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Greenstick Fracture

Greenstick Fracture

The bones of growing children exhibit unique characteristics, which, combined with the unique mechanisms of injury seen in children, result in fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures patterns differing significantly from those common in adults. The greenstick fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures is an incomplete fracture Incomplete Fracture Buckle or Torus Fracture usually seen in long bones Long bones Length greater than width. Bones: Structure and Types. The bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types is typically bent, and the fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures extends only partway through the bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types. Greenstick fractures Greenstick Fractures Osteomalacia and Rickets are at high risk for refracture and should be completely immobilized. Greenstick fractures Greenstick Fractures Osteomalacia and Rickets rarely require reduction but should be managed cautiously to prevent malunion Malunion Hip Fractures or angulation Angulation Buckle or Torus Fracture deformities. A patient with a greenstick fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures should be referred for orthopedic follow-up.

Last updated: 5 Apr, 2022

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Contents

Overview

Definition

A greenstick fracture is a partial thickness fracture, which involves a complete fracture of the cortex and periosteum on only 1 side of the bone. The fracture is termed “greenstick” as it resembles the break in a live, green twig where 1 side of the stick remains intact.

Greenstick fracture

Greenstick fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures of the radius Radius The outer shorter of the two bones of the forearm, lying parallel to the ulna and partially revolving around it. Forearm: Anatomy:
Greenstick fractures Greenstick Fractures Osteomalacia and Rickets feature disruption of the periosteum Periosteum Thin outer membrane that surrounds a bone. It contains connective tissue, capillaries, nerves, and a number of cell types. Bones: Structure and Types and cortex of the bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types on only 1 side. A plastic deformity Deformity Examination of the Upper Limbs of the ulna Ulna The inner and longer bone of the forearm. Forearm: Anatomy can also sometimes be seen.

Image by Lecturio.

Epidemiology

  • 12% of all U.S. pediatric Emergency Department (ED) visits are due to musculoskeletal injury.
  • Fractures are a large part of musculoskeletal injuries.
  • Greenstick fractures Greenstick Fractures Osteomalacia and Rickets most common ＜ age 10 but seen in all ages (adults included)
  • M:F ratio is 1:1
  • Increased risk with malnutrition Malnutrition Malnutrition is a clinical state caused by an imbalance or deficiency of calories and/or micronutrients and macronutrients. The 2 main manifestations of acute severe malnutrition are marasmus (total caloric insufficiency) and kwashiorkor (protein malnutrition with characteristic edema). Malnutrition in children in resource-limited countries and vitamin D Vitamin D A vitamin that includes both cholecalciferols and ergocalciferols, which have the common effect of preventing or curing rickets in animals. It can also be viewed as a hormone since it can be formed in skin by action of ultraviolet rays upon the precursors, 7-dehydrocholesterol and ergosterol, and acts on vitamin D receptors to regulate calcium in opposition to parathyroid hormone. Fat-soluble Vitamins and their Deficiencies deficiency

Etiology

Location:

  • Most common in long bones Long bones Length greater than width. Bones: Structure and Types:
    • Ulna Ulna The inner and longer bone of the forearm. Forearm: Anatomy
    • Radius Radius The outer shorter of the two bones of the forearm, lying parallel to the ulna and partially revolving around it. Forearm: Anatomy 
    • Fibula Fibula The bone of the lower leg lateral to and smaller than the tibia. In proportion to its length, it is the most slender of the long bones. Leg: Anatomy
    • Tibia Tibia The second longest bone of the skeleton. It is located on the medial side of the lower leg, articulating with the fibula laterally, the talus distally, and the femur proximally. Knee Joint: Anatomy
    • Femur
  • Can occur in any bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types (including flat bones Flat bones Bones: Structure and Types)

Causes:

  • Most commonly falls on an outstretched hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy (FOOSH)
  • Trampoline jumping (often with multiple children on a trampoline) most common activity for greenstick fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures
  • Also:
    • Motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology vehicle accident
    • Sports injury
    • Trauma secondary to child abuse Child abuse Child abuse is an act or failure to act that results in harm to a child’s health or development. The abuse encompasses neglect as well as physical, sexual, and emotional harm. Seen in all subsets of society, child abuse is a cause of significant morbidity and mortality in the pediatric population. Child Abuse

