Greenstick Fractures: Difference between revisions

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== Introduction ==
== Introduction ==
The makeup, anatomy, and histology of the pediatric skeletal system is not just a smaller version of the adult form; rather, it is unique in that it allows for rapid growth and change throughout development from childhood to adulthood.
Green stick fractures occurs in the children below 10 years of age. <ref name=":0" />. The incidence of it is 1 in 100 and the most commonly affected age group is between 5 to 14 years. It rarely occurs in adults.<ref name=":1">Lin YC, Wang WT. Greenstick fracture of the ulnar shaft following physical therapy in an adult: A case report. Medicine. 2020 Dec 11;99(50).</ref>There is partial thickness fracture where only cortex and periosteum gets affected on one side of the bone and it remains uninterrupted on the other side of the bone.<ref name=":0">Atanelov Z, Bentley TP. Greenstick fracture.</ref>Usually happens in long bones such as radius, ulna, femur, tibia, humerus. Green stick fractures are unstable and they continue to displace after first 2 weeks.<ref>Randsborg PH, Sivertsen EA. Distal radius fractures in children: substantial difference in stability between buckle and greenstick fractures. Acta orthopaedica. 2009 Oct 1;80(5):585-9.</ref> 


The majority of differences between adult and pediatric skeletal systems are due to the open physis in the pediatric population, which allows for continued growth prior to skeletal maturation during puberty and adulthood.[1] The physis is the growth plate in long bones including phalanges, fibula, tibia, femur, radius, ulna, and humerus. It allows for bone growth from a cartilage base, known as endochondral ossification, which differs from bone growth from mesenchymal tissue, or intramembranous ossification.[2] The physis is located towards the end of the long bone, with the epiphysis above it and metaphysis below it.[1] Long bones like the femur have 2 physes separated by a diaphysis, which is the shaft of a long bone. However, long bones like the phalanges have only one physis. The physis is split into 4 zones: (1) the reserve or resting zone, which is made up of hyaline cartilage; (2) the zone of proliferation, which is made up of multiplying chondrocytes that arrange into lacunae (lakes); (3) the zone of hypertrophy, where the chondrocytes stop dividing and start enlarging; and (4) the zone of calcification, where minerals are deposited into the lacunae to calcify the cartilage. The calcified cartilage breaks down allowing for vascular invasion and osteoblastic/osteoclastic bone matrix deposition and remodeling. Therefore, prior to ossification, the majority of pediatric bone is just calcified cartilage, which is very compliant when compared to the ossified bones of adults.[1] Due to their increased compliance, pediatric bones tend to have more bowing and bending injuries under stress that would cause a fracture in an adult bone.[1] Furthermore, the pediatric periosteum is more active, thicker and stronger in children, which greatly decreases the chance of open fractures and fracture displacement. These and other qualities of the pediatric periosteum, as well as the increased compliance of the pediatric bone, are responsible for the unique fracture patterns seen in pediatric patients. These fracture patterns include greenstick, torus, and spiral injuries, which are bending injuries rather than full thickness cortical breaks.[1] A greenstick fracture is a partial thickness fracture where only cortex and periosteum are interrupted on one side of the bone, while they remain uninterrupted on the other side.[1]<ref>https://www.ncbi.nlm.nih.gov/pubmed/30020651</ref>
== Etiology ==
 
'''Mechanism of injury''' is fall on the outstretched hand(FOOSH). It can also occur because of trauma such as road traffic accident, sports injuries or even a non accidental trauma (child hitting an object).<ref name=":0" />Vitamin D deficiency can also lead to greenstick fracture.<ref name=":0" />
== Etiology ==
Greenstick fractures occur most commonly after a fall on an outstretched arm (FOOSH); however, they can also occur due to other types of trauma including motor vehicle collisions, sports injuries, or non-accidental trauma where the child is hit with an object. Malnutrition, specifically vitamin-D deficiency increases the risk of greenstick fractures of the long bones after a trauma.


