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The bones of the children break differently – Greenstick Fracture.

Greenstick fracture is typical of kids, although anyone can have it. Enter here to find out why, and its possible problems in the long run.

Sadly, particularly for children, this fracture can yield undesired complications. This situation exists because of the precise composition of the children’s bones. And, of course, the importance the bone has at that critical age regarding further development and growth.

By reading this article, you would obtain in-depth knowledge directly from a doctor about a common type of fracture in children, greenstick fracture. Here, you would learn the definition, causes, symptoms, diagnosis, treatment, and a little more. Importantly, always with the most up to date information on the medical field.

How are broken bones in kids different?

The cornerstone for understanding why a bone fracture in a kid is slightly different is learning about its bone structure. The child or pediatric bone has distinctive features that contrast to the adult bone. So, let us jump into that.

A bone of a child cannot be perceived just as a smaller bone of an adult person. Its primary purpose in a human of this age is to serve growth. Therefore, it is under a continuous change in order to eventually migrate into an adult bone. Importantly, the core structure that allows this to happen is the open physis (or growth plate).

Archivo:Tib fib growth plates.jpg
Xray of the lower leg of a 12-year-old child showing growth plates

Furthermore, there are different types of bones. The growth plate exists in long bones, which are the ones composing body parts like the hand, leg, thigh, forearm, and arm. Its noteworthiness grounds on the fact that it allows the bone to grow differently, mainly from a cartilage base, which is known as endochondral ossification. That is why it is so crucial for healthy development.

The physis’ location is at the end of the bones (see the image below). What is above the physis is called epiphysis, and below it, metaphysis. Notably, long bones like the femur (thighbone) will have two physes, which are in separation by a diaphysis. And, shorter bones, like the ones in hand (phalanges), will only have one.

File:623 Epiphyseal Plate-Line.jpg
Growing vs mature long bone.

Characteristically, before a complete bone maturation, children’s bone mostly is calcified cartilage rather than actual bone. Therefore, it is more elastic when compared to adult bone. Besides, the external layer of the bone known as “periosteum” similarly, in children, it is different. In this particular population, this layer is thicker and stronger.

So, how this modifies the fractures?

Fractures could exist either as a complete or incomplete. A complete fracture is when from side to side, the bone breaks. On the other hand, in an incomplete fracture, there is only one side broken, like a greenstick fracture.

The child’s bone is more flexible. Therefore, it is keener to suffer more from bowing and bending injuries (or incomplete fractures) from the stress that usually would have caused a complete fracture in an adult.

Also, we said that the outer layer of the bone is way more strong in children’s bones than in adults. Well, this characteristic also plays a significant role in bone fracture. This layer is in relationship to lesser open and displaced fractures, which are among the ones with more complications.

Importantly, the difference between children and adults is not only how their bone breaks. It is also how the bones heal. The outer bone layer is “metabolically active,” which means that it is very good at producing energy. Therefore, children’s bone tendency is to heal faster than adults’.

Is there more than just one pediatric fracture?

A pediatric fracture is the term doctors use for describing the typical fracture patterns seen in this younger population of patients. The tendency here will be for incomplete fractures, and greenstick fracture is not the only one.

  • Torus fracture (which is the same as buckle fracture): Disruption of the bone in the site of the impact.
  • Greenstick fracture: Disruption of the bone in the side contrary to the site of impact.
  • Bowing fracture: There is no bone disruption, but it loses its normal alignment with the body, is angulated.

Furthermore, in children, the growth plate (or epiphyseal plate) is so essential that when a fracture touches it, there will be an individual classification for that. This type of fracture is known as the Salter-Harris fracture or growth plate fracture.

The most common sites for this type of fracture is in the forearm, and the arm, which will account for distal radius, and distal humerus, respectively. It has a classification in five types, which includes:

  • Type I: Transverse fracture of the growth plate, which separates the epiphysis from the metaphysis.
  • Type II: Transverse fracture of the metaphysis and growth plate.
  • Type III: Transverse fracture of the growth plate and epiphysis, which may extend to the joint and affect the articular surface.
  • Type IV: A total fracture of the three essential structures, as are the epiphysis, metaphysis, and growth plates. Besides, it enters and always affects the joint.
  • Type V: Total disruption of the physis. Typically because of a high impact trauma like a crush injury.