Pathophysiology

  • Unique features of pediatric bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types:
    • During growth, pediatric bones consist of calcified cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage: Histology
    • Periosteum Periosteum Thin outer membrane that surrounds a bone. It contains connective tissue, capillaries, nerves, and a number of cell types. Bones: Structure and Types is more active, thick, and resistant.
  • Pediatric bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types is more compliant.
  • More unstable fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures than buckle (or torus) fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures, with potential for angulation Angulation Buckle or Torus Fracture deformity Deformity Examination of the Upper Limbs and malunion Malunion Hip Fractures
Types of fractures comparison

Comparing healthy bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types with different types of fractures:
(a) closed fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures
(b) open fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures
(c) transverse fracture Transverse Fracture Overview of Bone Fractures
(d) spiral Spiral Computed tomography where there is continuous x-ray exposure to the patient while being transported in a spiral or helical pattern through the beam of irradiation. This provides improved three-dimensional contrast and spatial resolution compared to conventional computed tomography, where data is obtained and computed from individual sequential exposures. Computed Tomography (CT) fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures
(e) comminuted fracture Comminuted fracture A fracture in which the bone is splintered or crushed into a number of pieces. Overview of Bone Fractures
(f) impacted fracture Impacted Fracture Overview of Bone Fractures
(g) greenstick fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures
(h) oblique fracture Oblique Fracture Overview of Bone Fractures

Image: “Types of Fractures” by OpenStax College. License: CC BY 4.0

Related videos

4:14
Greenstick-, Buckle-, Apophyseal Avulsion-, Supracondylar and Toddler’s Fractures

Clinical Presentation and Diagnosis

Clinical presentation Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor of pediatric patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with greenstick fractures Greenstick Fractures Osteomalacia and Rickets is similar to other pediatric fractures.

History and physical

  • Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways after trauma with decreased range of motion Range of motion The distance and direction to which a bone joint can be extended. Range of motion is a function of the condition of the joints, muscles, and connective tissues involved. Joint flexibility can be improved through appropriate muscle strength exercises. Examination of the Upper Limbs
  • Physical exam reveals tenderness over fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures with possible deformity Deformity Examination of the Upper Limbs or angulation Angulation Buckle or Torus Fracture.
  • Detailed neurologic exam is essential.

Imaging

  • X-rays X-rays X-rays are high-energy particles of electromagnetic radiation used in the medical field for the generation of anatomical images. X-rays are projected through the body of a patient and onto a film, and this technique is called conventional or projectional radiography. X-rays are diagnostic:
    • At least 2 views should be obtained (orthogonal or right angle).
    • Image shows fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures on 1 side of the bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types and angular deformity Deformity Examination of the Upper Limbs (buckle) on the other.
  • Imaging of joint above and below injured bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types is recommended to rule out other associated injuries.
Comparison imaging of pediatric fractures

Examples of fractures from each category:
A: buckle fracture, rated as “buckle” on all readings
B: greenstick fracture, rated as “greenstick” on 20 of 24 readings
C: complete fracture, rated as “complete” on all readings
D: physeal fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures, as rated by all raters on both readings

Image: “Examples of fractures from each category” by The Department of Orthopaedic Surgery, Akershus University Hospital, Lørenskog, Norway. License: CC BY 2.0
Greenstick fracture of right tibia

Greenstick type fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures of the mid-shaft of right tibia Tibia The second longest bone of the skeleton. It is located on the medial side of the lower leg, articulating with the fibula laterally, the talus distally, and the femur proximally. Knee Joint: Anatomy:
Note the fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures on 1 side of the bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types and the slight angular deformity Deformity Examination of the Upper Limbs (buckle) on the opposite side.

Image: “Greenstick type fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures” by Lemire; licensee BioMed Central Ltd. License: CC BY 2.0

Related videos

7:18
Pediatric Fractures

Management

Management of a greenstick fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures is based on displacement Displacement The process by which an emotional or behavioral response that is appropriate for one situation appears in another situation for which it is inappropriate. Defense Mechanisms and amount of angulation Angulation Buckle or Torus Fracture of the fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures.

