Course:KIN366/ConceptLibrary/GreenstickFractures

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Movement Experiences for Children
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KIN 366
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Instructor: Dr. Shannon S.D. Bredin
Email: shannon.bredin@ubc.ca
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A greenstick fracture is an incomplete pediatric fracture that is a common injury in the long bones of children and infants. Due to the fact that children’s bones are softer and more flexible than adults, a child’s bone is able to bend without completely breaking because their bones are still growing and has yet to be fully calcified (Calmer & Vinci, 2002). With age the bones become more brittle and inflexible, which makes complete bone fractures more common among adults. A greenstick fracture may be difficult to diagnose because children may still have their full range of motion and may not feel much pain or swelling. Minor greenstick fractures are often misdiagnosed as sprains because they have similar symptoms (Randsborn & Sivertsen, 2009).
The term “greenstick fractures” derives from the analogy of fresh wood being green and breaking in a similar fashion. When a fresh tree branch is broken, it typically only breaks on one side, the outside of the bend, while the inner side of the bend remains intact.

Anatomy of a Pediatric Long Bone

Most greenstick fractures occur in the long bones of the child or infant. The long bone has three main parts:
Epiphysis: the end of the long bone, each end contains cartilage to ensure smooth movement in the joint and offers protection.
Physis: also know as the ‘growth plate’, contains cartilage cells that help the bone grow. Located between the epiphysis and metaphysis.
Metaphysis: just below the physis and above the diaphysis / shaft
Diaphysis: the shaft of the bone.
Periosteum: thick, nutrient layer around the bone; plays an important part in healing the outer bone.

Types of Pediatric Fractures

A pediatric fracture is unique from adult fractures because the properties and characteristics of the bone are different. An immature bone is soft and flexible, and a mature bone is hard and becomes more brittle with age (Calmer & Vinci, 2002). Here is an overview of the different types of pediatric fractures.

Complete Pediatric Fracture

The fracture propagates through the entire bone. Complete fracture classification get further broken down into spiral, oblique, and transverse fractures, depending on the nature of the break.

Incomplete Pediatric Fracture

Plastic Deformation or Bow Fracture

No visible fracture line can be seen on an x-ray, however a microscopic failure on one side of the bone causes it to slightly bend. This fracture is only seen in children, and almost always seen in the ulna, sometimes in the fibula.

Torus or Buckling Fracture

This fracture is the result of an impact force, such as falling on an outstretched arm. These fractures are usually stable, meaning that there is not a lot of displacement and a soft splint can often be used instead of a cast.

Greenstick Fracture

The bone is bent and a visible fracture line is seen on the tensile/ convex side of the bone; however, it does not propagate to the concave side of the bone. Depending on the severity, there is a number of different treatments.

Physeal Fracture

These are fractures that affect the physis/ growth plate of the bone. Most physeal injuries heal quickly, within 3 weeks, because it is the site of bone growth in infants and children. However, if the physis closes as a result of the injury, then a number of complications can occur – limb-length discrepancy, progressive deformity, or joint incongruity.

Signs and Symptoms

The signs and symptoms of a greenstick fracture can vary depending on the individual. Intense pain or severe deformity is not always present, and greenstick fractures are often misdiagnosed as strains or sprains (soft-tissue injuries). The typical signs and symptoms are comparable to a normal long bone fracture; however, the deformity may only be a slight bend. Children will typically cry uncontrollably in response to pain, which makes getting an accurate description of the pain type and location to be difficult (Guly, 2002). Typical symptoms of a greenstick fracture in a child or infant are as follows:

  • Pain and swelling on the fracture site
  • Slight bend at the affected limb
  • Uncontrollable crying in response to pain
  • Protective gestures on the fracture site
  • Redness on affected site
  • Pain when moving toes or fingers at the affected limb
  • Fever in severe cases

Causes

Childhood greenstick fractures frequently occur as the result of a fall. Arm fractures are more common than leg fractures because of the natural instinct to throw arms out to stop or brace a fall (Wright, Crepeau, Herrera-Soto, & Price, 2012). Blunt force trauma (a direct blow) can also cause a greenstick fracture. It is recommended that if a child suffers a fall that they be taken to hospital to rule out a greenstick fracture. As falls and blows are common in youth sport and the cause of many greenstick fractures, close attention to potential injuries should be taken when a child is participating in his or her sport.

Tests and Diagnosis

The most common and reliable way to confirm a greenstick fracture is to get an x-ray, although some greenstick fractures can still be hard to detect. In most cases the doctor will first conduct a physical exam, checking the injury for soreness, swelling, deformity, any open wounds, and other abnormalities (Calmer and Vinci, 2002). To check if there is any damage to areas other than the bone such as the nervous system, the doctor will ask the child to move the fingers or toes associated with the injured limb.

