Greenstick Fracture

By admin On Sep 15, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Greenstick Fracture

Greg Canty

K. Brooke Pengel

Basics

Description

Greenstick fractures are incomplete fractures that occur when a bone is exposed to bending forces. The bending forces are strong enough that the bone begins to fracture, but the force is not sufficient enough to result in a complete fracture:

The fracture appears on the tension (convex) side of the bone as a break in the periosteum and the cortex.
The compression side of the bone, or the concave surface, remains intact and appears as a hinge.
This fracture pattern is most commonly described in forearm fractures of growing children.
Greenstick fractures may be isolated or may coexist with other complete fractures in forearm injuries.

Epidemiology

Most recent study states up to 5% of childhood and adolescent fractures are of the greenstick variety (1)
Previous studies have estimated even greater percentages of childhood fractures are of the greenstick variety.
Although extremely rare, there have actually been a few case reports of greenstick fractures in the young adult population (2)
Forearm (radius or ulna) = most common
Proximal humerus
Tibia

Etiology

Greenstick fractures occur in children and adolescents because the bone is more:

Porous
Compliant
Resilient
Soft

Commonly Associated Conditions

Complete fracture of an accompanying bone (common)
Fracture/dislocation like a Monteggia variant (proximal 3rd ulna fracture with anterior disruption of radial head) (rare)

Diagnosis

Pre Hospital

Suspect with any forearm injury having a mild angular deformity, swelling, and pain

History

Establish mechanism of injury, which is often a fall on outstretched hand with some rotational force.
Inquire about any numbness, tingling, or pain out of proportion to exam findings.

Physical Exam

Pain and localized tenderness to palpation
Unwillingness to use or mobilize the affected extremity
Mild to moderate angular deformity
Swelling
Ecchymosis
Palpation of bony deformities
Crepitus
Assess the distal portion of the affected extremity for:
- Circulation (capillary refill and pulses)
- Motor function
- Sensation
Assess proximal and distal joints/bones for related injuries.

Diagnostic Tests & Interpretation

Imaging

Anteroposterior and lateral radiographs required for diagnosis
Look for tearing of the periosteum and cortex on the convex side of affected bone.
Concave surface of affected bone should have intact periosteum.
Plastic deformation of bone may also be apparent.
Oblique views may occasionally be helpful.
Repeat radiographs after reduction.

Differential Diagnosis

Complete fracture
Compound fracture
Plastic deformation/Bowing deformity
Torus (buckle) fracture
Contusion
Sprain

Treatment

Pre-Hospital

Ice to affected region for pain control and swelling
Splint in comfortable position using:
- Air splint or board
- Tape
- Rolled towels

ED Treatment

Pain control (see “Medications”)
Fracture reduction (3)[C]:
- Most greenstick fractures of the forearm are reduced by rotating the palm toward the apex of the fracture.
- Greenstick fractures are incomplete fractures, and may require completing the fracture in order to obtain adequate reduction.
Immobilize the injury with either a cast or splint:
- Immobilize in reduced position.
- Long arm cast/splint with elbow at 90° if fracture of proximal or middle 3rd of forearm
- May consider below-the-elbow cast if fracture is in distal 3rd of forearm (4)[B]
- Ensure proper 3-point molding to maintain reduction.
- Immobilize the joints proximal and distal to the injury.
Postreduction films after casting/splinting
Ensure reduction is maintained with immobilization prior to discharge from emergency department.

Medication

First Line

Ibuprofen (10 mg/kg) with max of 800 mg every 6–8 hr (5)[B]
Hydrocodone/acetaminophen (available as an elixir containing 7.5 mg hydrocodone/500 mg acetaminophen/15 mL):
- 12–15 kg = 3.75 mL every 4–6 hr (max 22.5 mL/day)
- 16–22 kg = 5 mL every 4–6 hr (max 30 mL/day)
- 23–31 kg = 7.5 mL every 4–6 hr (max 45 mL/day)
- 32–45 kg = 10 mL every 4–6 hr (max 60 mL/day)
- >46 kg = 15 mL every 4–6 hr (max 90 mL/day)
Oxycodone (available as an elixir containing 1 mg/1 mL) (6)[B]:
- 0.05–0.15 mg/kg every 4–6 hr

