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Forearm Shaft Fractures (including Monteggia and Galeazzi)

85 citationsUpdated Sep 2026
Illustration: elbow

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Forearm shaft fractures encompass isolated radial or ulnar diaphyseal injuries as well as complex fracture-dislocations such as Monteggia and Galeazzi patterns. Isolated radial diaphyseal fractures are more common than true Galeazzi fractures [2], while Bado type IV Monteggia-equivalent injuries are rare in adults [36]. Optimal outcomes depend on early recognition and the restoration and maintenance of anatomic alignment [3]. For adult diaphyseal fractures, open reduction and plate fixation is the standard against which all other treatments are compared [16]. This approach has become the surgical treatment of choice following a historical transition from nonsurgical methods with high complication rates to plate osteosynthesis after World War II [27].

Surgical fixation yields good results for adult both-bone forearm fractures, with only modest losses of forearm strength and rotation [19]. Internal fixation by plating leads to excellent results in a majority of patients [34], and locking compression plates perform similarly to dynamic compression plates [24]. Alternative operative options include closed nailing [6], new intramedullary nails [7], and the Point Contact Fixator, which offers a simple technique with shorter surgery duration and low complication rates [64]. In a prospective multicentric study of 387 fractures treated with the Point Contact Fixator, 355 fractured bones healed uneventfully within four months [64]. Galeazzi injuries are unstable fracture dislocations requiring surgical management to achieve optimal outcomes [25].

Non-operative management is acceptable for isolated ulnar shaft fractures, with both surgical and nonsurgical approaches reporting high union rates and good functional outcomes [12]. The majority of these fractures can be treated adequately by closed means using short casts [15], and essentially no immobilization allows rapid healing with a lower rate of loss of forearm motion [9]. In osteoporotic patients, a long arm cast is perhaps the safest treatment [5]. However, clinical studies continue to yield contradicting results, and retrospective data have not resolved the debate on optimal treatment for isolated ulnar shaft fractures [13]. Patients with open fractures or both-bone fractures lose significantly more forearm rotation irrespective of treatment [10]. Postoperative care should consider the long-term impact of bone atrophy after plate fixation [26], and routine films within 4 weeks of radial shaft fracture surgery are unlikely to change management and may not be warranted [22].

Anatomy & Pathophysiology

Forearm Biomechanics and Function

The forearm positions the hand in space through elbow and wrist flexion/extension and pronation/supination via the proximal and distal radioulnar joints [14]. Inadequate treatment of ulnar and radial shaft fractures can result in significant functional impairment [14]. Normal forearm pronosupination is 80 to 85 degrees in each direction [73, 74], with a functional range of motion for forearm rotation of 50 degrees [73, 74]. In full extension, 60% of axial load is transmitted through the radiocapitellar joint [73, 74]. Individualized kinematic modeling of forearm malunions reliably detects clinically relevant limitations of forearm rotation without requiring dynamic imaging [49].

Elbow Joint Anatomy and Stability

The elbow is a trocho-ginglymoid joint with trochoid motion through the radiocapitellar and proximal radioulnar joints and ginglymoid motion through the ulnohumeral joint [78]. The ulnohumeral articulation, medial ulnar collateral ligament (MUCL), and lateral ulnar collateral ligament (LUCL) complex are the primary stabilizers of the elbow [46]. Secondary stabilizers include the radiocapitellar articulation, common flexor tendon, common extensor tendon, and joint capsule [46]. The radial head is a concave elliptical structure covered with articular cartilage along the radiocapitellar joint and approximately 270° of the articular margin [67]. The radius is held in close approximation to the ulna at the proximal radioulnar joint by the annular ligament [67]. The contribution of concavity-compression stability across the radiocapitellar joint to overall elbow stability is clearly demonstrated [56]. The normal elbow has a range of motion from 0° to 140° from extension to flexion and 75° and 85° in pronation and supination respectively [46]. A functional arc for the elbow is 100° for flexion and extension and forearm rotation [46].

Fracture Definitions and Classification

Radial shaft fractures are defined as occurring between the radial neck proximally and the junction of the metaphysis and diaphysis distally, approximately 3 cm proximal to the distal articular surface [14]. Ulnar shaft fractures are defined as occurring between the distal aspect of the coronoid proximally and the ulnar neck distally [14]. The AO/OTA classification identifies forearm shaft fractures with the number 22, where Type A are simple, Type B are wedge, and Type C are complex fractures [48]. In this system, Monteggia fractures are classified as types A1.3 and B1.3 depending on whether the ulnar fracture is simple or wedged [48]. Galeazzi fracture dislocations are classified as types A2.3 and B2.3 depending on whether the radial fracture is simple or wedged [48]. Isolated ulna fractures are classified as stable if they have less than 50% displacement and less than 10 degrees of angulation [48].

