AP and true lateral radiographs true lateral radiograph is essential in determining the direction of displacement a slightly oblique view may cause the ulna to appear subluxed in a normal wrist, the ulnar styloid should point to the triquetrum in all views, including oblique projections additional views contralateral radiographs often helpful for comparison findings displaced distal radial shaft fracture DRUJ disruption may be subtle and radiographs must be scrutinized additional signs of DRUJ instability include ulnar styloid fracture widened DRUJ on posteroanterior view greater than or equal to 5mm radial shortening Treatment Nonoperative closed reduction with long arm casting indications first-line of treatment in children 92% of adults experience poor outcomes with non-operative management reduction requires anatomic reduction of both the radius fracture and the DRUJ supination is required for reduction if there is dorsal subluxation of the ulna pronation is required for reduction if there is volar subluxation of the ulna immobilization place in above elbow cast in supination outcomes good to excellent with proper reduction of the radius and concomitant DRUJ reduction, even in cases where the DRUJ injury was not initially recognized Operative open reduction internal fixation +/- DRUJ pinning indications unable to obtain anatomic closed reduction irreducible DRUJ due to interposed tendon or periosteum technique radial fixation can be done with volar plate or flexible IMN (see below) ORIF, soft tissue reconstruction of DRUJ and TFCC, +/- corrective osteotomy indications chronic DRUJ instability (a rare consequence of a missed injury) corrective osteotomy with soft tissue reconstruction of DRUJ and TFCC indications DRUJ subluxation is caused by a radial malunion a corrective osteotomy is also required in addition to reconstruction, otherwise a soft tissue reconstruction of the DRUJ alone will fail Technique ORIF with volar plating, +/- DRUJ pinning approach dorsal approach to DRUJ to remove interposed material (ECU) if unable to obtain closed reduction volar approach for ORIF(with plate) open reduction irreducible DRUJ requires an open reduction to remove interposed material reduction can be blocked by interposed tendon ECU most common interposed tendon periosteum DRUJ stability following fixation, test DRUJ (shuck test) if unstable, pin ulna to radius in supination if unstable with large ulnar styloid fragment, fix ulnar styloid and splint in supination ORIF with flexible intramedullary nailing, +/- DRUJ pinning approach percutaneous (with IMN) of radius fracture open reduction same as above DRUJ stability same as above Complications Delayed diagnosis Malunion/nonunion of the radius commonly a result of persistent ulnar subluxation Chronic DRUJ instability chronic DRUJ instability (a rare consequence of a missed injury) less common in children Acute carpal tunnel syndrome Superficial radial nerve palsy can be seen with IMN Ulnar nerve injury Stiffness limited pronosupination Extensor pollicis longus rupture Ulnar physeal arrest 55% incidence in Galeazzi-equivalent fractures