Forearm fractures and Monteggia or Galeazzi patterns

The forearm is not two independent sticks. Its bones and radioulnar joints create a rotating unit. Record mechanism, hand dominance, wounds and pain at both ends. Palpate radial head during gentle rotation only when safe and assess distal radioulnar tenderness and stability. In children, ulnar plastic deformation may be the only clue to a Monteggia lesion; the radial-head relationship must be checked on every view.

Adults need accurate restoration of length, radial bow and rotation, usually with plate fixation for unstable shaft and fracture-dislocation patterns. An apparently isolated stable ulnar fracture can use functional treatment with close review, but widening displacement or associated joint injury changes the plan. Children may remodel angulation, not persistent joint dislocation or major rotation. Rehabilitation starts finger movement early and progresses elbow, wrist and forearm rotation according to stability.

Adult both-bone fractures are usually unstable because muscle forces rotate and shorten each segment. Compression plating or another pattern-specific fixation restores the radial bow and ulnar length while preserving biology. The surgeon confirms proximal and distal radioulnar congruence after fixation and documents rotation. Monteggia treatment begins with anatomical ulnar restoration, which often reduces the radial head; persistent dislocation suggests malreduction or interposed tissue. In Galeazzi injury, radial fixation is followed by distal-joint stability testing and temporary stabilisation when unstable.

Children can often be treated with closed reduction and a well-moulded cast, but age, fracture level, rotation and remodelling potential matter. Plastic deformation deserves correction when it maintains radial-head dislocation. Check radiocapitellar alignment on every follow-up view and do not accept a joint that remains out because the ulnar line looks modest. Cast wedging or re-manipulation may address early loss of alignment, whereas delayed missed Monteggia injury becomes progressively harder to reconstruct. Parents need finger-perfusion and cast-pressure warning signs.

Compartment assessment continues after fixation because pain, swelling and tight dressings can evolve. Release external constriction completely to skin and reassess promptly when concern appears; pulses do not exclude pressure-related muscle ischaemia. Open injuries require the long-bone antibiotic and orthoplastic sequence, with wound excision and cover coordinated with fixation. A penetrating wound may injure median, ulnar or radial structures even if the bones look stable, so operative plans must follow the mapped examination rather than radiographs alone.

Therapy preserves tendon glide, forearm rotation and adjacent-joint movement. Encourage elevation and finger motion immediately, then progress elbow and wrist activity within fixation limits. Measure pronation and supination with the elbow positioned consistently. Persistent restriction may arise from malrotation, radioulnar synostosis, distal-joint incongruity or pain rather than simple weakness. A late patient with healed fracture but dislocated radial head needs specialist reconstruction assessment; repeated forceful manipulation risks nerve and cartilage injury.

Imaging review should be structured. On each AP and lateral, follow both cortices, compare radial bow, inspect proximal and distal radioulnar spacing and ensure the radiocapitellar line intersects the capitellum. A true lateral is essential before declaring radial-head location. In a Galeazzi pattern, ulnar styloid fracture, widened distal joint or altered ulnar variance supports instability but examination after radial reduction remains decisive. CT may clarify complex joint fragments, while MRI is rarely needed during initial shaft management unless a specific soft-tissue question persists.

Discharge documentation states cast or wound care, elevation, permitted finger and joint motion, lifting restriction and an emergency route for worsening pain, numbness, colour or swelling. Adults with plates need counselling about infection, hardware irritation and refracture risk after later removal. Children require early radiographic review because redisplacement can occur before symptoms change. Once union is established, return to manual work and sport progresses with rotation, grip and load tolerance rather than radiographic date alone.