Pathophysiology of Monteggia Fracture-Dislocations

Monteggia fracture dislocations involve a fracture of the ulnar shaft with dislocation of the radial head [53]. The mechanism of injury for Type I Monteggia lesions is theorized to involve a direct blow to the posterior forearm, hyperpronation force on an outstretched arm, or elbow hyperextension [98]. Biomechanical changes in Monteggia fractures involve longitudinal displacement of the radial head causing it to slip out of the annular ligament while the ligament remains intact [110]. Increasing magnitudes of soft tissue disruption result in greater anterior radial head instability in anterior Monteggia injuries [107]. The direction of radial head dislocation (anterolateral or posterolateral) may depend on the rotational position of the forearm at the time of the primary adduction injury [122]. Anatomic reduction of the ulna is critical to achieving a favorable outcome as it indirectly reduces the radiocapitellar joint [123]. Correction of ulnar deformity with elongation and angulation opposite to the radial head dislocation is the most important factor for reducing and preserving the radial head in chronic cases [124]. Problems with the elbow related to fractures of the coronoid process and the radial head remain the most challenging elements in the treatment of Monteggia injuries [32]. The ulnar fracture pattern in anterior Monteggia injuries may be simple diaphyseal or complex metaphyseal, with the latter having a less favorable prognosis due to associated elbow fracture dislocation [44]. Most major traumatic plastic bowing deformities of the ulna involved rotation rather than bending [112]. Severe osseous, soft tissue, and neural trauma affect the functional results of the elbow region in unusual patterns of Monteggia fracture-dislocation [94].

Pathophysiology of Galeazzi Fracture-Dislocations

Migration of the radius under loads in Galeazzi fracture dislocations implies disruption of both the central band and triangular fibrocartilage complex [114]. Inaccurate contouring of a compression plate can reverse the normal sagittal bow of the radius, generating deforming forces that lead to anterior dislocation of the distal end of the ulna [126]. The mechanism causing delayed radial head dislocation associated with radial shaft malunion involves eccentric torque on the radial head during forearm pronation [115].

Associated Injuries and Variants

Radial head dislocation can occur with radial shaft fractures, an unusual injury managed by principles similar to Monteggia fractures [1]. Adult Monteggia lesions can present with ipsilateral wrist fractures, a combination not previously mentioned in adult literature but described in children [55]. Ulnohumeral dislocation can occur despite an intact radiocapitellar joint, representing a rare Monteggia variant [56]. The exact mechanism of injury for Type IV Monteggia fractures is unknown but is assumed to be similar to Type I injuries accompanied by a fracture of the radius [58]. Posterior Monteggia fractures remain a complex management problem requiring a balance between ensuring fracture union and preserving elbow function and range of movement [61]. The clinical outcome of posterior Monteggia fractures remains unpredictable, particularly when there is an associated radial head fracture [23].

Classification

General Principles and Definitions

Forearm shaft fractures are defined as injuries occurring between the radial neck proximally and the junction of the metaphysis and diaphysis distally, approximately 3 cm proximal to the distal articular surface for the radius, and between the distal aspect of the coronoid proximally and the ulnar neck distally for the ulna [14]. Fractures are described according to location, pattern, displacement, and associated soft tissue disruption [48]. Therapeutic assessment involves determining which bone(s) are fractured, the location (proximal, middle, distal third), the fracture pattern (simple transverse, simple oblique, comminuted), instability at the distal or proximal radioulnar joint, whether the fracture is open or closed, presence of previous implants or deformity, and bone stock status [48]. No single classification system accounts for all variables regarding location, pattern, displacement, and soft tissue disruption [48]. In most instances, forearm shaft fractures are classified according to location (proximal, middle, and distal third) or fracture comminution [48]. Open forearm fractures are classified according to Gustilo's classification and the OTA open fracture classification [48]. Monteggia and Galeazzi fractures have their own specific subclassifications distinct from general shaft fracture classifications [48].

AO/OTA Classification

The AO/OTA classification is the most widely used fracture classification for fractures of the forearm [48]. Forearm diaphyseal fractures are identified by the number 22 in the AO/OTA system, where 2 represents the forearm and 2 represents the shaft [48]. Type A fractures are simple, Type B are wedge fractures, and Type C are complex (highly comminuted or segmental) fractures [48]. Type A and B fractures involve either the ulna (types A1, B1), the radius (types A2, B2), or both bones (types A3, B3) [48]. Type C fractures involve both bones, with a simple fracture of the radius and segmental comminution of the ulna in type C1, a simple fracture of the ulna and segmental comminution of the radius in type C2, and segmental comminution of both bones in type C3 [48]. The utility of the AO/OTA system in the management of forearm fractures is restricted mainly to research purposes due to the complexity of its nomenclature and low reliability [48].

Monteggia Fracture-Dislocations: Monteggia fractures are classified as types A1.3 and B1.3 depending on whether the ulnar fracture is simple (A1.3) or wedged (B1.3) [48]. Simple fracture of the ulna with dislocation of the radial head (Monteggia) is classified as 22-A1.3 [48]. Wedge fracture of the ulna with dislocation of the radial head (Monteggia) is classified as 22-B1.3 [48]. Monteggia fracture dislocations in which both the radius and ulna are fractured are classified as type A3.2 or B3.2 [48].

