section name header

Basics ⬇

Author: GregCanty, MD

Description

Greenstick fractures are incomplete fractures that occur when a bone is exposed to angulation and rotational bending forces. The bending forces are strong enough that the bone begins to fracture on tension side, 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

  • Studies suggest up to 5% of childhood and adolescent fractures are of the greenstick variety (1)[B].
  • Some studies suggest an even greater percentage of childhood fractures may be of the greenstick variety.
  • Although extremely rare, there have actually been a few case reports of greenstick fractures in the young adult population (2)[B].
  • Forearm (radius or ulna) = most common
  • Proximal humerus
  • Tibia

Etiology and Pathophysiology

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 ⬆ ⬇

Prehospital:

  • 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.

Differential Diagnosis

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

Diagnostic Tests & Interpretation

  • 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.
  • Radius crossover sign may be helpful in determining rotational malalignment after reduction (3)[B]. The typical radiographs, where the radius crossover sign is present, demonstrate a pronated appearance of the proximal forearm with a neutral position of the distal forearm.
  • Repeat radiographs after reduction.

Treatment ⬆ ⬇

General Measures

  • Prehospital:
    • Ice to affected region for pain control and swelling
    • Splint in comfortable position using:
      • Air splint or board.
      • Tape.
      • Rolled towels.
  • Emergency department (ED) treatment:
    • Pain control (see “Medication”)
    • Fracture reduction (4)[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 degrees if fracture of proximal or middle third of forearm
      • May consider below-the-elbow cast or removable splint if fracture is in distal third of forearm (5)[B]
      • Ensure proper three-point molding to maintain any reduction.
      • Postreduction films after casting/splinting (Look for radius crossover sign discussed in imaging.)
    • Ensure reduction is maintained with immobilization prior to discharge from ED.

Medication

First Line

  • Ibuprofen (10 mg/kg) with maximum of 800 mg every 6 to 8 hr (6)[B]
  • Oxycodone (available as an elixir containing 1 mg/1 mL) (7)[B]:
    • 0.05 to 0.15 mg/kg every 4 to 6 hr

Second Line

  • Fentanyl 1 to 2 μg/kg IV every 1 to 4 hr (maximum dose 50 μg); may also consider intranasal 1.5 μg/kg (maximum 100 μg)
  • Morphine 0.1 to 0.2 mg/kg every 2 to 4 hr (maximum 10 mg)

Issues for 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

Admission, Inpatient, and Nursing 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 available within 1 wk
    • Splint/cast care/pain management instructions:
      • Ice/cold pack application
      • Elevation of the injured limb
      • Analgesic plans for mild, moderate, and severe pain
      • Return precautions

Ongoing Care ⬆ ⬇

Follow-up Recommendations

Patient Monitoring

  • With greenstick fractures of the forearm, clinical follow-up and radiographs obtained at 2 to 6 wk postinjury reduce overall care costs and radiation exposure without compromising clinical results (8)[B].
  • Greenstick fractures of the tibia are at risk for valgus deformity and may be followed for 1 to 2 yr.
  • 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
  • Unrecognized accompanying injuries

Additional Reading ⬆ ⬇

  • FlynnJM, SkaggsDL, WatersPM, eds. Rockwood and Wilkins’ Fractures in Children. 8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2015.
  • MencioGA, SwiontkowskiMF, eds. Green’s Skeletal Trauma in Children. 5th ed. Philadelphia, PA: Saunders; 2015.
  • WengerDR, PringME, PennockAT, et al, eds. Rang’s Children’s Fractures. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2018.

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.
  2. Casey PJ, Moed BR. Greenstick fractures of the radius in adults: a report of two cases. J Orthop Trauma. 1996;10(3):209–212.
  3. Wright PB, Crepeau AE, Herrera-Soto JA, et al. Radius crossover sign: an indication of malreduced radius shaft greenstick fractures. J Pediatr Orthop. 2012;32(4):e15–e19.
  4. Noonan KJ, Price CT. Forearm and distal radius fractures in children. J Am Acad Orthop Surg. 1998;6(3):146–156.
  5. Boutis K, Howard A, Constantine E, et al. Evidence into practice: pediatric orthopaedic surgeon use of removable splints for common pediatric fractures. J Pediatr Orthop. 2015;35(1):18–23.
  6. 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;54(4):553–560.
  7. 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(9):627–633.
  8. Ting BL, Kalish LA, Waters PM, et al. Reducing cost and radiation exposure during the treatment of pediatric greenstick fractures of the forearm. J Pediatr Orthop. 2016;36(8):816–820.

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.
  • Forearm fractures have tremendous potential for remodeling, but greenstick fractures require monitoring after reduction to ensure reduction is maintained.
  • Beware of the long-term risk for a valgus deformity following greenstick fractures of the tibia.