Greenstick Fracture

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.

Epidemiology

• 12% of all pediatric ED visits in the U.S. are due to musculoskeletal injuries.
• 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 deficiency Vitamin D Deficiency A nutritional condition produced by a deficiency of vitamin D in the diet, insufficient production of vitamin D in the skin, inadequate absorption of vitamin D from the diet, or abnormal conversion of vitamin D to its bioactive metabolites. It is manifested clinically as rickets in children and osteomalacia in adults. Fat-soluble Vitamins and their Deficiencies

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

Clinical Presentation and Diagnosis

Clinical presentation 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.

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 the 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.

• Closed reduction Closed Reduction Radial Head Subluxation (Nursemaid’s Elbow) and immobilization Immobilization Delirium:
  • Indicated for significant angulation Angulation Buckle or Torus Fracture.
  • Required for almost all greenstick fractures Greenstick Fractures Osteomalacia and Rickets.
  • Delay casting by a few days to reduce the risk of recasting due to edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema.
• Immobilization Immobilization Delirium:
  • Duration: approximately 6 weeks
  • Cast types:
    • Distal fractures: short 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 cast
    • Proximal fractures: 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 cast, may be switched to short 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 at ~3 weeks.
• 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 Supracondylar fracture Supracondylar fractures are the most common elbow fractures in the pediatric population. The most common mechanism of injury involves a fall on an outstretched hand, resulting in a fracture of the distal humerus. Patients frequently present with pain, visible deformity, and limited range of motion of the injured elbow. Supracondylar Fracture: 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 Supracondylar fracture Supracondylar fractures are the most common elbow fractures in the pediatric population. The most common mechanism of injury involves a fall on an outstretched hand, resulting in a fracture of the distal humerus. Patients frequently present with pain, visible deformity, and limited range of motion of the injured elbow. Supracondylar Fracture 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.