Galeazzi Fracture-Dislocations: Galeazzi fracture dislocations are classified as types A2.3 and B2.3 depending on whether the radial fracture is simple (A2.3) or wedged (B2.3) [48]. Simple fracture of the radius with dislocation of the distal radioulnar joint (Galeazzi) is classified as 22-A2.3 [48]. Wedge fracture of the radius with dislocation of the distal radioulnar joint (Galeazzi) is classified as 22-B2.3 [48]. Galeazzi fracture dislocations in which both the radius and ulna are fractured are classified as type A3.3 or B3.3 [48].

Monteggia Fracture-Dislocations

Bado established a system of classification for Monteggia lesions in 1962 based on the mechanism of injury, treatment, and results [21]. The Bado classification distinguishes among four types of Monteggia lesions [21].

Bado Type I: Defined as a fracture of the ulnar diaphysis at any level with anterior angulation at the fracture site and an associated anterior dislocation of the radial head [21].

Bado Type II: Defined as a fracture of the ulnar diaphysis with posterior angulation at the fracture site and a posterolateral dislocation of the radial head [21].

Bado Type III: Defined as a fracture of the ulnar metaphysis with a lateral or anterolateral dislocation of the radial head [21].

Bado Type IV: Defined as a fracture of the proximal third of the radius and ulna at the same level with an anterior dislocation of the radial head [21].

Bado included "Monteggia equivalent injuries" based on similarity of proposed injury mechanism, which added to confusion because most do not involve dislocation of the proximal radioulnar joint [21]. Monteggia equivalent injuries included in the Bado system include anterior dislocation of the radial head, fracture of the ulnar diaphysis with fracture of the neck of the radius, fracture of the neck of the radius, and fracture of the ulnar diaphysis with fracture of the proximal third of the radius with the radius fracture being proximal to the ulnar fracture [21]. Monteggia equivalent injuries also include fracture of the ulnar diaphysis with anterior dislocation of the radial head and fracture of the olecranon, and posterior dislocation of the elbow [21].

Monteggia described a fracture of the proximal third of the ulna with anterior dislocation of the radial head from both the proximal radioulnar and radiocapitellar joints [100]. Application of the eponym Monteggia to all injuries with radiocapitellar subluxation or dislocation has led to confusion [100]. Monteggia injuries can be defined as a type of fracture-dislocation of the diaphyseal forearm with dislocation of the proximal radioulnar joint, or as a fracture of the ulna with subluxation or dislocation of the radiocapitellar joint [100]. The definition of Monteggia injury as a diaphyseal forearm fracture-dislocation excludes fractures at the metaphyseal or elbow joint level that have limited proximal radioulnar joint malalignment [100]. The definition of Monteggia injury as ulnar fracture with radiocapitellar subluxation or dislocation includes injuries that are types of elbow fracture-dislocations and do not involve the forearm [100]. The Jupiter classification captures the injury pattern of radial head/neck fracture and comminution of the proximal ulna with coronoid involvement as a subgroup of Bado posterior Monteggia lesions [97].

Galeazzi Fracture-Dislocations

Galeazzi fracture-dislocation is a complex injury presenting with a radial fracture and disruption of the distal radioulnar joint (DRUJ) [95]. Galeazzi fracture-dislocations are classified in true GFD, where the DRUJ is disrupted, and equivalent GFD, where the DRUJ is not disrupted [95]. Letts and Rowhani classified Galeazzi fracture-dislocations using the direction of the ulna: volar or dorsal [95]. Acute Galeazzi dislocations are classified as simple when a reduction can be easily achieved, and complex characterized by irreducibility or unstable reduction [95]. Galeazzi fracture-dislocations are further subdivided in relation to the radial fracture (incomplete and complete) and ulnar injury (true dislocation versus physeal fracture) [95].

Isolated Ulnar Shaft Fractures

Isolated ulna fractures are classified as stable or unstable [48]. Stable isolated ulna fractures are defined as those with less than 50% of displacement and less than 10 degrees of angulation [48].

Clinical Presentation

General Forearm Fractures

Inadequate treatment of ulnar and radial shaft fractures results in significant dysfunction [14]. Clinicians must maintain a high index of suspicion for associated complications, particularly given the noteworthy frequency of neurological complications concomitant to forearm fractures [41]. Elbow dislocation with ipsilateral radial and ulnar shaft fractures is a rare injury pattern that requires considerable force to produce [50]. When this specific combination occurs, the clinician must have a high suspicion for associated complications [50]. In pediatric patients with both-bone forearm fractures, every physician should recognize the signs and symptoms of flexor entrapment [105].

Isolated Radial Shaft Fractures

Simple, isolated radial shaft fractures are generally very rare injuries [28]. However, a 40-year study of skiers and snowboarders identified simple, isolated radial shaft fractures as the most common fracture type in that population [28]. Some of these injuries in skiers and snowboarders may have been underdiagnosed Galeazzi subluxations [28]. Radial head dislocation with a radial shaft fracture is an unusual injury [1].

