The case

A gradeschooler presents to the Emergency Department after injuring his arm on the playground. He jumped off the elevated platform while shouting “I am Iron Man!” He was alas, not Iron Man, and instead snacked his arm directly on a ladder. now his arm hurts a lot and the school called his parents. He’s embarrassed. The school had to fill out, like, seventeen forms. An ambulance got called. Everyone was talking about it, and his nickname is now Tony Stank.

In the Emergency Department you got X-Rays because his arm looked like it was bent weird. here is what they showed.

The Diagnosis

This is a greenstick fracture of the radius. A greenstick fracture is distinct from the buckle or torus fracture that you are also familiar with. These incomplete long bone fractures are seen in children under ten years of age and are either due to longitude forces during a fall onto an outstretched hand, or as was the case here, a direct blow perpendicular to the bone itself. The cortex and periosteum are only completely broken on one side.

The reason that the bones break like they do is because of the robust periosteum that young children possess. Imagine taking an unripe banana and trying to snap it in half. You will “break” the actual fruit inside, but the peel will remain intact to a degree. That’s the periosteum – It allows for these types of fractures where part of the bone “breaks” and the other side is held together. The eponymous fracture name comes from the similarly descriptive breaking of a newly grown branch/twig that is still “green” on the inside.

Management

These fractures are rarely open – but if it is give antibiotics ASAP! Cefazolin would be a great choice. Otherwise the degree of adulation dictates what you do next. Generally a fracture greater than 15-20 degrees necessitates closed reduction. This should be done under IV procedural sedation for most children this age. A minimally angulated fracture can be splinted in the ED without manipulation. The ideal splint for this fracture would be a sugar tong. Children will eventually need a cast for up to 6 weeks. Fortunately healing is rapid, and recovery rate is incredibly high.

References

Atanelov Z, Bentley TP. Greenstick Fracture. [Updated 2020 Aug 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513279/

Saber et al. Radiopaedia: Greenstick Fractures. https://radiopaedia.org/articles/greenstick-fracture?lang=us

Schmuck et al. Greenstick fractures of the middle third of the forearm. A prospective multi-centre study. Eur J Pediatr Surg. 2010 Sep;20(5):316-20.