Overview
Definition:
Galeazzi fracture involves a fracture of the radius with associated disruption of the distal radioulnar joint (DRUJ)
Monteggia fracture involves a fracture of the proximal third of the ulna with associated dislocation of the radial head
Both are less common in children than isolated radial or ulnar shaft fractures, but require specific recognition and management due to the potential for significant functional impairment.
Epidemiology:
Galeazzi fractures are rare in children, accounting for less than 1% of all pediatric fractures, and are more common in adolescents
Monteggia fractures are also uncommon, with a bimodal age distribution: younger children (3-10 years) typically sustain a fracture of the ulna shaft with a posterolateral radial head dislocation, while older children and adolescents may have more complex injuries
Falls on an outstretched hand (FOOSH) are the most common mechanism of injury.
Clinical Significance:
These fractures are significant because they involve a disruption of the radioulnar joints, which are crucial for forearm rotation (pronation and supination)
Inadequate management can lead to chronic pain, stiffness, limited range of motion, and malunion, severely impacting a child's functional ability and quality of life
Prompt and accurate diagnosis and treatment are paramount.
Clinical Presentation
Symptoms:
Pain at the fracture site
Swelling and bruising
Deformity of the forearm or elbow
Inability to pronate or supinate the forearm
Tenderness localized to the radius (Galeazzi) or ulna shaft and radial head (Monteggia)
Palpable deformity or crepitus
Numbness or tingling in the hand may indicate nerve involvement.
Signs:
Obvious deformity of the forearm (e.g., prominent distal ulna in Galeazzi, palpable ulnar swelling and absent radial head at elbow in Monteggia)
Swelling and ecchymosis around the radius or ulna and/or elbow
Tenderness to palpation over the affected bone and joint
Limited range of motion, especially pronation and supination
Radial pulse assessment is crucial
neurovascular compromise may be present.
Diagnostic Criteria:
Diagnosis is primarily based on clinical suspicion and confirmed by radiographic imaging
The Bado classification is often used for Monteggia fractures, categorizing them based on the direction of radial head displacement (Type I: anterior
Type II: posterior
Type III: lateral
Type IV: anterior or posterior with associated radius fracture)
There is no specific classification for Galeazzi fractures in children, but the diagnosis is made by identifying a radius shaft fracture with associated DRUJ widening or instability.
Diagnostic Approach
History Taking:
Mechanism of injury (FOOSH, direct blow)
Age of the child
Specific location of pain and swelling
Any previous injuries to the limb
Any associated neurological symptoms (numbness, tingling) or vascular concerns (cold extremity, absent pulse)
Assessment for child abuse in cases of unexplained fractures is essential.
Physical Examination:
Inspect for deformity, swelling, and ecchymosis
Palpate the entire length of the radius and ulna, and the elbow and wrist joints for tenderness, crepitus, or instability
Assess neurovascular status of the entire limb, including radial pulse, capillary refill, sensation, and motor function of the hand and fingers
Evaluate the integrity of the DRUJ (Galeazzi) and the radial head articulation (Monteggia).
Investigations:
Radiographs are the cornerstone of diagnosis
Standard anteroposterior (AP) and lateral views of the affected forearm and elbow are mandatory
For Galeazzi fractures, dedicated views of the wrist and distal forearm are essential to assess the DRUJ
In Monteggia fractures, elbow views are critical to visualize the radial head dislocation
If significant displacement or associated injuries are suspected, CT scan may be considered
Comparison views with the contralateral limb can be helpful in assessing alignment, especially in younger children
Elbow flexion views may be necessary to assess for occult radial head dislocation.
Differential Diagnosis:
Isolated radius or ulna shaft fractures
Distal radius fractures (Colles, Smith)
Elbow dislocations
Olecranon fractures
Scaphoid fractures
Brown tumor of bone
Tumor or infection in the bone
Non-accidental trauma presentation should always be considered.
Management
Initial Management:
Immediate immobilization with a splint to relieve pain and prevent further displacement
Application of ice packs
Elevation of the limb
Neurovascular assessment is crucial and must be repeated frequently
Analgesia for pain control.
