What is the treatment for a green stick fracture in a pediatric patient's ankle?

Treatment of Green Stick Pediatric Ankle Fractures

For green stick fractures of the pediatric ankle, functional treatment with a removable brace or splint is recommended over rigid immobilization, as this approach leads to faster recovery of function and earlier return to normal activities.

Diagnosis and Assessment

When evaluating a pediatric patient with a suspected ankle fracture:

• Apply the Ottawa Ankle and Foot Rules to determine the need for radiography, which have high sensitivity (99.7%) for detecting fractures in children over 5 years of age 1
• Green stick fractures are incomplete fractures where one side of the bone is broken while the other is bent
• Distinguish from sprains through proper imaging, as recent MRI studies suggest many clinically diagnosed "low-risk ankle fractures" may actually be sprains or bone bruises 2

Treatment Algorithm

Step 1: Initial Management (0-72 hours)

• Implement the PRICE protocol 1:
  • Protection: Protect the ankle from further injury
  • Rest: Limit weight-bearing for 48-72 hours
  • Ice: Apply for 15-20 minutes every 2-3 hours
  • Compression: Use elastic bandage to reduce swelling
  • Elevation: Keep ankle elevated above heart level

Step 2: Primary Treatment (Days 3-14)

• Use a removable ankle brace or splint rather than a rigid cast 1, 2
  • Low-quality evidence shows better functional outcomes at 4 weeks with braces compared to rigid casts
  • Children treated with braces return to normal activities approximately 6 days earlier than those in casts
  • Patient preference strongly favors removable braces over rigid casts

Step 3: Rehabilitation (Beginning Days 3-7)

• Initiate functional rehabilitation within 48-72 hours of injury 1:
  1. Begin with gentle range of motion exercises
  2. Progress to strengthening exercises
  3. Add balance and proprioceptive training
  4. Gradually return to sport-specific activities

Step 4: Follow-up and Monitoring

• Clinical reassessment at 2-4 weeks 1
• Limit post-treatment imaging to cases where it would change management 1
• Monitor for proper alignment and healing

Medication Considerations

• NSAIDs (e.g., ibuprofen) can help reduce pain and swelling 1
• Evidence shows NSAIDs improve pain control, decrease swelling, and speed return to activity

Special Considerations

Potential Complications

• Watch for progressive valgus deformity, which can occur after green stick fractures 3
• Consider surgical intervention only if:
  • Significant displacement or angulation is present
  • Medical treatment has been maximized for at least 12 months and deformity persists 1
  • The patient has symptoms interfering with function

Age Considerations

• Surgical options depend on remaining growth potential 1
• Guided growth techniques must be performed 2-3 years before skeletal maturity
• Complications from osteotomy are reduced when performed later in childhood

Common Pitfalls to Avoid

1. Overtreatment with rigid immobilization: This delays return to function and activities
2. Failure to provide a protective sock with braces: Can lead to pressure-related complications 2
3. Unnecessary follow-up imaging: Only perform imaging that will change management 1
4. Neglecting functional rehabilitation: Essential for optimal recovery and prevention of recurrence

By following this approach, most pediatric patients with green stick ankle fractures will achieve excellent outcomes with minimal disruption to their activities and development.