Isolated Ulnar Shaft Fractures

The majority of isolated ulnar shaft fractures can be treated adequately by closed means, with the use of short casts recommended for most cases [15]. Clinical studies continue to yield contradicting results regarding the optimal treatment of these fractures, and retrospective studies are not able to solve the debate [13]. The healing characteristics of isolated ulnar shaft fractures do not appear to differ substantially between surgical and nonsurgical treatment [35]. However, nearly 20% of patients treated nonsurgically for isolated ulnar shaft fractures may require eventual open reduction and internal fixation [35].

Monteggia Fracture-Dislocations

Bado established a classification system based on the mechanism of injury, treatment, and results, distinguishing four types of Monteggia lesions [21]. Bado also included a number of so-called Monteggia equivalent injuries based on the similarity of their proposed injury mechanism, though most do not involve dislocation of the proximal radioulnar joint [21].

Type I: Fracture of the ulnar diaphysis at any level with anterior angulation at the fracture site and an associated anterior dislocation of the radial head [21]. Type II: Fracture of the ulnar diaphysis with posterior angulation at the fracture site and a posterolateral dislocation of the radial head [21]. Type III: Fracture of the ulnar metaphysis with a lateral or anterolateral dislocation of the radial head [21]. Type IV: Fracture of the proximal third of the radius and ulna at the same level with an anterior dislocation of the radial head [21].

The exact mechanism of injury for Type IV Monteggia fractures is unknown, but it is assumed to be similar to the Type I injury accompanied by a fracture of the radius [58]. Monteggia fractures can be easily overlooked if radiographs of the elbow are not taken [38]. Pre-existing congenital radial head dislocations can lead to inappropriate surgical intervention in the context of Monteggia fractures [38]. In young children with Monteggia fracture-dislocations, radial neck fractures may be missed on initial roentgenograms, and clinicians must be cautious against overlooking them [51].

Problems with the elbow related to fractures of the coronoid process and the radial head remain the most challenging elements in the treatment of Monteggia fractures [32]. The clinical outcome of posterior Monteggia lesions remains unpredictable, particularly when there is an associated radial head fracture [23]. In adult anterior Monteggia fracture dislocations, the ulnar fracture pattern may be either a simple diaphyseal injury or a more complex metaphyseal injury [44]. Complex metaphyseal ulnar injuries involve an element of fracture dislocation at the elbow joint itself and have a less favourable prognosis [44]. The localization of the ulna fracture can give a hint for postoperative outcome in Monteggia fractures and Monteggia-like lesions, although increasing instability in Monteggia fractures located further distally was not confirmed [104]. It is unusual to sustain two Monteggia fractures of the same forearm, and no case of this occurrence has been found in the literature [4].

Galeazzi Fracture-Dislocations

The Galeazzi fracture is defined as a fracture of the middle to distal third of the radius associated with dislocation and/or instability of the distal radioulnar joint (DRUJ) [39]. It has been described as a fracture of necessity, referring to the need for surgical treatment for optimal results, and is also known as the Piedmont fracture or the reverse Monteggia fracture [39]. Galeazzi fracture-dislocations often go unrecognized, and an unstable Galeazzi lesion can be mistaken for a simple radius fracture [39]. Dislocation of the distal radioulnar joint should be suspected at the time of injury with a displaced fracture of the distal shaft of the radius [39]. Persistent instability of the distal radioulnar joint leads to an unfavorable result, characterized by pain at the joint and restriction of forearm rotation [39].

The ability to accurately diagnose true Galeazzi injuries preoperatively based on radiographs alone is limited [82]. Radial shortening was greater, on average, in patients who had clinically significant DRUJ injury as compared to those with isolated radial shaft fractures alone [82]. However, the difference in radial shortening between patients with clinically significant DRUJ injury and those with isolated radial shaft fractures was not helpful in diagnosing the injury [82]. Increasing the criterion for radial shortening to 10 mm was not accurate for diagnosis in individual cases [82]. Using a 10 mm radial shortening criterion resulted in more patients with no DRUJ instability than it did Galeazzi injuries [82]. Less than half of patients meeting the 10 mm radial shortening criterion had required intervention to the DRUJ [82]. Three patients with DRUJ instability would have been missed using the 10 mm radial shortening criterion, while four patients would have been overdiagnosed [82]. The large standard deviation and wide range of values in both groups supports the argument that shortening is not an individually reliable parameter for diagnosing Galeazzi injuries [82].

Investigations

Plain radiography: Plain radiographs remain the hallmark and best screening test for elbow evaluation [46]. In the context of radial shaft fractures, an obliquity greater than 30 degrees is predictive of distal radioulnar joint instability (P = 0.001) and represents the most sensitive radiological parameter (76%) for predicting this instability [101]. More distally located radial shaft fractures are significantly associated with higher rates of distal radioulnar joint fixation [120]. Pre-existing congenital radial head dislocations can lead to inappropriate surgical intervention if not recognized on imaging [38].

CT: CT is helpful when assessing for malunion architecture and the location and pattern of osteophytes and/or loose bodies [81]. Three-dimensional CT is used to check for heterotopic ossification [81]. Malunited diaphyseal fractures of both forearm bones showed complex deformities, which suggests that 3-dimensional modeling may be a more effective method than standard computed tomography or radiographs [54].