Medical Management:
Pain management with analgesics like paracetamol or ibuprofen
Opioid analgesics may be required for severe pain
Antibiotics are generally not indicated unless there is an open fracture.
Surgical Management:
Indications for surgery include irreducible dislocations, significant displacement of the fracture fragments, open fractures, neurovascular compromise, or when closed reduction fails to achieve and maintain adequate stability
For Galeazzi fractures, ORIF of the radius and often fixation of the DRUJ is required
For Monteggia fractures, closed reduction and casting may be successful in stable fractures, especially in younger children
However, persistent dislocation, instability, or significantly displaced ulna fractures often necessitate ORIF of the ulna and closed or open reduction of the radial head
Reattachment or repair of the annular ligament may be needed
In cases of recalcitrant radial head instability, percutaneous pinning of the radial head to the capitellum can be considered.
Supportive Care:
Frequent neurovascular checks are essential, especially post-reduction or surgery
Monitoring for signs of compartment syndrome
Proper cast care and skin hygiene
Nutritional support to aid healing
Rehabilitation program initiated post-cast removal.
Complications
Early Complications:
Compartment syndrome of the forearm
Neurovascular injury (radial, ulnar, or median nerve palsy)
Open fracture contamination and infection
Malreduction or failure of reduction of the radial head or DRUJ
Stiffness of the elbow or wrist.
Late Complications:
Nonunion or malunion of the radius or ulna
Chronic instability of the DRUJ or radial head
Post-traumatic arthritis of the elbow or wrist
Persistent limitation of forearm rotation (pronation/supination)
Volkmann's ischemic contracture
Growth disturbances in younger children.
Prevention Strategies:
Accurate diagnosis and prompt treatment
Achieving and maintaining adequate reduction of both the fracture and the associated joint instability
Careful neurovascular monitoring
Appropriate immobilization and timely removal of casts
Aggressive management of compartment syndrome
Adherence to rehabilitation protocols.
Prognosis
Factors Affecting Prognosis:
Age of the child (younger children have better healing potential)
Degree of displacement and comminution
Presence and severity of neurovascular compromise
Success of achieving and maintaining anatomical reduction
Development of complications such as compartment syndrome or infection
Adherence to rehabilitation.
Outcomes:
With timely and appropriate management, most pediatric Galeazzi and Monteggia fractures have an excellent prognosis, with return to full function and range of motion
However, persistent instability or significant malunion can lead to long-term functional deficits
Older children and adolescents may have a slightly less favorable prognosis compared to very young children.
Follow Up:
Regular follow-up appointments are crucial
Initial follow-up typically involves clinical assessment and radiographs at 1-2 weeks post-injury or surgery to assess healing and alignment
Subsequent follow-ups are usually at 4-6 weeks, and then at 3-6 months to monitor for late complications and assess functional recovery
Long-term follow-up may be necessary for children with significant growth plate involvement or persistent functional limitations.
Key Points
Exam Focus:
Galeazzi: Radius fracture + DRUJ disruption
Monteggia: Proximal ulna fracture + radial head dislocation
Bado classification for Monteggia fractures
Importance of elbow and wrist X-rays
Potential for neurovascular compromise and compartment syndrome
Surgical intervention is often required for instability.
Clinical Pearls:
Always obtain complete forearm and elbow X-rays for suspected fractures in these regions
Remember the adage: "When the ulna is intact, the radius is usually fractured (Galeazzi)
when the radius is intact, the ulna is usually fractured (Monteggia)." Pay meticulous attention to neurovascular status pre- and post-treatment
Consider non-accidental trauma in the differential diagnosis of any unexplained pediatric fracture.
Common Mistakes:
Missing the associated joint injury (DRUJ in Galeazzi, radial head in Monteggia)
Inadequate radiographic views leading to missed diagnoses
Failure to adequately assess or monitor neurovascular status
Inappropriate immobilization or premature cast removal
Underestimating the risk of compartment syndrome
Delays in surgical intervention when indicated.