Considerations before an Examination

If a child has fallen or taken a direct blow and is suffering pain, then it is highly recommended that the child be taken to the hospital for an examination. Valuable information that is worth recording for health care professionals includes:

  • Nature of injury; specifics on how it occurred
  • The symptoms being experienced and if they have gotten better/ worse
  • Key medical information such as previous fractures, allergies, medical problems, medications, etc.
  • Any questions you want to ask the doctor

Some common questions that a physician may ask include:

  • What was the mechanism of injury? How did the injury occur?
  • Where exactly is the pain?
  • Is any walking or weight bearing possible?
  • Is the pain radiating?
  • Is there any aggravating or alleviating factors?
  • Is the child experiencing any other injuries or medical complains? Is the child sick?

If the examination and x-ray reveal a greenstick fracture then the physician will treat and immobilize the area, and in some severe cases, refer to a pediatric orthopaedic surgeon.

Treatment

The first step in treating a greenstick fracture is to make sure the bone is back in it's proper alignment. Often the bone will be in good position and no invasive treatment is needed; however, in some cases sedation or surgery may be required for realignment of the bone. It is critical that the bone is set properly because if a bone repairs in a position out of alignment, then complications may occur and functional movement could be impaired (Kropman, Bemelman, Segers, & Hammacher, 2010). In most greenstick fractures affecting the arms and legs a hard plaster cast will be applied to immobilize the area and guarantee healing in the proper anatomic position. Although these hard casts are effective in the healing of the bone, they are often difficult to keep dry and hygienic. Another problem is that complete immobilization has been shown to lead to rapid atrophy (reduction) of the associated muscle fiber (Kropman et al., 2010). A removable soft splint can also be used to treat a greenstick fracture, often when the fracture is stable or mostly healed. This splint also immobilizes the injured area and has the advantage of being able to be taken off for short periods of time. This can make showering a lot easier, and can allow the area to breath and be taken though a pain free range of motion (Kropman et al. 2010). A removable splint may also be applied after a hard cast is taken off and the injury is mostly healed. A follow-up x-ray a few weeks after the injury is highly recommended as greenstick fractures can continue to displace weeks after the injury (Calmer & Vinci, 2002). An x-ray will confirm that the bone is mending appropriately. In most cases four to eight weeks is required for complete healing, which depends largely on the severity of the break and the age of the child. To avoid re-injury after the cast or splint is removed high-impact activity should be avoided for one to two weeks. A physiotherapist may be helpful at this point to help rebuild muscle and function but is not necessary and a normal active lifestyle should suffice.

Prevention

The best way to prevent a greenstick fracture is for a child to lead an active and healthy lifestyle to ensure that the child develops healthy and strong bones. An active lifestyle that involves controlled, repetitive low-impact (hiking, running, soccer, ect.) can help build bone density (Randsborg & Sivertsen, 2009). Developing fundamental movement skills through an active lifestyle can also reduce the frequency of falling and injury. A healthy, well-balanced diet can also have a large impact on bone health; refer to a dietary professional for more information on nutrition can be a worthy investment. Ensuring that a child always wears the necessary protective equipment is important to help prevent fractures and other injuries. Using a car seat or seat belt can prevent serious injuries from occurring, including greenstick fractures. Proper footwear and tied shoelaces can also reduce the frequency of falling.  

References

Budd, L., Paquette, K., (2011) The basic types of pediatric fractures, differences from adults and care as a primary care physician. Learn Pediatrics. Retrieved from learnpediatrics.sites.olt.ubc.ca/files/2012/04/fractures.pdf

Calmar, A., Vinci, RJ. (2002). c. Clinical Pediatric Emergency Medicine, 3(2):86-93.

Guly, H.R. (2002) Injuries initially misdiagnosed as sprained wrist (beware the sprained wrist). Emergency Medical Journal.;19, 41–42

Kropman, R. J., Bemelman, M., Segers, M. M., & Hammacher, E. R. (2010). Treatment of impacted greenstick forearm fractures in children using bandage or cast therapy: a prospective randomized trial. The Journal Of Trauma, 68(2), 425-428. doi:10.1097/TA.0b013e3181a0e70e

Mayo Clinic Staff. (2013). Diseases and condition: greenstick fractures. Mayo Clinic. Retrieved from http://www.mayoclinic.org/diseases-conditions/greenstick-fractures/basics/definition/con-20027302

Randsborg, P.-H., & Sivertsen, E. A. (2009). Distal radius fractures in children: substantial difference in stability between buckle and greenstick fractures. Acta Orthopaedica, 80(5), 585–589. doi:10.3109/17453670903316850

Schmuck, T., Altermatt, S., Büchler, P., Klima-Lange, D., Krieg, A., Lutz, N., & ... Hasler, C. (2010). Greenstick fractures of the middle third of the forearm. A prospective multi-centre study. European Journal Of Pediatric Surgery: Official Journal Of Austrian Association Of Pediatric Surgery 20(5), 316-320. doi:10.1055/s-0030-1255038

Wright, P. B., Crepeau, A. E., Herrera-Soto, J. A., & Price, C. T. (2012). Radius crossover sign: an indication of malreduced radius shaft greenstick fractures. Journal Of Pediatric Orthopedics, 32(4), e15-e19. doi:10.1097/BPO.0b013e3182468cec