This classification defines further treatment. Classically, type I and II will not always require surgery. Conversely, type III, and IV will require open reduction and internal fixation. This means using wires or screws to put the bone back in alignment.

What is a greenstick fracture?

A greenstick fracture is a partial thickness fracture where there is only an interruption of the external bone layer on one side of the bone, whereas the other remains intact.

The theory explaining greenstick fractures is simple. A child’s bone is immature; hence, it has more collagen than an adult bone. The higher ratio of immature cells over mature and fully formed ones, being the latter more rigid, is what increases the odds of having this type of fracture in children.

What happens in a greenstick fracture?

Greenstick fractures mostly exist due to a fall on an outstretched hand. However, it can happen because of other types of trauma, such as vehicle collisions, sports injuries (stress fracture), or without accidents, like child maltreatment.

Therefore, for having a broken bone, what is necessary is an injury from whatever source. In specific scenarios, children may have bone weakness due to poor nutrition or lack of vitamin-D. And, they become vulnerable, it is more likely for them to develop greenstick fractures in contrast to the other kids.

Furthermore, it is important to highlight other essential features of the greenstick fractures. The growth plate has a stable surrounding by metaphysis, diaphysis, and outer bone layer. And, despite that powerful surrounding, the core of the growth plate is weak; hence, it is where most of the fractures occur.

Sadly, injury of the growth plate can lead to bone growth impairment, with many complications in the long run, as we will see. Greenstick fractures can occur anywhere throughout the bone. However, if there is growth plate involvement, its name no longer is greenstick fracture. It will be a Salter-Harris fracture.

How are the bones classified?

Firstly, let us define what the types of fractures are—for then, giving a specific name for the greenstick fracture.

Classification according to the cause.

In this classification, there would be three major types. The list includes:

  • Classical fracture: Fractures that exist because of a high energy impact, like a collision. This situation is the most common for fractures, a trauma that breaks the bone.
  • Pathologic fracture: There is a bone weakness due to an underlying disease that predisposes the bone to fractures with mild traumas. This situation ranges from preventable illnesses like osteoporosis to devastating bone cancer.
  • Stress fracture: This fractures grounds on repetitive movements that end in bone damage.

Classification according to the mechanism of fracture production.

Here, there would be two groups, fractures either by direct and indirect mechanisms of production. The former implies that the trauma was directly on the bone and broke it. Then, the latter has several ways of occurring because it means that injury was not directly on the bone, but broke it anyway. It includes:

  • Compression fracture: it tends to affect the bones in the spinal column.
  • Flexion fracture.
  • Shear fracture: It mostly causes a transverse fracture.
  • Torsion fracture: It mostly cases an oblique fracture.
  • Traction fracture: This fracture is typical of avulsion fracture in which the muscle-tendon pulls a part of the bone in which it is inserted.

Classification according to skin affection.

Here the classification is straightforward into open or closed fractures. The former means there is a skin breach due to injury. Therefore, there is more risk of infections, impairs bone healing, and halts possible medical treatments.

On the other hand, closed fractures are fractures that are not in communication with the outside world. In here, there is not any skin hole or opening that can yield complications.

Classification according to the fracture pattern.

The fracture pattern is how the fracture looks in specialized imaging medical exams. There are two broad groups.

Firstly, there is an incomplete fracture in which the fracture is not affecting the whole bone, just partially. Most of the time, these types of fractures are from children; it includes:

  • Fissures.
  • Greenstick fracture.
  • Torus fracture.

Secondly, there is a complete fracture in which the whole bone is broken. Its division comprises the following:

  • Simple complete fracture: There is just one fracture line, and all the bone segments are in its normal alignment.
  • Displaced complete fracture: The resulting bone fragments from the fracture lose its normal alignment.
  • Comminuted fracture: More than two bone fragments are resulting from the fracture.

