Rockwood Children CH8

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SECTION TWO • Upper Extremity

fixation in the often small distal ulnar fracture fragment. Further injury to the physis should be avoided during operative expo- sure and reduction because of the high risk of growth arrest. 81 ORIF of Galeazzi Fractures Open reduction of the radius is indicated in Galeazzi fractures or fracture equivalents in cases of failure to obtain or main- tain fracture and DRUJ reduction. This most often occurs with unstable complete fractures in older adolescents. Preoperative Planning Preoperative planning and patient positioning are similar as described above. Unlike adult Galeazzi fracture dislocations, advanced imaging (e.g., CT or MRI) is rarely needed in pediatric patients. Surgical Approach Open reduction and internal fixation of complete radius frac- tures is performed through a standard volar approach, as described above. In the majority of acute injuries, with anatomic reduction of the radius, restoration of radial length and align- ment will allow for spontaneous reduction of the DRUJ. Occa- sionally, however, the DRUJ dislocation cannot be reduced via closed means (Fig. 8-46). In these situations, the first intraop- erative step is to reassess the quality of radial fracture reduction and fixation. Following this, open reduction of the DRUJ may be performed to remove any interposed soft tissues blocking reduc- tion (periosteum, extensor carpi ulnaris tendon, extensor digiti quinti tendon, other ligamentous structures). 56,86,110,126,151,172,201

The easiest approach for open reduction of the DRUJ is an extended ulnar approach. Care should be taken to avoid injury to the ulnar sensory nerve branches, which typically pass obliquely from proximal volar to distal dorsal in the region of the ulnar styloid. This approach allows exposure both volarly and dorsally to extract the interposed soft tissues and repair the torn structures. Alternatively, a Bowers’ approach to the DRUJ may be used (Fig. 8-47). A curvilinear incision is made over the DRUJ. The fifth dorsal extensor compartment is incised and the extensor digiti quinti is retracted. The DRUJ lies immedi- ately deep to this interval, and the joint may be opened and inspected, facilitating reduction.

Technique

✔ ✔ ORIF of Galeazzi Fractures: SURGICAL STEPS

❑❑ Expose distal radius fracture ❑❑ Anatomic reduction and stabilization of radius • Plate fixation preferred ❑❑ Careful intraoperative assessment of forearm rotation and DRUJ stability • Intraoperative fluoroscopy to confirm DRUJ alignment ❑❑ If DRUJ not reducible, open reduction via ulnar or Bowers’ approach ❑❑ If DRUJ not reducible in setting of distal ulnar physeal fracture, open reduction and stabilization of ulnar fracture performed ❑❑ Radioulnar pinning in cases of reducible but unstable DRUJ reduction ❑❑ Long-arm cast immobilization for 6 weeks • If utilized, radioulnar pin removal 4 to 6 weeks postoperatively

Figure 8-46.  An adolescent girl presented 4 weeks after injury with a painful, stiff wrist. A: By examina- tion, she was noted to have a volar distal radioulnar dislocation that was irreducible even under general anesthesia. B: At the time of surgery, the distal ulna was found to have buttonholed out of the capsule, and there was entrapped triangular fibrocartilage and periosteum in the joint. (Courtesy of Children’s Orthopaedic Surgery Foundation.) A B