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