Pediatric emergency medicine trisk 3477 3477
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paralysis of the extension of the fingers or thumb, may be present with Monteggia
fractures ( Figs. 111.27 and 111.28 ).
In the Galeazzi fracture-dislocation (fracture of the radius with dislocation of
the distal radioulnar joint), the child will typically resist pronation and supination
and have wrist tenderness ( Fig. 111.29 ). With significant dislocations, the ulnar
styloid may appear prominent, but in minor dislocations the pain and examination
findings can be minimal. Distal neurovascular injury is rare, but chronic pain,
weakness, and limitation of supination and pronation can result from missed
injuries.
Management . Standard radiographic views, including the joints above and below
the fracture, are typically sufficient for diagnosis. Failure to fully evaluate the
elbow and the wrist may result in missed fractures or dislocations. With suspected
bowing fractures comparison views of the contralateral forearm may prove
helpful. Failure to recognize a bowing fracture can result in permanent loss of
supination and pronation because the potential for remodeling is minimal ( Fig.
111.4 ).
Orthopedic consultation and closed reduction are required for a variety of
forearm shaft fractures. In general, immediate orthopedic consultation is
recommended for displaced fractures any shaft fracture angulated more than 10 to
15 degrees. It should be noted that greenstick fractures may be unstable or have
significant rotational deformity. Therefore, although the periosteum and the
remaining intact cortex will limit the degree of angulation, closed reduction may
be indicated irrespective of the extent of angulation. For bowing fractures, there
are no strict guidelines regarding indications for closed reduction; however, any
bowing fracture that presents with obvious forearm deformity or restricts
pronation or supination merits immediate orthopedic referral. With complete
fractures of the forearm, if the ends of the bones are well opposed and angulation
and rotation are minimal, a well-applied sugar-tong splint is adequate initial
treatment with outpatient orthopedic follow-up. Closed reduction, although not
always as simple as it may appear, is the preferred initial approach.
If only one forearm bone is fractured, radiographs of the wrist and elbow
should be carefully reviewed to evaluate for a Galeazzi or Monteggia fracturedislocation. These two injury patterns may be obvious by examination or may be
subtle, and thus overshadowed by the more apparent shaft fracture of the radius or
ulna. The classic Monteggia injury is a fracture of the proximal third of the ulna
with an associated radial head dislocation. A Galeazzi fracture-dislocation
consists most often of a radius fracture at the junction of the middle and distal