Second Line

Fentanyl 1–2 mcg/kg every 1–4 hr (max 100 mcg)
Morphine 0.1–0.2 mg/kg every 2–4 hr (max 10 mg)

Additional Treatment

Referral

Refer if unable to maintain reduction
Refer for any signs of median nerve or tendon entrapment
Refer for any progressive deformity

Surgery/Other Procedures

Rarely indicated unless nerve/tendon entrapment or inability to maintain reduction

In-Patient Considerations

Admission Criteria

Any suspicion of a nonaccidental injury (NAI):

History is best predictor of NAI.
Best predictor of NAI is whether history is consistent with injury pattern/severity

Discharge Criteria

Pain is well controlled.
Orthopedic referral within 1 wk
Splint or cast care instructions:
- Ice/cold pack application
- Elevation of the injured limb
- Analgesic medication
- Return precautions

Ongoing Care

Follow-Up Recommendations

Patient Monitoring

Repeat radiographs should be obtained at 1 and 2 wks to ensure alignment is being maintained.
Beware of the risk for greenstick fractures of the tibia to result in a valgus deformity (follow for 1–2 yrs)
Loss of reduction or progression of any deformity warrants surgical consideration, although younger patients have excellent capability of remodeling and rarely require surgery.

Prognosis

Greenstick fractures are expected to heal completely.
Complications are rare.
Remodeling capabilities are tremendous in young patients.
Excellent prognosis

Complications

10–15% of greenstick fractures may lose reduction after immobilization.
Nerve or tendon sheath entrapment
An unrecognized accompanying injury

References

1. Cheng JC, Shen WY. Limb fracture pattern in different pediatric age groups: a study of 3,350 children. J Orthop Trauma. 1993;7:15–22.

2. Casey PJ, Moed BR. Greenstick fractures of the radius in adults: a report of two cases. J Orthop Trauma. 1996;10:209–212.

3. Noonan KJ, Price CT. Forearm and distal radius fractures in children. J Am Acad Orthop Surg. 1998;6:146–156.

4. Bohm ER, Bubbar V, Yong Hing K, et al. Above and below-the-elbow plaster casts for distal forearm fractures in children. A randomized controlled trial. J Bone Joint Surg Am. 2006;88:1–8.

5. Drendel AL, Gorelick MH, Weisman SJ, et al. A Randomized Clinical Trial of Ibuprofen Versus Acetaminophen With Codeine for Acute Pediatric Arm Fracture Pain. Ann Emerg Med. 2009.

6. Koller DM, Myers AB, Lorenz D, et al. Effectiveness of oxycodone, ibuprofen, or the combination in the initial management of orthopedic injury-related pain in children. Pediatr Emerg Care. 2007;23:627–633.

Additional Reading

Rang's children's fractures. Wenger DR, Pring ME, eds. 3rd edition, Lippincott Williams & Wilkins, 2005.

Rockwood and Wilkins' fractures in children. Beaty JH, Kasser JR. 6th edition, Lippincott Williams & Wilkins, 2005.

Skeletal trauma in children. Green NE, Swiontkowski MF. 4th edition, Saunders, 2008.

Codes

ICD9

812.00 Fracture of unspecified part of upper end of humerus, closed
813.81 Fracture of unspecified part of radius (alone), closed
813.82 Fracture of unspecified part of ulna (alone), closed

Clinical Pearls

Examine surrounding bones/joints closely for accompanying injuries such as a both-bone forearm fracture or a Monteggia-variant fracture/dislocation.
Incomplete fractures, like the greenstick, may require completing the fracture for adequate reduction.
Reduce radial greenstick fractures by rotating the forearm so that the palm is pointing toward the apex of the fracture.
Follow greenstick fractures closely after reduction to ensure adequate reduction is maintained.
Beware of the long-term risk for a valgus deformity following greenstick fractures of the tibia.