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CASE REPORT
Year : 2014  |  Volume : 14  |  Issue : 2  |  Page : 168-171

Early rehabilitation in unstable bilateral Galeazzi fracture dislocation: Role of transfixing K wires


Department of Orthopaedics, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi, India

Date of Web Publication9-Oct-2014

Correspondence Address:
Daipayan Chatterjee
64/10, Dhakuria Station Road, Kolkata - 700 031, West Bengal
India
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DOI: 10.4103/1319-6308.142378

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  Abstract 

The Galeazzi fracture is a fracture of the middle to distal third of the radius associated with dislocation and/or instability of the distal radioulnar joint (DRUJ). Operative treatment followed by conventional immobilization of 6-8 weeks is usually followed by good outcome, but it takes nearly 1 year for occupational rehabilitation and most cases are associated with restricted terminal range of motion. To avoid these consequences, early commencement of rehabilitation is necessary but for that the DRUJ must be stable after radial fixation. Here, we report a case of early rehabilitation in a 36-years-old horse trainer with bilateral Galeazzi fracture dislocation where both DRUJ were unstable after fixation of radius but transfixing K wires provided the required stability needed for early mobilization. The patient had complete range of motion and occupational rehabilitation by 4 months.

  Abstract in Arabic 

دور طريقة التثبيت بأسلاك k في إعادة التأهيل المبكر في الكسور التنائية غير المستقرة Galeazzi fracture dislocation)
ان كسر Galeazzi fracture هو كسر من الوسط إلى الثلث من عظم الكعبرة يكون مصحوبا بخلع أو عدم استقرار في مفصل الكعبري الزندي العلوي DRUJ ويمكن معالجة هذا النوع من الكسور بالتدخل الجراحي المصحوبة بطريقة التجميد التقليدية لمدة تتراوح بين ستة و ثمانية أسابيع قد أظهرت نتائج جيدة ' إلاّ أن المريض يحتاج إلى برنامج إعادة تأهيل لمدة سنة كاملة ، وفي معظم الحالات تكون حركته محدودة. ولتفادي مثل هذه العواقب يجب أن يبدأ برنامج إعادة التأهيل في وقت مبكر . إلا أنه في حالة خلع مفصل الكعبؤي الزندي DRUJ يجب تثبيت الخلع إشعاعيا .
وعلى سبيل المثال نعرض هنا حالة مرضية لأحد مدربي الخيول في السادسة و الثلاثين من عمره أصيب بكسر ثنائي Galeazzi fracture و التثبيت استطاع أن يستعيد حركته في خلال أربعة أشهر باستخدام أسلاك K.

Keywords: Bilateral, distal radio-ulnar joint, galaezzi, rehabilitation, transfixing k- wires


How to cite this article:
Chatterjee D. Early rehabilitation in unstable bilateral Galeazzi fracture dislocation: Role of transfixing K wires. Saudi J Sports Med 2014;14:168-71

How to cite this URL:
Chatterjee D. Early rehabilitation in unstable bilateral Galeazzi fracture dislocation: Role of transfixing K wires. Saudi J Sports Med [serial online] 2014 [cited 2021 Jun 25];14:168-71. Available from: https://www.sjosm.org/text.asp?2014/14/2/168/142378


  Introduction Top


The Galeazzi fracture is a fracture of the middle to distal third of the radius associated with dislocation and/or instability of the distal radioulnar joint (DRUJ). [1] Because of the poor results of nonoperative treatment, this injury has been referred to as a "fracture of necessity" in adults. [2] Galeazzi fracture dislocations represent 3-4% of forearm fractures and bilateral Galeazzi fracture dislocations are rare. [3],[4] Operative treatment followed by conventional immobilization of 6-8 weeks is usually followed by good outcome, but it takes nearly 1 year for occupational rehabilitation and most cases are associated with restricted terminal range of motion. To avoid these consequences, early commencement of rehabilitation is necessary but for that the DRUJ must be stable after radial fixation. Here, we report a case of early rehabilitation in bilateral Galeazzi fracture dislocation where both DRUJ were unstable after fixation of radius but transfixing K wires provided the required stability needed for early mobilization that hastened his occupational rehabilitation.