Classification according to stability.

Here there will be two types. A stable fracture is the one that does not tend to lose its body alignment. On the other hand, unstable fractures are the ones that tend to lose the normal arrangement.

A fracture is more difficult to handle when the bone parts are spread. Therefore, an unstable or even worse, a displaced fracture is a worse scenario.

What type of fracture is a greenstick fracture?

Basically, a greenstick fracture is an incomplete fracture. Also, it depends on the mechanism of production or cause or skin affection, as we recently saw, that it could similarly classify as other types of fractures.

How common is greenstick fracture?

The greenstick fractures occur more often in a long bone. These bones have their location in the leg, forearm, arm, and chest, which will account for fibula and tibia, ulna and radius, humerus, and clavicle, correspondingly. Interestingly, the most common one is the arm and forearm fracture. Hence, upper extremity fracture.

Nevertheless, it can occur virtually, anywhere in the body, like in the face, although with a much lower frequency. For example, condylar fractures are among the most common pediatric mandibular fractures. From which, low subcondylar fractures are the most common and are greenstick most of the time.

Let us talk a little more about it.

Specifically, distal radius fracture is the most common fracture in childhood. The forearm has two bones, the radius and the ulna. The distal radius is the portion of the bone that is closer to the wrist bones. And, also, the wrist is structured on eight little bones. All of them can be seen in the image below.

Importantly, the wrist joint is formed by the binding of the distal radius and the wrist bones. It is not uncommon for someone that falls with the outstretched hand to have, besides the radius fracture, wrist fractures, or an ulnar fracture. As you can see in the image, all the bones are nearby and in a close relationship.

File:Wrist anatomy.jpg
Wrist Anatomy.

Then again, in the elbow, there is the direct articulation between humerus and the ulna. Plus, a coupling between the radial head and capitulum of the humerus. When children fall on an outstretched arm, the capitulum could cause tremendous stress over the radius head and neck, which may result in its fracture. Therefore, the radius, or any other bone, could be broken in several places, depending on how it happened.

File:915 Elbow Joint.jpg
Elbow joint

Who is most likely to get a greenstick fracture?

Importantly, up to 12% of children’s visits to the emergency department in the United States are because of injury in the bones or muscles. The fractures occupy a representative proportion in that number, mostly in complications.

Moreover, greenstick fractures are most likely to be found in the children below ten years old. However, it can also occur in adults.

There are risk factors that, if existent on children, it could lead to an increase in the risk of sustaining a greenstick fracture. For example, children with inadequate nutrition, or with a vitamin-D insufficiency have a higher risk of it after direct trauma on their long bones.

Can adults get a greenstick fracture?

Yes, it is less common for adults, but, similarly, it is a possibility to have a greenstick fracture. However, the locations and frequency are no the same as in children.

What are the symptoms of greenstick fractures?

Regularly, the signs and symptoms, and the previous history of a patient with a greenstick fracture are otherwise identical as any fracture.

A doctor will be asking for age, injury location, skin affection, and the injury mechanism. Also, it would want to discard soft tissue (flesh underneath the skin) or nerve involvement that could suppose a more complicated fracture.

The list of symptoms include:

  • A patient will refuse to move the body part where the injury is.
  • The patient could be crying inconsolably.
  • There will be a complaint about pain in the injured area.
  • A patient could be overprotective over the injured area.

The list of the signs or doctor’s findings include:

  • Decreased movement of the injured body part.
  • Pain elicited by touching the injured area.
  • There is swelling in the injured area.

Moreover, mild fractures may be overlooked by parents. This situation is in light of perhaps more soothing symptoms in these fractures. Therefore, it exposes kids with fractures to endure their ailment without conventional measures that assure correct healing. Please, remember that, in the end, it could carry complications in the long run. For acknowledging possible difficulties, refer to the next question.

Is greenstick fracture capable of yielding complications?