MRI: MRI can be used to evaluate ligaments and tendons, but it is rarely indicated for elbow stiffness [81].

Physical Examination and Neurovascular Assessment: The physical exam for elbow pathology is directed by history and location of the patient's pain in the anterior, posterior, medial or lateral aspect of the elbow [46]. Active and passive flexion, extension, supination, and pronation should be evaluated using a goniometer for accurate measurement [81]. If the elbow has less than 90° to 100° of flexion, the posterior bundle of the medial collateral ligament (MCL) is contracted and must be released to restore flexion [81]. The ulnar nerve is of utmost importance in elbow examination because of its anatomic proximity to the elbow [81]. Electromyography/nerve conduction velocity studies should be performed if any question about neurologic dysfunction exists [81]. An assessment for ulnar nerve subluxation should be performed, as subluxation is a relative contraindication for an arthroscopic procedure secondary to possible iatrogenic nerve injury [81].

Other Considerations: Bado set forth a system of classification for Monteggia lesions based on the mechanism of injury, treatment, and results that established distinction among four types [21]. The ulnar fracture pattern in anterior Monteggia fractures may be either a simple diaphyseal injury or a more complex metaphyseal injury which has a less favourable prognosis [44]. Complex metaphyseal ulnar injuries in anterior Monteggia fractures involve an element of fracture dislocation at the elbow joint itself [44]. The contribution of concavity-compression stability across the radiocapitellar joint to overall elbow stability is clearly demonstrated in a rare Monteggia variant with ulnohumeral dislocation despite an intact radiocapitellar joint [56]. Elbow stability is determined by primary and secondary stabilizers, with the ulnohumeral articulation, the MUCL, and the LUCL complex being the three primary stabilizers [46]. Secondary stabilizers of the elbow include the radiocapitellar articulation, the common flexor tendon, the common extensor tendon, and the joint capsule [46]. A functional arc in each plane for the elbow is 100° for flexion and extension and forearm rotation [46]. Atypical forearm fractures are probably more common than reported in the literature to date, and all forearm lesions were accompanied by preceding atypical femur fractures [17]. Forearm fractures were more common in snowboarders than in skiers [28]. The most common forearm fractures in a 40-year study of skiers and snowboarders were simple, isolated radial shaft fractures [28]. Some isolated radial shaft fractures in snowboarders may have been underdiagnosed Galeazzi subluxations [28]. Two cases of the Galeazzi lesion described mechanical blocks to closed reduction of the dislocated inferior radio-ulnar joint [125].

Treatment

Non-Operative

Nonoperative management of forearm fractures in adults typically leads to unacceptable outcomes [90]. Even in minimally displaced fractures, deforming forces typically lead to shortening and angulation in adult forearm fractures [90]. Consequently, nonoperative management is typically reserved for the pediatric population and the uncommon nondisplaced fracture pattern [90]. Isolated ulnar shaft fractures can be treated simply, cheaply, and effectively by providing minimal support and early mobilization [102]. An above-elbow cast was unnecessarily restrictive for the treatment of isolated ulnar fractures in adults [63]. However, nonoperative treatment of displaced ulnar nightstick fractures produces a high risk of complications, and the fracture characteristics determine patient outcome [117].

Operative

Indications: In the adult, combined radius and ulna both-bones forearm fractures are usually treated with operative fixation to achieve goals of maintaining length and radioulnar joint relationships [90]. Treatment options for forearm fractures include closed management and various surgical treatment methods, with the goal to maintain length and radioulnar joint relationships to regain full pronosupination [90]. The forearm plays an important role in positioning of the hand in space by flexion and extension of the elbow and wrist as well as pronation and supination through the proximal and distal radioulnar joints [14].

Surgical Approach / Technique: Compression plate techniques as advocated by the AO/ASIF group have become the surgical treatment of choice in simple adult forearm fracture patterns [90]. Bridge plating methods have also been used in more complex fracture patterns for forearm fractures [90]. The evolution of operative treatment for forearm diaphyseal fractures highlights the transition from nonsurgical methods with high complication rates to plate osteosynthesis as the surgical treatment of choice after World War II [27]. The technique of using an internal fixator (Point Contact Fixator) is a simple one for the fixation of forearm fractures, resulting in shorter duration of surgery with a low rate of complications compared with conventional techniques [64]. This article concentrates on the management principles of difficult forearm fractures from penetrating trauma and provides specific examples to illustrate fracture fixation techniques [37].

Implant Selection: The results of locking compression plates and dynamic compression plates for treatment of fractures of the forearm in adults are similar [24]. Clinical and functional outcomes of LCP plating of diaphyseal forearm fractures are comparable to the use of conventional implants [59]. Results of surgical fixation have been good, with only modest losses of forearm strength and rotation [19].

