Greenstick Fracture

The bones of growing children exhibit unique characteristics, which, combined with the unique mechanisms of injury seen in children, result in fracture patterns differing significantly from those common in adults. The greenstick fracture is an incomplete fracture usually seen in long bones. The bone is typically bent, and the fracture extends only partway through the bone. Greenstick fractures are at high risk for refracture and should be completely immobilized. Greenstick fractures rarely require reduction but should be managed cautiously to prevent malunion or angulation deformities. A patient with a greenstick fracture should be referred for orthopedic follow-up.

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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 of the radius:
Greenstick fractures feature disruption of the periosteum and cortex of the bone on only 1 side. A plastic deformity of the ulna can also sometimes be seen.

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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 most common < age 10 but seen in all ages (adults included)
  • M:F ratio is 1:1 (males are more likely to fracture a bone)
  • Increased risk with malnutrition and vitamin D deficiency

Etiology

Location:

  • Most common in long bones:
    • Ulna
    • Radius 
    • Fibula
    • Tibia
    • Femur
  • Can occur in any bone (including flat bones)

Causes:

  • Most commonly falls on an outstretched hand (FOOSH)
  • Trampoline jumping (often with multiple children on a trampoline) most common activity for greenstick fracture
  • Also:
    • Motor vehicle accident
    • Sports injury
    • Trauma secondary to child abuse

Pathophysiology

  • Unique features of pediatric bone:
    • During growth, pediatric bones consist of calcified cartilage
    • Periosteum is more active, thick, and resistant.
  • Pediatric bone is more compliant.
  • More unstable fracture than buckle (or torus) fracture, with potential for angulation deformity and malunion

Clinical Presentation and Diagnosis

Clinical presentation of pediatric patients with greenstick fractures is similar to other pediatric fractures.

History and physical

  • Pain after trauma with decreased range of motion
  • Physical exam reveals tenderness over fracture with possible deformity or angulation.
  • Detailed neurologic exam is essential.

Imaging

  • X-rays are diagnostic:
    • At least 2 views should be obtained (orthogonal or right angle).
    • Image shows fracture on 1 side of the bone and angular deformity (buckle) on the other.
  • Imaging of joint above and below injured bone is recommended to rule out other associated injuries.

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Management

Management of a greenstick fracture is based on displacement and amount of angulation of the fracture.

  • Angulated fracture may require reduction or even completing the fracture (there is a lack of consensus on management).
  • Generally treated by casting or splinting after reduction of deformity
  • Forearm greenstick fractures frequently require reduction followed by immobilization in a long arm splint or cast.
  • Fracture may have increasing deformity after casting and potential for malunion; therefore, frequent orthopedic consultation is required.

Clinical Relevance

Additional important pediatric skeletal injuries:

  • Buckle (or torus) fracture: a fracture affecting growing metaphyseal bone secondary to compression load where the bone buckles or compresses. A buckle fracture is generally considered a stable fracture with a good prognosis and treated by immobilization.
  • Supracondylar fracture: a complete fracture affecting the distal humerus after FOOSH. A supracondylar fracture is a common fracture of the elbow in children and requires immediate orthopedic consultation. Many cases are associated with neurovascular injury and require surgical intervention. 
  • Apophyseal avulsion fracture: Apophysis is a secondary ossification center found in non–weight-bearing segments of bones and a site of ligament or tendon insertion. Acute apophyseal avulsion fracture occurs when a portion of apophysis is pulled off by ligament, usually secondary to explosive movements and eccentric muscular contractions. An apophyseal avulsion fracture is primarily treated conservatively with rest and pain control but may require surgical repair if a fragment of avulsed bone 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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