Generally, greenstick fractures have outstanding outcomes. Nearly all of the fractures heal without compromising bone functionality or appearance.

However, if the greenstick fracture does not receive proper immobilization plus close doctor monitoring, a child will have the risk of:

  • Having a second greenstick fracture in the same place.
  • The fracture converts into a complete fracture.
  • The fracture worsens into a displaced fracture.

Importantly, a displaced fracture is the one that causes deformity. Accordingly, when a doctor is looking for fracture displacement, most of the time will search for body deformity.

How is a greenstick fracture diagnosed?

Greenstick fractures evaluation requires an X-ray of the injured body part or area of complaint. Most of the time, the X-ray will show a bending injury with a fracture line that does not entirely pass the bone.

Typically, there will be a fracture in the site of trauma, and in the opposite place of the bone, due to compressive forces, it will exist deformation.

Do greenstick fractures require surgery?

No, the treatment of greenstick fractures does not require surgery. A splint or a cast will be more than enough, also, in the situation where the bone bending causes a significant angulation. A doctor will perform special maneuvers called “closed reduction,” which means putting back the bone in alignment without surgery. For then, the patient can start using its immobilization treatment.

How is a greenstick fracture treated?

All greenstick fractures treatment require immobilization. Visiting specifically an orthopedic (or bone) doctor is a general recommendation, although it depends on the bone bending (angulation) and age of the child.

The cast is a hard material that wraps up the site of the injury, including one joint above and below the fracture, for keeping it as still as possible. Firstly, cotton is used to pad the skin, and then the cast material is applied wet. In a few minutes, it will become hard enough to sustain the extremity in whatever position it is. This position will be specific for the fracture’s location. Unless told otherwise, the cast must be dry and clean for avoiding complications.

Medic Treating Patient, accident, adult, african, bandage, bed, HD wallpaper
A cast.
Source: here.

The splint is a device either rigid or flexible that manages to maintain a movable body part still or protected. This treatment modality has the advantage of being removable. Therefore, a removable splint will be useful for patients when taking a bath, which in the case of having a cast can be bothersome.

It would depend on the specific fracture, but, right now, there are studies worldwide comparing the cast versus the splint. The splint is cheaper, and in some studies, it yields comparable results to the cast performance. However, this situation is still a matter of discussion. For now, the splint is for milder fractures and early immobilization. On the other hand, the cast is for more definitive treatment.

How long does a greenstick fracture take to heal?

Fracture healing is a process that, in this case, will usually take six weeks with a cast or splint. However, that is just the immobilization. After that, it would depend on the progress and the site or severity of the fracture if further time or additional treatment is needed.

Can the fracture heal without the cast?

No, a proper fracture healing always requires immobilization treatment either with a cast or a splint. By not doing so, the child is vulnerable to all the possible complications of greenstick fractures, which includes even worse fractures anytime soon.

What can I do if my child is having symptoms?

This tool is a greenstick fracture symptoms checker. Its design intends to gather most of the risk factors, signs and symptoms of a fracture, in order to determine the likelihood of a child having a fracture. And, most likely, a greenstick fracture. It is free, and it would only take a few minutes.

What do you think?

Written by Dr. Esteban Kosak

Doctor of Medicine - MD Recently Graduated from Medical School and inspired to aid the global population during this situation. I think that we shall no longer be waiting to see a doctor when we feel sick. Several times we feel disease searches in Google drive us to a rabbit hole and come out thinking that we may die of cancer or something very serious, given that symptoms may seem to fit a wide variety of illnesses. Since I recently graduated from medical school. I have all the medical information fresh in my mind. My thorough experience as an expert researcher allows me to very-well known the different diseases and conditions that affect human bodies. Empowered by the United Nations 17 Sustainable Development Goals (SGDs). I think that we all can provide a grain of sand to help humanity. That's why we created Symptoms.Care a place where you can come and screen your symptoms and find what different illnesses can be related to them. Armed with the right information you can instantly, discretely, secure and from the comfort of your home talk with a Doctor that can Evaluate your Symptoms and help you seek the right treatment.


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