Other Considerations: Timely surgical management with plating and radial head prosthesis of a rare Bado type IV Monteggia-equivalent fracture in adults results in a good prognosis [36]. The successful operative treatment of Monteggia fracture dislocation with associated radial head fracture yields excellent results [31]. The importance of holding a high index of suspicion of a possible radial head fracture in Monteggia fracture dislocations is reiterated by case reports of successful operative treatment [31]. Galeazzi fracture-dislocations often go unrecognized and can be mistaken for a simple radius fracture [39]. The goal of the treatment for Galeazzi fractures is an anatomic reduction and a rigid internal fixation of the radial fracture [39]. Two years after surgical treatment of a Galeazzi fracture, there is a mean absolute loss of strength of supination of 16.1 kg (12.5%) and pronation of 19.1 kg (27.2%) [45].

Revision: Treatment of diaphyseal forearm non-unions using classic techniques of compression plating osteosynthesis and autologous bone grafting if needed will lead to a high union rate (100% in the reported series) [106].

Complications and Malunion: Forearm malunions may occur following either non-operative or operative treatment of acute fractures as well as following deformity correction surgery [89]. This small series of complex fractures of the forearm represents a good example of the range of injuries which can be sustained [18].

Complications

Neurological and Soft Tissue: Monteggia fractures risk being overlooked if elbow radiographs are not obtained, and pre-existing congenital radial head dislocations can lead to inappropriate surgical intervention [38].

Bony Healing and Union: In the osteoporotic patient, an isolated fracture of the ulnar shaft is perhaps most safely treated in a long arm cast to avoid complications such as stress fracture of the radius following non-union [5]. A stress fracture of the radius can occur following non-union of an isolated fracture of the ulna [5].

Implant-Related and Long-Term: The long-term fixation of forearm diaphyseal fractures using a locking plate leads to progressive bone atrophy [20]. Monteggia-like lesions with unreconstructible radial head fracture and treatment with radial head replacement are prone to complications and revisions [119].

Functional Outcomes and Instability: The clinical outcome remains unpredictable, particularly when there is an associated radial head fracture in posterior Monteggia lesions [23].

Recovery

Other Considerations: The healing characteristics of isolated ulnar shaft fractures do not appear to differ substantially between surgical and nonsurgical treatment, although nearly 20% of patients treated nonsurgically may require eventual ORIF [35]. Posterior Monteggia fractures remain a complex management problem with a fine balance between the need to ensure fracture union and the preservation of elbow function and range of movement [61]. In a study of repositioning the annular ligament in the management of missed Monteggia fracture, all patients had no pain and full elbow function at the latest follow-up [42].