  Case report Top


A 36-years-old man, horse trainer by occupation presented to the orthopedics emergency department with a history of fall on outstretched hands with forearm in pronation while riding a horse. Clinically injury to head, neck, chest, abdomen, pelvis, and lower limbs were ruled out. The patient complained of severe pain and deformity in his wrists and forearms bilaterally. On examination, bilateral forearms were found to be deformed at middle third and distal one-third junction with swelling, tenderness, and instability of bilateral wrists. Ulnar heads were found to have dislocated dorsally bilaterally [Figure 1]. There was no distal neurovascular deficit. Findings were correlated radiographically and a diagnosis of bilateral Galeazzi fracture dislocation was established [Figure 2] and [Figure 3]. Open reduction and internal fixation of right radial fracture with seven hole LC-DCP (limited contact dynamic compression plate) [Figure 4] and left radial fracture with seven hole DCP (dynamic compression plate) [Figure 5] and [Figure 6] was achieved by Henry's approach. Stability of the DRUJ was assessed fluoroscopically. The right DRUJ was found to be stable from 30° supination to 10° pronation while the left DRUJ was found to be stable from 40° supination to 15° pronation beyond which there was a tendency to dislocate. Intraoperative decision to explore the ulnar collateral ligaments and triangular fibrocartilage complex (TFCC) was taken. On exploration TFCC on the right side and the ulnar collateral ligaments bilaterally were found to be torn and were repaired with monofilament absorbable sutures followed by K wire fixation of bilateral DRUJ. Reduction and position of K wires were checked fluoroscopically and were found to be satisfactory. Patient was given bilateral above elbow slabs with wrists immobilized in 30° supination for the first 2 days. After the first wound inspection, custom-made above elbow braces with hinge at elbow and wrist immobilized in 30° supination were applied bilaterally for unrestricted mobilization of elbow. After complete healing of the stitch line (2 weeks), active and active-assisted supination and pronation were started. K wires were removed after 1 month and reduction throughout the range of wrist rotation was assessed fluoroscopically. DRUJ was found to be stable bilaterally. Wrist mobilization in sagittal plane was begun at 1 month. Coronal plane movements were initiated after 6 weeks. By 8 weeks almost full range of wrist movements were achieved and wrist strengthening exercises were started. By the end of 4 months patient was found to have bilateral painless, stable, and functional wrists and had started working as a horse trainer once again. The range of motion on right side was 80° supination and pronation, 70° of dorsiflexion, and 50° palmar flexion, whereas that on the left side was 85° of supination, 80° of pronation, 75° of dorsiflexion, and 50° palmar flexion.
Figure 1: Clinical photograph of the case with bilateral Galeazzi fracture dislocation. Ulnar heads dislocated dorsally visible clinically

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Figure 2: Anteroposterior view radiographs of bilateral forearm with wrist showing bilateral Galeazzi fracture dislocation

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Figure 3: Lateral view radiograph of bilateral forearm with wrist showing bilateral Galeazzi fracture dislocation with dorsal dislocation of ulnar heads

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Figure 4: Postoperative anteroposterior and lateral view radiograph of right forearm with wrist showing aligned radial shaft fracture fixed with LC-DCP and reduced DRUJ transfi xed by K wire. LC-DCP = limited contact
dynamic compression plate, DRUJ = distal radioulnar joint


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Figure 5: Postoperative oblique and lateral view radiograph of left forearm with wrist showing aligned radial shaft fracture fixed with DCP and reduced DRUJ transfi xed by K wire. DCP = dynamic compression plate,
DRUJ = distal radioulnar joint


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Figure 6: Intraoperative clinical photograph showing fixation of left radius by seven hole LC -DCP. LC-DCP = Limited contact dynamic compression plate

