Overview
Definition:
Greenstick fractures are incomplete fractures where the bone bends and breaks on one side but remains intact on the other, resembling a green twig
Buckle (or torus) fractures are a type of incomplete fracture characterized by a bulging or compression of the metaphyseal bone, commonly seen in the distal radius and tibia, without a distinct cortical break
Both are prevalent in pediatric long bones due to their greater bone elasticity and less ossified cortices compared to adults.
Epidemiology:
Pediatric fractures account for approximately 15-25% of all fractures, with incomplete fractures like greenstick and buckle being the most common types
Buckle fractures are the most frequent type of forearm fracture in children under six years old
Greenstick fractures are also common in younger children, often occurring in the radius, ulna, tibia, and fibula.
Clinical Significance:
Accurate diagnosis and appropriate immobilization of greenstick and buckle fractures are crucial for optimal bone healing, preventing long-term deformities, and minimizing pain and functional impairment in children
Understanding the differences in their mechanism, radiographic appearance, and management is vital for pediatricians and orthopedic surgeons preparing for DNB and NEET SS examinations.
Clinical Presentation
Symptoms:
Sudden onset of pain at the fracture site
Swelling and tenderness over the affected bone
Visible deformity may be absent or subtle
The child may refuse to use the affected limb
History of a fall or direct trauma to the bone
Absence of crepitus, which is more common in complete fractures.
Signs:
Localized tenderness on palpation
Palpable swelling
Mild deformity may be evident, often described as a "bump" or angulation
Range of motion may be limited due to pain
Neurovascular status of the distal limb must be assessed and documented
Skin integrity should be checked for any open wounds.
Diagnostic Criteria:
Diagnosis is primarily based on clinical suspicion and confirmed by radiographic imaging
Radiographs typically show characteristic signs: for greenstick fractures, a visible cortical disruption on one side with buckling or angulation on the other
for buckle fractures, a focal bulging or compression of the bone cortex without a discrete fracture line.
Diagnostic Approach
History Taking:
Detailed mechanism of injury: mechanism of trauma (fall, direct blow)
Age of the child is a critical factor influencing bone elasticity
Any prior fractures or bone conditions
Characterization of pain: onset, severity, exacerbating/alleviating factors
Assessment of functional limitation
History of falls or abuse should be considered.
Physical Examination:
Systematic examination of the affected limb, including inspection for swelling, deformity, and skin integrity
Palpation for point tenderness and crepitus (less common in these fractures)
Assessment of distal pulses, capillary refill, sensation, and motor function to rule out neurovascular compromise
Compare with the contralateral limb.
Investigations:
Radiography is the gold standard
Standard anteroposterior (AP) and lateral views of the affected bone and adjacent joints are essential
In cases of suspected occult fractures or when initial radiographs are equivocal, oblique views or comparison with the contralateral limb may be helpful
CT or MRI are rarely indicated for these uncomplicated fractures but may be considered for complex injuries or when bony detail is crucial.
Differential Diagnosis:
Other pediatric fractures (complete, plastic deformation)
Soft tissue injury (sprain, contusion)
Physeal injuries (Salter-Harris fractures)
Stress fractures
Bone tumors or metabolic bone disease (less common presentations)
Abuse-related injuries.
Management
Initial Management:
Pain control with analgesics (e.g., paracetamol, ibuprofen)
Immobilization with a splint (e.g., posterior plaster splint) to provide initial comfort and prevent further displacement
Avoid aggressive manipulation unless a significant deformity needs correction, and even then, be cautious.
Immobilization Choices:
The choice of immobilization depends on the location, degree of angulation, and stability of the fracture
Buckle Fractures: Typically managed conservatively with a short arm cast or splint for 3-6 weeks
Cast should immobilize the wrist and elbow if the distal radius/ulna is involved
Immobilization is usually well-tolerated
Greenstick Fractures: If minimally displaced (<10 degrees angulation), a simple cast is often sufficient
If there is significant angulation, gentle closed reduction may be attempted to achieve acceptable alignment (usually <10-15 degrees of angulation is acceptable in pediatric long bones, especially in younger children)
Post-reduction, immobilization in a cast is required, typically for 4-8 weeks depending on the bone and age
The cast should extend beyond the fracture site and include the joints above and below.
Reduction Techniques:
Gentle closed reduction is indicated for greenstick fractures with significant angulation that is unlikely to remodel spontaneously
This involves applying gentle pressure in the opposite direction of the deformity
The goal is to achieve acceptable alignment, not necessarily anatomical reduction
Over-reduction should be avoided
Post-reduction radiographs are crucial to confirm alignment.
Supportive Care:
Elevation of the limb to reduce swelling
Application of ice packs for pain and edema control
Education for parents/guardians on cast care, signs of complications (e.g., compartment syndrome, cast tightness), and activity restrictions
Regular follow-up appointments for clinical and radiographic assessment.
Complications
Early Complications:
Neurovascular compromise (rare, but important to monitor)
Compartment syndrome (very rare in incomplete fractures but can occur with excessive swelling or tight casting)
Skin breakdown under the cast
Post-reduction malunion if reduction is not adequate.
Late Complications:
Growth disturbance if the physis is involved or affected by initial trauma
Malunion leading to residual deformity and functional impairment (less common due to remodeling potential)
Stiffness or decreased range of motion
Nonunion (extremely rare for these fracture types).
Prevention Strategies:
Careful assessment of neurovascular status before and after immobilization
Ensuring the cast is not too tight
Regular monitoring for signs of complications
Appropriate selection of immobilization technique and duration
Aiming for acceptable, not necessarily anatomical, alignment in greenstick fractures due to excellent remodeling capacity.
Prognosis
Factors Affecting Prognosis:
Age of the child (younger children have better remodeling potential)
Degree of initial displacement and angulation
Involvement of the physis
Adequacy of immobilization and reduction
Presence of any associated injuries.
Outcomes:
The prognosis for both greenstick and buckle fractures is generally excellent
With appropriate management, most children achieve full functional recovery with minimal or no long-term sequelae
Remodeling capacity in children often corrects residual angulation over time
Growth disturbances are the primary concern if the physis is significantly impacted.
Follow Up:
Initial follow-up within 1-2 weeks to check for cast fit, swelling, and neurovascular status
Subsequent follow-up at 4-6 weeks with radiographs to assess healing and bony union
Complete union and return to full activity typically occurs within 6-8 weeks
Long-term follow-up is generally not required unless growth disturbances are suspected or there is significant residual deformity.
Key Points
Exam Focus:
Recognize the radiographic appearance of greenstick (incomplete break with bending) vs
buckle (cortical impaction/bulging)
Understand that both are incomplete pediatric fractures with excellent remodeling potential
Key management is conservative immobilization
reduction is reserved for significant angulation in greenstick fractures
Always assess neurovascular status.
Clinical Pearls:
In young children, accept a greater degree of angulation for greenstick fractures as remodeling will likely correct it
Buckle fractures often require only a simple splint or cast and are very stable
Remember to date and time all neurovascular assessments
Consider non-accidental trauma if the mechanism is inconsistent with the injury.
Common Mistakes:
Over-reduction of greenstick fractures, leading to instability or reversal of angulation
Inadequate immobilization leading to displacement
Failure to recognize and manage early signs of compartment syndrome or neurovascular compromise
Ignoring the potential for physis injury when assessing these fractures.