Key Evidence

  • [L5] An excellent clinical result was obtained in this unusual injury by adhering to the basic principles learnt from the management of Monteggia and other proximal forearm fractures. [1] (10.1016/0020-1383(95)00077-m)
  • [L4] Isolated fractures of the radial diaphysis are more common than true Galeazzi fractures. [2] (10.1016/j.jhsa.2005.09.003)
  • [L5] Optimal outcomes in the treatment of forearm fracture–dislocations depend on early recognition and management, with restoration and maintenance of anatomic alignment being the key principles. [3] (10.1016/j.hcl.2015.01.010)
  • [L5] This case is presented because it is unusual to sustain two Monteggia fractures of the same forearm and the authors could find no such case in a review of the literature. [4] (10.1016/0020-1383(80)90007-8)
  • [L4] We feel that in the osteoporotic patient, an isolated fracture of the ulnar shaft is perhaps most safely treated in a long arm cast. [5] (10.1007/bf00431043)
  • [L4] Closed nailing can be treatment of choice in any forearm shaft fractures. [6] (10.1016/s0020-1383(11)70027-4)
  • [L4] Treatment of adult forearm diaphyseal fracture with the new intramedullary nails have promising results. [7] (10.1016/s0020-1383(13)70138-4)
  • [L4] Although most ulnar shaft fractures heal successfully with nonsurgical management, a substantial percentage of these fractures do not. [8] (10.1016/j.jhsa.2023.09.009)
  • [L4] In isolated ulnar shaft fractures, essentially no immobilization allows rapid healing with a lower rate of loss of forearm motion compared to literature reports. [9] (10.2106/00004623-198365030-00007)
  • [L4] Both surgical and nonsurgical management of isolated ulnar shaft fractures are reported as acceptable forms of treatment with high union rates and good functional outcomes. [12] (10.1016/j.hcl.2007.01.004)
  • [Letter] Clinical studies continue to yield contradicting results, and retrospective studies are not able to solve the debate on the optimal treatment of isolated ulnar shaft fractures. [13] (10.1016/j.injury.2015.07.010)
  • [L4] The majority of isolated fractures of the ulnar shaft can be treated adequately by closed means, and the use of short casts is recommended. [15] (10.1016/0020-1383(81)90004-8)
  • [L3] Atypical forearm fractures are probably more common than reported in the literature to date, and all forearm lesions were accompanied by preceding atypical femur fractures. [17] (10.1016/j.injury.2020.10.087)
  • [L4] This small series of complex fractures of the forearm represents a good example of the range of injuries which can be sustained. [18] (10.1016/0020-1383(83)90090-6)
  • [L4] Results of surgical fixation have been good, with only modest losses of forearm strength and rotation. [19] (10.5435/jaaos-22-07-437)
  • [L4] The long-term fixation of forearm diaphyseal fractures using a locking plate leads to progressive bone atrophy. [20] (10.1016/j.jhsg.2021.05.013)
  • [L5] [21] (10.1016/j.hcl.2007.01.008)
  • [L3] Films obtained within 4 weeks of surgery for radial shaft fractures are unlikely to change postoperative management and may not be warranted during routine postoperative follow-up. [22] (10.1177/1558944715627629)
  • [L4] The clinical outcome remains unpredictable, particularly when there is an associated radial head fracture. [23] (10.1016/0020-1383(95)00187-5)
  • [L4] The results of these two different fixation methods for treatment of fractures of the forearm in adults are similar. [24] (10.1016/s0020-1383(13)70155-4)
  • [L5] Galeazzi injuries are unstable fracture dislocations requiring surgical management to achieve optimal outcomes. [25] (10.1016/j.hcl.2020.07.006)
  • [L4] Treatment plans for forearm fracture should take into consideration the impact of bone atrophy long after plate fixation. [26] (10.1016/j.jhsa.2017.03.041)
  • [L5] This article reviews the evolution of operative and nonsurgical treatment techniques for forearm diaphyseal fractures from preanesthesia times until today, highlighting the transition from nonsurgical methods with high complication rates to plate osteosynthesis as the surgical treatment of choice after World War II. [27] (10.1016/j.jhsa.2013.06.020)
  • [L3] [28] (10.1097/corr.0000000000001982)
  • [L4] The results of the current study suggest that following open reduction and internal fixation of the radius in patients with Galeazzi fracture-dislocations and with stable DRUJs, immobilization in supination for 4 weeks does not have an advantage over immobilization in neutral for a shorter period. [29] (10.1016/j.jhsa.2011.12.021)
  • [L4] This case report illustrates the successful operative treatment of Monteggia fracture dislocation with associated radial head fracture with excellent results and reiterates the importance of holding a high index of suspicion of a possible radial head fracture in Monteggia fracture dislocations. [31] (10.1016/j.injury.2005.05.017)
  • [L4] Problems with the elbow related to fractures of the coronoid process and the radial head remain the most challenging elements in the treatment of these injuries. [32] (10.2106/00004623-199812000-00003)
  • [L4] Internal fixation by plating is a satisfactory method of treatment for adult forearm fractures, leading to excellent results in a majority of patients. [34] (10.1016/0020-1383(83)90162-6)
  • [L4] The healing characteristics of isolated ulnar shaft fractures do not appear to differ substantially between surgical and nonsurgical treatment, although nearly 20% of patients treated nonsurgically may require eventual ORIF. [35] (10.1016/j.jhsa.2022.02.009)
  • [Case_report] Timely surgical management with plating and radial head prosthesis of this rare Bado type IV Monteggia-equivalent fracture in adults results in a good prognosis. [36] (10.5397/cise.2021.00752)
  • [L5] This article concentrates on the management principles of difficult forearm fractures from penetrating trauma and provides specific examples to illustrate fracture fixation techniques. [37] (10.1016/s0749-0712(21)00459-5)
  • [L4] Monteggia fractures can be easily overlooked if radiographs of the elbow are not taken, and pre-existing congenital radial head dislocations can lead to inappropriate surgical intervention. [38] (10.1016/j.injury.2005.08.028)
  • [Paper] [39] (10.1016/j.hcl.2007.03.004)
  • [L4] The frequency of neurological complications concomitant to forearm fractures is noteworthy. [41] (10.1016/j.otsr.2016.04.014)
  • [L4] All patients had no pain and full elbow function at the latest follow-up. [42] (10.1097/bpo.0000000000000584)