  • Angulated fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures may require reduction or even completing the fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures (there is a lack of consensus on management).
  • Generally treated by casting or splinting after reduction of deformity Deformity Examination of the Upper Limbs
  • Forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term “forearm” is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm: Anatomy greenstick fractures Greenstick Fractures Osteomalacia and Rickets frequently require reduction followed by immobilization Immobilization Delirium in a long arm Arm The arm, or “upper arm” in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm: Anatomy splint or cast.
  • Fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures may have increasing deformity Deformity Examination of the Upper Limbs after casting and potential for malunion Malunion Hip Fractures; therefore, frequent orthopedic consultation is required.

Clinical Relevance

Additional important pediatric skeletal injuries:

  • Buckle (or torus) fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures: a fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures affecting growing metaphyseal bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types secondary to compression Compression Blunt Chest Trauma load where the bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types buckles or compresses. A buckle fracture Buckle Fracture Buckle or Torus Fracture is generally considered a stable fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures with a good prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas and treated by immobilization Immobilization Delirium.
  • Supracondylar fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures: a complete fracture Complete Fracture Overview of Bone Fractures affecting the distal humerus Humerus Bone in humans and primates extending from the shoulder joint to the elbow joint. Arm: Anatomy after FOOSH. A supracondylar fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures is a common fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures of the elbow in children and requires immediate orthopedic consultation. Many cases are associated with neurovascular injury and require surgical intervention. 
  • Apophyseal avulsion fracture Avulsion fracture Tearing away of the cortical bone fragment at the location of a strong ligament or tendon attachment. The bone fragment detachment site often occurs near a soft site (e.g., growth plate) at the base where ligaments; tendons; or joint capsules attach. Overview of Bone Fractures: Apophysis is a secondary ossification center Secondary ossification center Development of the Limbs found in non–weight-bearing segments of bones and a site of ligament or tendon insertion. Acute apophyseal avulsion fracture Avulsion fracture Tearing away of the cortical bone fragment at the location of a strong ligament or tendon attachment. The bone fragment detachment site often occurs near a soft site (e.g., growth plate) at the base where ligaments; tendons; or joint capsules attach. Overview of Bone Fractures occurs when a portion of apophysis is pulled off by ligament, usually secondary to explosive movements and eccentric muscular contractions. An apophyseal avulsion fracture Avulsion fracture Tearing away of the cortical bone fragment at the location of a strong ligament or tendon attachment. The bone fragment detachment site often occurs near a soft site (e.g., growth plate) at the base where ligaments; tendons; or joint capsules attach. Overview of Bone Fractures is primarily treated conservatively with rest and pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways control but may require surgical repair if a fragment of avulsed bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types is large and significantly displaced. 

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(1):15-22. doi: 10.1097/00005131-199302000-00004. PMID: 8433194.
  2. Naranje SM, Erali RA, Warner WC Jr, Sawyer JR, Kelly DM. Epidemiology of Pediatric Fractures Presenting to Emergency Departments in the United States. J Pediatr Orthop. 2016 Jun;36(4):e45-8. doi: 10.1097/BPO.0000000000000595. PMID: 26177059.
  3. Chasm RM, Swencki SA. Pediatric orthopedic emergencies. Emerg Med Clin North Am. 2010 Nov;28(4):907-26. doi: 10.1016/j.emc.2010.06.003. PMID: 20971397.
  4. Nellans KW, Kowalski E, Chung KC. The epidemiology of distal radius fractures. Hand Clin. 2012 May;28(2):113-25. doi: 10.1016/j.hcl.2012.02.001. Epub 2012 Apr 14. PMID: 22554654; PMCID: PMC3345129.
  5. Franklin CC, Robinson J, Noonan K, Flynn JM. Evidence-based medicine: management of pediatric forearm fractures. J Pediatr Orthop. 2012 Sep;32 Suppl 2:S131-4. doi: 10.1097/BPO.0b013e318259543b. PMID: 22890452.
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