Pediatric emergency medicine trisk 3476 3476
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FIGURE 111.25 Complete fractures of the midshafts of the radius and ulna in a 9-year-old boy.
Efforts at closed reduction failed; internal fixation was necessary.
Clinical Considerations
Clinical recognition . Radial and ulnar shaft fractures have a number of fracture
patterns including greenstick, torus (buckle), plastic deformation, and complete.
The management of these fractures depends on the age, type of fracture, and
degree of displacement. If there is wrist or elbow pain and swelling associated
with deformity suggestive of forearm fracture, the clinician must consider the
possibility of Galeazzi or Monteggia fracture-dislocation pattern, respectively.
Triage considerations . These patients often present with an obvious deformity.
The injured extremity should be splinted and analgesia provided while awaiting
further evaluation. A focused neurovascular assessment should be performed.
Clinical assessment . In many instances, emergency clinicians can provide the
satisfactory initial, if not definitive, management for many forearm injuries.
However, careful history and assessment for associated fracture or dislocation is
important in understanding the full complexity of the injury and determining the
type of imaging and consultation necessary. The incidence of neurovascular
injury is low in forearm fractures; nevertheless, the initial evaluation should
include a thorough examination of circulation, sensory, and motor nerve function
distal to the injury.
Monteggia fractures (ulnar shaft fracture with radial head dislocation) may be
diagnosed on physical examination by palpation of the dislocated radial head (
Fig. 111.26 ). These children will frequently have considerable pain and swelling
at the elbow with limited flexion and forearm supination. A palsy of the posterior
interosseous nerve, a motor branch of the radial nerve resulting in weakness or
