What is Greenstick Fracture?
The structure and makeup of a child’s skeleton isn’t just a smaller version of an adult’s. It’s special because it allows for quick growth and changes as the child grows into an adult. The biggest differences between an adult and child’s skeletal system come from something called the physis, or growth plate, in the child’s skeleton. This allows their bones to continue growing until they reach adulthood.
The growth plate is part of long bones, including those in the fingers, lower leg, thigh, forearm, and upper arm. It causes bone growth from cartilage, a process called endochondral ossification, which is different from bone growth in tissues. It’s found towards the end of the bone, with the epiphysis (or end of the bone) above it and the metaphysis (the narrow portion of the bone) below it. Big bones like the thigh bone have two growth plates separated by the shaft of the bone, whereas bones like finger bones only have one growth plate.
This growth plate has four areas. First, the reserve or resting zone made of hyaline cartilage; second, the area of growth where cartilage cells multiply and create spaces (or lakes); third, the area where these cells stop dividing and start growing; and finally, the region where minerals get deposited into these spaces to harden, or calcify, the cartilage. Once hardened, the cartilage can break down, allowing for the invasion of blood vessels and the creation and reshaping of bone tissue.
So, before hardening, most of a child’s bone is just hardened cartilage, which is more flexible compared to the hardened bones of adults. Because of their flexibility, children’s bones tend to bend and curve more under stress, which in adults would cause a fracture. Also, the outer layer of a child’s bone (the periosteum), is more active, thicker, and stronger, which significantly reduces the chances of fractures and their displacement. These characteristics, along with the flexibility of children’s bones, cause unique fracture patterns seen only in children. These fractures include greenstick, torus, and spiral injuries, which involve bending rather than breaking the full thickness of the bone.
A greenstick fracture is a kind of fracture where only the outer layer and hard part of the bone are broken on one side, while they remain unbroken on the other side.
What Causes Greenstick Fracture?
Greenstick fractures often happen after someone falls onto an extended arm. However, they might also occur due to other kinds of injuries, such as car crashes, sports-related injuries, or from being hit with an object intentionally. Not having enough nutrition, especially vitamin D, raises the chances of getting these fractures in the longer bones after an injury.
Risk Factors and Frequency for Greenstick Fracture
About 12% of all emergency department visits for children in the United States are because of injuries to the muscles, joints, and bones. Broken bones make up a large part of these injuries and can lead to serious health complications. A specific kind of break, called a greenstick fracture, is most often seen in children under 10 years old, but it can happen to people of all ages, including adults. Both males and females can have them equally, although males are more likely to experience broken bones in general.
Signs and Symptoms of Greenstick Fracture
Greenstick fractures are just like any other type of bone fracture. It’s important for the doctor to know the person’s age, gender, where the fracture occurred, whether the skin is broken or not, and how the injury happened. Additionally, the doctor will examine the area to assess the health of the surrounding skin, nerves, and blood vessels. They will also check the joints above and below the fracture to see if there are any more hidden fractures.
Typically, people with this type of fracture may have suffered an accident, like falling down or being hit with a baseball bat. Sometimes, however, the injury might not be accidental, which is something the doctor will also consider. Depending on the patient’s age, they may either not be able to or refuse to move the injured area, cry uncontrollably, express pain in the injured area, or guard it protectively.
- Decreased motion range of the injured area
- Pain when the injured area is touched
- A bruise over the injured area
- Swelling
- Skin changes, such as abrasions or cuts
- Signs of nerve or blood vessel damage
Injuries to the forearm might mean there’s also nerve damage, especially to the median nerve. Therefore, it’s important to include a complete nerve check for all traumatic injuries. Sometimes, signs of non-accidental injury might include multiple injuries or bruises in different stages of healing that don’t follow commonly seen injury patterns for the patient’s age.
