Greenstick Fracture

Greenstick fracture is an incomplete fracture of a long bone in a child, in which the cortex breaks on the tension side and bends on the compression side, like a green twig.

• It occurs in children under 10 years because paediatric bone is more flexible and has thick periosteum.
• It most often affects the forearm (radius and ulna) after a fall on an outstretched hand.
• Angulation may be present, and the bone may re-fracture or deform if not properly treated.
• Remodelling potential is excellent in young children, especially near the growing ends of the bone.

Pain, swelling and deformity follow a fall.

• Pain, localised tenderness, swelling and refusal to use the limb.
• Bowing deformity or angulation of the forearm.
• Reduced range of movement; crepitus is uncommon as the fracture is incomplete.
• Check neurovascular status: radial pulse, capillary refill, sensation, and median, ulnar and radial nerve function.
• Differential diagnosis: buckle fracture, complete fracture, plastic deformation (bowing without cortical break), Monteggia and Galeazzi fracture dislocations, growth plate injury, elbow dislocation and non-accidental injury.
• Complications: malunion, angular deformity, loss of forearm rotation, refracture, compartment syndrome (rare), nerve injury and growth disturbance.

Diagnosis is by X-ray.

• Two views (anteroposterior and lateral) including joints above and below the fracture.
• Radiograph shows cortical break on one side with bowing or angulation of the other cortex.
• Assess angulation, rotation and associated dislocation of the radial head (Monteggia) or distal radioulnar joint (Galeazzi).
• Consider skeletal survey if non-accidental injury is suspected.

Management depends on angulation and age.

• Supportive: analgesia, elevation, ice, and splintage.
• Pharmacological: paracetamol 15 mg/kg every 6 hours and ibuprofen 5 to 10 mg/kg every 8 hours. Oral morphine 0.1 to 0.2 mg/kg for severe pain. Procedural sedation: intranasal fentanyl 1.5 micrograms/kg, nitrous oxide 50 percent, or ketamine 1 mg/kg intravenously.
• Minimal angulation (under 10 to 15 degrees in children under 10 years, accepted because of remodelling): above-elbow cast for 4 to 6 weeks.
• Greater angulation: closed reduction under sedation or anaesthesia, and apply a well-moulded above-elbow cast; if needed, complete the fracture deliberately during reduction to correct the deformity and prevent angulation recurring. Repeat X-ray at 1 week and 2 weeks to check position.
• Procedures: surgical fixation (elastic nails or Kirschner wires) for unstable, irreducible or older children with significant angulation or rotation.
• Special groups: adolescents have less remodelling potential, so need more accurate reduction. Suspected abuse requires safeguarding evaluation.
• Red flags: severe pain, tense swelling, pain on passive finger stretch (compartment syndrome), absent pulses, open fracture, neurological deficit and fracture dislocation.
• Follow-up: X-ray and clinic at 1 week and 2 weeks, then cast removal at 4 to 6 weeks. Advise return to sport after 8 to 12 weeks.