Unlike adults, where Galeazzi fractures have been termed the fracture of necessity (necessitating operative fixation), the majority of Galeazzi fractures in children can be successfully treated nonoperatively. However, the moniker of “fracture of necessity” still applies, in that, in order to treat this fracture nonoperatively, an anatomic reduction is necessary, as is weekly radiographic follow-up to ensure appropriate alignment is maintained. The indications and contraindications to nonoperative management are illustrated in Table 3. Though successful treatment with immobilization in both long- and short-arm casts has been reported, inferior results have been reported with short-arm compared to long-arm casting in a case series of pediatric Galeazzi fractures (Walsh et al. 1987). As children approach skeletal maturity, the chance for failure of nonoperative treatment approaches that of adults (up to 92 %) and operative treatment should be strongly considered in any patient with closed physes (Eberl et al. 2008).

The reduction maneuver for pediatric Galeazzi fractures is dependent on the characteristics of the injury, including the apex of the radius fracture and associated ulnar head dislocation. In the case of an apex volar radius fracture and an associated volar dislocation of the ulnar head, forearm pronation and volar forearm pressure often provide the reduction force necessary to allow for reduction of the radius angulation and a dorsal relocation of the ulnar head. Apex dorsal radius fracture angulation with an associated dorsal ulnar dislocation is reduced with supination of the forearm and dorsal forearm pressure. The arm is placed in a sugar-tong splint following reduction and overwrapped into a cast after the initial period of swelling subsides. Healing typically takes 4–6 weeks, and a protective splint is recommended for an additional 6–12 weeks due to increased refracture rates in distal shaft fractures (Fig. 3).

In the event that an anatomic closed reduction cannot be obtained or maintained, open reduction is required. Reduction of the DRUJ can be blocked by the extensor tendons, buttonholing of the ulnar head through the wrist capsule and extensor retinaculum, and interposed periosteum (Karlsson and Appelqvist 1987; Hanel and Scheid 1988; Castellanos et al. 1999; Landfried et al. 1991). Figure 4 illustrates the pediatric Galeazzi fracture variant involving a radius fracture coupled with a dorsal DRUJ dislocation, with a block to reduction by interposed extensor retinaculum (Landfried et al. 1991). Additionally, malreduction of the radius fracture can lead to an irreducible DRUJ.

Close radiographic follow-up is essential in these cases as loss of reduction can occur in up to 15 % of cases. The chance of a Galeazzi fracture requiring surgical treatment in a child increases as the patient nears skeletal maturity. Additionally, late presentation of an unrecognized Galeazzi fracture can prove challenging to treat nonoperatively, due to difficulty in obtaining an anatomic reduction of the radius and DRUJ, and operative stabilization may be necessary for these patients.

Outcome data for nonoperative treatment of Galeazzi fractures are limited, as there are few large series of these injuries. However, the overall outcomes for closed reduction and casting for these injuries are generally excellent or good with minimal sequelae (Eberl et al. 2008; Imatani et al. 1996). Even patients with Galeazzi fractures that are misdiagnosed initially and treated as simple radial shaft or distal radius fractures tend to regain full range of motion and suffer no long-term disability (Eberl et al. 2008). A minority of patients treated without surgery may lose some terminal motion (usually around 10°) at the wrist, most often terminal supination or wrist extension (Imatani et al. 1996; Letts and Rowhani 1993). Additionally, one series reported a 10 % rate of subjective occasional mild weakness and pain in nonoperatively treated patients (Eberl et al. 2008).

Surgical treatment is indicated for a subset of pediatric Galeazzi fractures who fail initial closed reduction attempts. Open fracture/dislocations, injuries treated closed that experience loss of reduction or are unable to be anatomically reduced primarily, or those fractures in skeletally mature individuals are indications for operative intervention.

The patient is placed under general anesthesia and placed on a regular operating table with a hand table attached (Table 4). Care is taken to position the patient as close to the hand table as possible to maximize the amount of the patient’s upper extremity located on the hand table. A non-sterile tourniquet is used. Prior to skin incision, the surgeon should attempt to reduce the fracture in the manner mentioned in the previous section. If anatomic reduction cannot be obtained, open reduction is necessary. The arm is exsanguinated with an Esmarch bandage, and the pneumatic tourniquet is then inflated. The recommended tourniquet pressure in children is 50–100 mmHg above systolic pressure (Table 5).