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