== Epidemiology ==
== Epidemiology ==
Approximately 12% of all pediatric emergency department visits in the United States are due to musculoskeletal injuries. Fractures make up a large percentage of musculoskeletal injuries resulting in significant morbidity and complications. Greenstick fractures are most likely to be found in the pediatric population under 10 years of age but can occur in any age group, including adults.[3] There is equal incidence rate in female and male patients, however, male patients are more likely to sustain fractures
Fractures are the most common musculoskeletal injuries. It is most found in children below 10 years of age. It is less commonly seen in adults. The incidence rate among male and female is the the same.<ref name=":0" />The overall incidence of pediatric distal forearm fractures, including greenstick fractures, is approximately 738.1/100,000 persons/year.<ref>Korup LR, Larsen P, Nanthan KR, Arildsen M, Warming N, Sørensen S, Rahbek O, Elsoe R. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9233428/ Children’s distal forearm fractures: a population-based epidemiology] study of 4,316 fractures. Bone & joint open. 2022 Jun 6;3(6):448-54.</ref>


== Pathophysiology ==
== Pathophysiology ==
A greenstick fracture is a partial thickness fracture where only cortex and periosteum are interrupted on one side of the bone but remain uninterrupted on the other.[1] They occur most often in long bones, including the fibula, tibia, ulna, radius, humerus, and clavicle. Most commonly, they occur in the forearm and arm involving either the ulna, radius or humerus.[1][3] This is because people brace falls with an outstretched arm, resulting in fractures to the upper extremities.
Green stick [[Fracture|fractures]] occur in arm and forearm which involves ulna, radius or humerus. Greenstick fractures may manifest in various anatomical regions, including the face, chest, scapula, and virtually all bones throughout the body. However, their occurrence in these locations is notably less frequent compared to their prevalence in long bones.<ref>Atanelov Z, Bentley TP. [https://www.ncbi.nlm.nih.gov/books/NBK513279/ Greenstick fracture.]</ref> The diaphysis and metaphysis are calcified in adult population and its weak in children leading to greenstick ,torus and plastic bending injuries. Greenstick fractures occurs anywhere in diaphysis and metaphysis but if the fracture is at the level of physis, it is no longer a green stick fracture.<ref name=":0" />
 
== History and Physical Examination  ==
It is similar to any other fracture. Age, location, involvement of the soft tissue , gender and mechanism of injury, neurovascular status are important features of history and examination.
 
Pain on palpation, reduced range of motion and ecchymosis over injured part , edema, abrasion , laceration are the findings of physical examination.<ref name=":0" />
 
== Physiotherapy Treatment ==
It can be treated by splinting but close monitoring of the family members is required. The duration of immobilization required to align the fragments properly is usually of 6 weeks.   
 
==== Physiotherapy Techniques ====
Physiotherapy treatment for greenstick fractures may include the following techniques<ref>Greenstick Fracture: Diagnosis and Prognosis - How Physiotherapy Returns Strength & Mobility; 2015 Dec 3.[https://www.physioinqstclair.com.au/blog/greenstick-fracture-diagnosis-and-prognosis-how-physiotherapy-returns-strength-mobility Available from:]</ref>:


Greenstick fractures can also occur in the face, chest, scapula and virtually every bone in the body, but with much less frequency than long bones.[3] For example, greenstick fractures can occur in the jaw and nose.[7] Condylar fractures are the most common pediatric mandibular fractures, accounting for up to 55% of all mandibular fractures.[8] There are 3 types of condylar fractures. Low subcondylar fractures are the most common and are incomplete greenstick fractures the majority of the time.[8] Nasal trauma most commonly leads to greenstick fractures in the pediatric population due to an unfused midline suture and majority cartilage make up of the nasal bones.[9]
* Massage and Heat Therapy: Employed for the purpose of alleviating persistent discomfort and diminishing residual swelling.
* Joint Manipulation: Physiotherapists may delicately manipulate the joint to facilitate the breakdown of initial scar tissue impeding normal range of motion.
* Exercise Program: Following a tailored exercise program designed by the physiotherapist is crucial for regaining full movement and preventing complications caused by tissue damage.


