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CASE REPORT

Unusual Presentation Of Galeazziís Variant Fracture(In Children) With Ulnar Nerve Involvement

 Muhammad Ahsan Saleem*,Michael Maru*,Catherine Lennox *

* Department of Orthopaedics, University Hospital of North tees and Hartlepool, Stockton on tees

Address for Correspondence:

Dr. Muhammad Ahsan Saleem
University hospital of North Tees and Hartlepool.
Hardwick Road, Stockton on tees.TS19 8PE.
Phone: 07983623636
Email: masakhtar@gmail.com

J.Orthopaedics 2007;4(3)e16

Keywords:
Galeazziís variant fracture; ulnar nerve entrapment; children

Background:

Fractures of the distal radius in Children are common but a fracture of the distal radius with a distal ulnar epiphyseal fracture and anterior displacement otherwise known, as Galleaziís Fracture with ulnar nerve entrapment is very rare. In children such fractures have been referred as a variant of Galleazziís fracture. None of the previously reported Galleaziís equivalent fractures in children described the signs and symptoms of ulnar nerve entrapment. In this case a small fragment of the ulnar epiphysis was found to be the cause.

Case Report :

A 17-year-old lad presented to A & E with dorsally angulated fracture of left distal radius after having a fall from 7 feet on to the outstretched left hand. On examination there was dorsal deformity of the left wrist. There was no neurovascular deficit at that time. X-rays confirmed the communited fracture of distal shaft radius. A molded cast under sedation was applied on the same day patient presented.  

On the first post-operative day, the patient complained of paraesthesia in little finger and the ulnar border of ring finger of left hand. Initially the impression was that the symptoms of ulnar nerve compression were due to the very tight plaster, it was released immediately, but the symptoms didnít improve. On further review of X-rays a small fragment of ulnar epiphysis was found to be displaced on volar aspect of the wrist.

Figure 1. Missing fragment of distal ulnar epiphysis displaced anteriorly over the volar aspect of ulna.  

Open reduction under anesthesia was carried out and the ulnar was found entrapped in between the fragment of ulnar epiphysis and distal ulna. The nerve was freed and ulnar epiphyseal fragment was reduced and held in its original position with the help of 2 K-wires.  

Three weeks after the operation the patient was reviewed in fracture clinic. Examination revealed complete loss of sensations in ulnar nerve territory of left hand. No motor deficit was detected. Re X-ray confirmed that the fixation has failed and fragment has displaced. Hence, left wrist was re-explored via extending the original incision under G.A. The ulnar nerve was stretched tightly across the extruded fragment of distal ulnar epiphysis and this fragment was mal-rotated. It was not possible to reduce the fragment hence this was sacrificed allowing the nerve to lie free. All wires were removed and wound was washed out.

 

Figure 2.distal ulnar epiphysis displaces again after initial reduction with the help of K-wires

Figure 3.Ulnar nerve freed from the displaced ulnar fragment and distal ulna  

The Pt. was followed up in the Out patient fracture clinic. He had limitation of wrist extension by 5 degree, supination was limited 10 degree but has full range of flexion and pronation. The sensations in little finger gradually improved.

Discussion :

The classical Galleaziís fracture is defined as fracture of shaft of radius with distal radioulnar joint dislocation but in children this fracture has been referred as a Galeazziís Variant fracture and it involves the ulnar epiphysis in place of distal radioulnar joint. First description is by Reckling (1982). To our knowledge there is no previous case reports in the literature describing ulnar nerve entrapment in Galleaziís variant fracture. There are only few case reports mentioning ulnar nerve involvement by multiple distal ulnar fragments but none of these fractures are classed under Galeazziís variant fracture≤ī≥.  

Our case report is unique in a sense that itís a Galeazziís variant fracture involving ulnar nerve only by a single fragment of epiphysis, which to our knowledge has not been reported before. Another challenge in our case was that, the child was only 17 years old and sacrificing the ulnar epiphysis may result in arrest of growth plate but that was unadvisable. Five months post injury the patient was regularly followed up and has now been discharged from outpatient clinic with no signs of distal ulnar growth arrest.  

The mechanism of injury in our case is somewhat similar to the Galeazziís fracture i.e. fall on outstretched hand with flexion at elbow but it is indeed very crucial to identify the complications of Galeazziís equivalent fracture in children as in our case there were two potential risks involved:  

Arrest of distal ulnar growth plate.

Loss of ulnar nerve function.  

Though in our patient we initially missed the ulnar nerve entrapment but as soon as we realized  

Prompt diagnosis is a key in the management of such fractures, if delayed can lead to malunion with reduced function of the wrist specially in children.

 

Reference :

  1. Imatani J, Hashizume H, Nishida K, Morito Y and Inoue H. The Galleazi-equivalent lesion in children revisited. J hand surgery [br] 1996 Aug; 21B (4) 455-7.

  2. Saitoh S, Koiwai H, Sensui K. Double type III epiphyseal separation of distal ulna associated with ulnar nerve palsy. J ortho. Trauma 1997 Feb-mar 11(2) 138-41.

  3. Osada D, Tamai K, Kuramochi T, Saotome K. Three epiphyseal fracture (distal radius, Ulna and proximal radius) and diaphyseal ulnar fracture in 7 year childís forearm. J of orthopedic trauma 2001 Jun-Jul; 15(5) 375-7.

  4. Letts M, Rowhani D. Galleazi equivalent injuries of the wrist in children. J of orthopedics 1993; 13(5) 561-66.

 

This is a peer reviewed paper 

Please cite as : Muhammad Ahsan Saleem : Unusual Presentation Of Galeazziís Variant Fracture(In Children) With Ulnar Nerve Involvement

J.Orthopaedics 2007;4(3)e16

URL: http://www.jortho.org/2007/4/3/e16

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