Synopsis
Treat the radius and ulna as a linked functional ring, recognise Monteggia and Galeazzi fracture-dislocations, document nerve and vessel status, and restore length, rotation and joint congruence.
- Examine and image the whole forearm including elbow and wrist; a paired-bone ring injury is missed when images stop at the fracture.
- Trace the radiocapitellar line on every elbow view: it should pass through the capitellum, and loss of alignment suggests radial-head dislocation.
- Monteggia is an ulnar fracture or plastic deformity with radial-head dislocation; Galeazzi is a radial-shaft fracture with distal radioulnar-joint disruption.
- Document radial and ulnar pulses and median, anterior interosseous, radial, posterior interosseous and ulnar functions before and after splintage.
- Suspect compartment syndrome from worsening pain and passive-stretch pain even when pulses remain present.
- For open long-bone injury, give intravenous prophylaxis within one hour, cover the wound and avoid bedside washout.
- Most adult both-bone, Monteggia and Galeazzi injuries require anatomical fixation to restore length, radial bow, rotation and joint congruence.
- Children have greater remodelling and may be treated by closed reduction and casting, but radial-head and distal-joint alignment must remain acceptable.
- After fixation or casting, define forearm rotation, elbow and wrist movement and weight-bearing restrictions and monitor compartment and nerve findings.
Key red flags
Escalating pain, tense compartments, passive finger stretch pain or progressive weakness and paraesthesia requires immediate compartment assessment and decompression when diagnosed.
A wound, exposed bone, cool hand, pulse change or expanding swelling triggers urgent open-fracture and orthovascular management.
An ulnar fracture with radial-head malalignment or radial fracture with painful unstable distal radioulnar joint is not an isolated shaft fracture.
A child with plastic deformation or subtle ulnar bow can have radial-head dislocation despite an inconspicuous fracture line.
Painful deformity, shortening and loss of pronation or supination follow substantial forearm trauma.
Ulnar fracture or bowing with radial-head dislocation causes elbow pain and abnormal radiocapitellar alignment.
Radial-shaft fracture with ulnar-head prominence, wrist pain and distal radioulnar instability defines this pattern.
Disproportionate increasing pain, passive finger stretch pain and progressive neurological change requires emergency action.
Finger and thumb extension weakness with preserved cutaneous sensation can accompany proximal radial-head displacement.
Investigation priorities
Show both bones and include elbow and wrist for linked joint injury.
Management branches
A forearm fracture or deformity follows trauma.
- Expose from shoulder to fingers, remove rings and inspect wounds and compartments.
- Record named nerves and pulses and provide analgesia, alignment and a padded splint.
- Obtain full-length images and identify radial-head and distal-radioulnar alignment explicitly.
Remodelling and stable closed treatment are appropriate.
- Achieve a gentle closed reduction and cast without excessive swelling pressure.
- Confirm radiocapitellar and distal-radioulnar relationships immediately and at early follow-up.
- Repeat neurovascular checks and escalate loss of position, rotation or joint congruence.