== References ==
== References ==
<references />
<references />
[[Category:Fractures]]
[[Category:Fractures]]
[[Category:Musculoskeletal/Orthopaedics]]
[[Category:Paediatrics]]
[[Category:Paediatrics - Conditions]]
[[Category:Rehabilitation Interventions]]

Latest revision as of 09:52, 20 November 2023

Original Editor - Nupur Smit Shah

Top Contributors - Nupur Smit Shah, Esraa Mohamed Abdullzaher, Olaniyan Victor, Kim Jackson, Wanda van Niekerk and Lucinda hampton  

Introduction[edit | edit source]

Green stick fractures occurs in the children below 10 years of age. [1]. The incidence of it is 1 in 100 and the most commonly affected age group is between 5 to 14 years. It rarely occurs in adults.[2]There is partial thickness fracture where only cortex and periosteum gets affected on one side of the bone and it remains uninterrupted on the other side of the bone.[1]Usually happens in long bones such as radius, ulna, femur, tibia, humerus. Green stick fractures are unstable and they continue to displace after first 2 weeks.[3]

Etiology[edit | edit source]

Mechanism of injury is fall on the outstretched hand(FOOSH). It can also occur because of trauma such as road traffic accident, sports injuries or even a non accidental trauma (child hitting an object).[1]Vitamin D deficiency can also lead to greenstick fracture.[1]

Epidemiology[edit | edit source]

Fractures are the most common musculoskeletal injuries. It is most found in children below 10 years of age. It is less commonly seen in adults. The incidence rate among male and female is the the same.[1]The overall incidence of pediatric distal forearm fractures, including greenstick fractures, is approximately 738.1/100,000 persons/year.[4]

Pathophysiology[edit | edit source]

Green stick fractures occur in arm and forearm which involves ulna, radius or humerus. Greenstick fractures may manifest in various anatomical regions, including the face, chest, scapula, and virtually all bones throughout the body. However, their occurrence in these locations is notably less frequent compared to their prevalence in long bones.[5] The diaphysis and metaphysis are calcified in adult population and its weak in children leading to greenstick ,torus and plastic bending injuries. Greenstick fractures occurs anywhere in diaphysis and metaphysis but if the fracture is at the level of physis, it is no longer a green stick fracture.[1]

History and Physical Examination[edit | edit source]

It is similar to any other fracture. Age, location, involvement of the soft tissue , gender and mechanism of injury, neurovascular status are important features of history and examination.

Pain on palpation, reduced range of motion and ecchymosis over injured part , edema, abrasion , laceration are the findings of physical examination.[1]

Physiotherapy Treatment[edit | edit source]

It can be treated by splinting but close monitoring of the family members is required. The duration of immobilization required to align the fragments properly is usually of 6 weeks.

Physiotherapy Techniques[edit | edit source]

Physiotherapy treatment for greenstick fractures may include the following techniques[6]:

  • Massage and Heat Therapy: Employed for the purpose of alleviating persistent discomfort and diminishing residual swelling.
  • Joint Manipulation: Physiotherapists may delicately manipulate the joint to facilitate the breakdown of initial scar tissue impeding normal range of motion.
  • Exercise Program: Following a tailored exercise program designed by the physiotherapist is crucial for regaining full movement and preventing complications caused by tissue damage.

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Atanelov Z, Bentley TP. Greenstick fracture.
  2. ↑ Lin YC, Wang WT. Greenstick fracture of the ulnar shaft following physical therapy in an adult: A case report. Medicine. 2020 Dec 11;99(50).
  3. ↑ Randsborg PH, Sivertsen EA. Distal radius fractures in children: substantial difference in stability between buckle and greenstick fractures. Acta orthopaedica. 2009 Oct 1;80(5):585-9.
  4. ↑ Korup LR, Larsen P, Nanthan KR, Arildsen M, Warming N, Sørensen S, Rahbek O, Elsoe R. Children’s distal forearm fractures: a population-based epidemiology study of 4,316 fractures. Bone & joint open. 2022 Jun 6;3(6):448-54.
  5. ↑ Atanelov Z, Bentley TP. Greenstick fracture.
  6. ↑ Greenstick Fracture: Diagnosis and Prognosis - How Physiotherapy Returns Strength & Mobility; 2015 Dec 3.Available from:
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