  • [L4] The ulnar fracture pattern may be either a simple diaphyseal injury or a more complex metaphyseal injury which has a less favourable prognosis, in part because such injuries also involve an element of fracture dislocation at the elbow joint itself. [44] (10.1016/s0020-1383(97)88339-8)
  • [L3] Two years after surgical treatment of a Galeazzi fracture, there is a mean absolute loss of strength of supination of 16.1 kg (12.5%) and pronation of 19.1 kg (27.2%). [45] (10.1302/0301-620x.95b11.31524)
  • [L4] Individualized kinematic modeling of forearm malunions reliably detects clinically relevant limitations of forearm rotation without requiring dynamic imaging. [49] (10.1097/corr.0000000000003945)
  • [L5] [50] (10.1016/s0020-1383(02)00143-2)
  • [Case_report] [53] (10.1007/s12593-011-0041-z)
  • [L4] Malunited diaphyseal fractures of both forearm bones showed complex deformities, which suggests that 3-dimensional modeling may be a more effective method than standard computed tomography or radiographs. [54] (10.1016/j.jhsa.2013.03.052)
  • [L5] [55] (10.1016/0020-1383(81)90013-9)
  • [L4] The contribution of concavity-compression stability across the radiocapitellar joint to overall elbow stability is clearly demonstrated. [56] (10.1177/1758573216673527)
  • [L5] [58] (10.1007/s00068-008-8028-6)
  • [L4] Clinical and functional outcomes of LCP plating of diaphyseal forearm fractures are comparable to the use of conventional implants. [59] (10.1007/s00402-010-1119-y)
  • [L5] As they suggest in their paper, posterior Monteggia fractures remain a complex management problem with a fine balance between the need to ensure fracture union and the preservation of elbow function and range of movement. [61] (10.1016/s0020-1383(97)87231-2)
  • [L1] An above elbow cast was unnecessarily restrictive. [63] (10.1016/s0020-1383(00)00051-6)
  • [L2] This study demonstrated that the technique of using an internal fixator is a simple one for the fixation of forearm fractures, resulting in shorter duration of surgery with a low rate of complications compared with the data reported in the literature on conventional techniques for forearm fracture stabilization. 355 fractured bones healed uneventfully within four months. [64] (10.1016/s0020-1383(01)00126-7)
  • [L3] [82] (10.1016/j.injury.2016.04.003)
  • [L4] [89] (10.1007/s11552-014-9635-9)
  • [L4] [90] (10.1016/j.hcl.2010.04.002)
  • [L4] Severe osseous, soft tissue, and neural trauma affect the functional results of the elbow region. [94] (10.1186/1749-799x-1-12)
  • [L4] [95] (10.1055/s-0040-1712515)
  • [L4] [97] (10.1016/j.jhsa.2021.07.023)
  • [Case_report] [98] (10.1007/s00402-010-1253-6)
  • [L5] [100] (10.1016/j.ocl.2012.08.007)
  • [L3] A radial shaft fracture obliquity greater than 30 degrees is predictive of distal radioulnar joint instability (P = 0.001) and was the most sensitive radiological parameter (76%) for predicting this instability. [101] (10.1177/1753193418756591)
  • [L2] Isolated ulnar shaft fractures can be treated simply, cheaply and effectively by providing minimal support and early mobilization. [102] (10.1016/0020-1383(91)90043-e)
  • [L3] The localization of the ulna fracture can give a hint for postoperative outcome in Monteggia fractures and Monteggia-like lesions, but increasing instability in fractures located further distally was not confirmed. [104] (10.1186/s13018-022-03195-1)
  • [L4] Every physician who cares for pediatric both-bone forearm fractures should recognize the signs and symptoms of flexor entrapment. [105] (10.1007/s11552-012-9439-8)
  • [L4] Treatment of diaphyseal forearm non-unions using classic techniques of compression plating osteosynthesis and autologous bone grafting if needed will lead to a high union rate (100% in our series). [106] (10.1007/s00402-010-1071-x)
  • [L5] Increasing magnitudes of soft tissue disruption result in greater anterior radial head instability. [107] (10.1016/j.jse.2019.10.025)
  • [L5] Biomechanical changes explain the pathological changes in the annular ligament during Monteggia fractures; longitudinal displacement of the radial head causes it to slip out of the annular ligament while the ligament remains intact. [110] (10.1186/s13018-015-0170-3)
  • [L4] Most major traumatic plastic bowing deformities of the ulna involved rotation rather than bending. [112] (10.1016/j.jse.2011.12.006)
  • [L5] Migration of the radius under loads implies disruption of both the central band and triangular fibrocartilage complex. [114] (10.1016/j.jhsg.2023.06.003)
  • [Case_report] The mechanism causing delayed radial head dislocation involved eccentric torque on the radial head during forearm pronation resulting from malunion of the radius. [115] (10.1016/j.jse.2006.05.014)
  • [L3] Nonoperative treatment of displaced fractures produces a high risk of complications, and the fracture characteristics determine patient outcome. [117] (10.1016/j.injury.2015.02.012)
  • [L4] Monteggia-like lesions with unreconstructible radial head fracture and treatment with radial head replacement are prone to complications and revisions. [119] (10.1186/s13018-019-1540-z)
  • [L3] More distally located radial shaft fractures are significantly associated with higher rates of DRUJ fixation. [120] (10.1177/15589447211006836)
  • [L4] The direction of radial head dislocation (anterolateral or posterolateral) may depend on the rotational position of the forearm at the time of the primary adduction injury. [122] (10.2106/00004623-197759040-00024)
  • [L4] Anatomic reduction of the ulna is critical to achieving a favorable outcome, as it indirectly reduces the radiocapitellar joint. [123] (10.5435/jaaos-d-19-00625)
  • [L4] Correction of the ulnar deformity with elongation and angulation of the ulna in the opposite direction of the dislocation of the radial head is the most important factor for the reduction and consequent preservation of the radial head. [124] (10.1097/mop.0000000000000710)
  • [L4] Two cases of the Galeazzi lesion are described, in which a mechanical block to closed reduction of the dislocated inferior radio-ulnar joint was encountered. [125] (10.1016/0020-1383(77)90053-5)
  • [Case_report] Inaccurate contouring of a compression plate can reverse the normal sagittal bow of the radius, generating deforming forces that lead to anterior dislocation of the distal end of the ulna. [126] (10.2106/00004623-199304000-00014)

See Also

References

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6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.