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  Discussion Top


The dislocation of ulnar head in Galeazzi fracture dislocation may be dorsal (commoner) or volar (rare) depending on the mechanism of injury. If the fall is on the outstretched hand with forearm in pronation, the dislocation is dorsal as is observed in this case, and if forearm is in supination at the time of injury, the dislocation is volar. [2] Traditionally, in dorsal dislocation type of Galeazzi fracture, postsurgical immobilization of the forearm and the wrist in supination has been recommended for 6-8 weeks. [5] Adams recommended long-arm cast immobilization for 4 weeks followed by short-arm cast for 2 weeks. [6] Postsurgical prolonged immobilization in a long-arm cast for 4-6 weeks has also been recommended by Giannoulis et al., even after transfixation of DRUJ by K wire. [7] Longer immobilization has been thought to foster healing of the supporting structures of DRUJ. However, such long periods of immobilization and late initiation of rehabilitation leads to permanent restriction of terminal range of motion of the wrist and also delays the return to work. [2],[4],[8] Keeping this in mind, Gwinn et al., reported an early mobilization protocol for Galeazzi fracture-dislocation, and the results were heartwarming. [9] But use of this protocol was recommended only in patients with stable DRUJ after radial fixation. However, we have instituted early rehabilitation in this patient with unstable DRUJ after radial fixation and met with a successful outcome. We have hypothesized that the transfixing K wires in DRUJs contributed to their stability and prevented redislocation during early rehabilitation. This allowed early initiation of rotational and sagittal plane mobilization of the wrist with periodic radiographic monitoring to exclude redislocation. However, retaining the K wire till 4-6 weeks and avoidance of coronal plane mobilization of the wrist till 6 weeks is recommended to provide ample time for the ligaments and TFCC to heal. Moreover, when K wire is removed, fluoroscopic evaluation of the maintenance of reduction of DRUJ during the range of motion of the wrist is recommended. Mikic also reported that temporary radioulnar transfixation gave better results when compared with no transfixation. [1] However, he did not study its effect on early rehabilitation in Galeazzi fracture dislocation. Thus, we can conclude that early rehabilitation under regular supervision can be started in cases of post-radial fixation unstable DRUJ if transfixed by K wires.

 
  References Top

1.
Mikic ZD. Galeazzi fracture-dislocations. J Bone Joint Surg Am 1975;57:1071-80.  Back to cited text no. 1
    
2.
Kim S, Ward JP, Rettig ME. Galeazzi fracture with volar dislocation of the distal radioulnar joint. Am J Orthop (Belle Mead NJ) 2012;41:E152-4.  Back to cited text no. 2
    
3.
Clare DJ, Corley FG, Wirth MA. Ipsilateral combination monteggia and galeazzi injuries in an adult patient: A case report. J Orthop Trauma 2002;16:130-4.  Back to cited text no. 3
    
4.
Jafari D, Taheri H, Shariatzade H, Mazhar FN, Jalili A, Ghahramani MH. Bilateral combined Monteggia and Galeazzi fractures: A case report. Med J Islam Repub Iran 2012;26:41-4.  Back to cited text no. 4
    
5.
Sebastin SJ, Chung KC. A historical report on Riccardo Galeazzi and the management of Galeazzi fractures. J Hand Surg Am 2010;35:1870-7.  Back to cited text no. 5
    
6.
Adams BD. Distal radioulnar joint instability. In: Green DP, editor. Operative Hand Surgery. 5 th ed. New York: Churchill Livingstone; 2005. p. 618-9.  Back to cited text no. 6
    
7.
Giannoulis FS, Sotereanos DG. Galeazzi fractures and dislocations. Hand Clin 2007;23:153-63.  Back to cited text no. 7
    
8.
Nanno M, Sawaizumi T, Takai S. Case of bilateral Galeazzi fractures associated with dislocation of the right elbow. J Nippon Med Sch 2011;78:384-7.  Back to cited text no. 8
    
9.
Gwinn DE, O'Toole RV, Eglseder WA. Early motion protocol for select Galeazzi fractures after radial shaft fixation. J Surg Orthop Adv 2010;19:104-8.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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