Testing for Greenstick Fracture
In order to diagnose your injury, your doctor might take an x-ray of the affected area. The x-ray typically shows an injury where the fracture hasn’t gone all the way through the bone. Essentially, there’s a crack on one side of the bone, but it doesn’t extend to the other side. This results in the other side of the bone showing signs of being slightly deformed due to the pressure exerted on it.
Treatment Options for Greenstick Fracture
If a bone is bent significantly in a greenstick fracture, medical professionals need to maneuver it back into place and keep it steady, a process known as closed reduction and immobilization. These fractures always need to be immobilized, with a cast typically applied a few days after the injury to accommodate any swelling that might occur. It’s usually recommended that the injured child see an orthopedic specialist right away, depending on how severe the bend is and the child’s age.
The cast for a greenstick fracture of a long bone like the arm or leg typically needs to stay on for about six weeks. The type of cast used depends on the fracture’s location. For example, fractures closer to the hand or foot can have a shorter cast, while those closer to the body, or proximal fractures, might need a longer cast initially. These longer casts could be switched out for a shorter one halfway through healing, which is roughly three weeks in. Because the healing process for proximal fractures can be more complicated, these patients usually need to check in with their orthopedic specialist more often.
Because greenstick fractures are more unstable and more likely to lead to a second fracture or a bone shifting out of place compared to other types of fractures, all patients with greenstick fractures should be seen by an orthopedic specialist at some point.
While less common, gently bent (or slightly angulated) greenstick fractures can sometimes be treated with a splint instead of a cast, as long as the patient can be closely monitored. Splinting can be a less expensive alternative to casting and allows the patient more flexibility, including being able to remove the splint for showering.
What else can Greenstick Fracture be?
There are various types of bone fractures that doctors need to take into account when diagnosing a patient with bone injury. These include:
- A Salter-Harris fracture, which commonly affects growing children
- A torus fracture, also known as a ‘buckle’ fracture. This type is common in kids and happens when one side of the bone buckles or bends without breaking
- A toddler’s fracture, usually a minor spiral fracture in the lower leg area
- A spiral fracture, which happens when a bone is broken by a twisting force
- Non-accidental fractures, which are fractures resulting from child abuse or other forms of violence
- An open fracture, when a broken bone punctures the skin
- A pathologic fracture, which is a fracture in a bone weakened by disease
- Non-displaced fractures, where the bone cracks or breaks but stays in place
- Lastly, plastic deformities, which occur when a bone bends without breaking, but does not return to its original shape
These different types of fractures each require specific treatment and care to ensure proper healing.
What to expect with Greenstick Fracture
In simple terms, the outlook is usually positive for greenstick fractures, which are a type of broken bone. Most of them heal well and don’t result in any functional changes or noticeable differences in the appearance of the injured bone.
However, if these fractures aren’t correctly immobilized or the patient doesn’t receive the right orthopedic follow-up, there’s a risk of the fracture happening again, becoming a complete break, or the broken pieces of bone moving out of place.
Possible Complications When Diagnosed with Greenstick Fracture
Greenstick fractures, which are incomplete fractures in bones, are risky because they are unstable and need to be set promptly. If a greenstick fracture occurs once, there’s a good chance it may happen again in the same area, especially in the forearm. After fixing a greenstick fracture in the radius, which is one of the two bones of the forearm, doctors need to take x-Rays of the whole bone to ensure that the fixed part matches the unbroken section in terms of orientation. This process, known as the radius crossover sign, can reduce the likelihood of a bone deformity and loss of movement in the forearm. There have been cases where a greenstick fracture in the scapula, or shoulder blade, has led to a condition called winged scapula, where the scapula sticks out from the back.
Preventing Greenstick Fracture
Injuries from accidents or sports activities, often from falling onto an outstretched hand (FOOSH), can sometimes result in broken bones. These situations need to be assessed urgently to prevent further issues. It’s important to quickly immobilize greenstick fractures, which are incomplete fractures commonly seen in children, to prevent the bone from breaking completely or moving out of place. During the healing period, people need to avoid activities with a high risk of falling because there is a high chance of the bone breaking again or completely.
