What is the management plan for a greenstick fracture?

Management of Greenstick Fractures

The management of greenstick fractures should focus on conservative treatment with functional taping or splinting for non-displaced fractures, while considering completion of the fracture for those with significant angulation to prevent secondary deformities. 1

Assessment and Diagnosis

• Evaluate key fracture characteristics:

  • Location (most common in distal radius in children)
  • Displacement and angulation
  • Rotation
  • Neurovascular status
  • Integrity of surrounding structures

• Diagnostic imaging:

  • X-rays are standard but ultrasound has been shown to be more sensitive for detecting undisplaced greenstick and torus fractures 2
  • Consider multiple views to fully assess the fracture pattern

Treatment Algorithm

Non-displaced or Minimally Displaced Fractures

1. Conservative management:

   • Functional taping or splinting
   • Removable braces (such as Futuro splints)
   • Double Tubigrip bandaging has shown superior results for undisplaced fractures in terms of:
     • Less interference with activities of daily living
     • Reduced stiffness
     • Better grip strength maintenance 2

2. Immobilization period:

   • Typically 3-4 weeks depending on:
     • Patient age (younger patients heal faster)
     • Fracture location
     • Fracture stability

Displaced Fractures

1. Closed reduction:

   • Indicated for fractures with unacceptable angulation (>70 degrees) 1
   • Apply gentle pressure to restore anatomical alignment

2. Consideration for fracture completion:

   • Completing the fracture (breaking the intact cortex) may be considered to:
     • Achieve better reduction
     • Reduce the risk of secondary deformities
   • However, this does not prevent refracture and should be done cautiously 3

3. Post-reduction immobilization:

   • Cast or splint for 4-6 weeks
   • Position depends on fracture location (typically in functional position)

Follow-up Protocol

1. Initial follow-up at 1-2 weeks:

   • Assess pain control
   • Check for displacement
   • Evaluate finger/limb motion 1

2. Radiographic follow-up at 4-6 weeks:

   • Confirm fracture healing
   • Assess for signs of partial consolidation
   • Continue immobilization if consolidation is incomplete to prevent refracture 3

Rehabilitation

1. Early mobilization:

   • Begin as soon as immobilization is discontinued
   • Start with gentle active range of motion exercises
   • Progress to strengthening exercises as tolerated

2. Return to activities:

   • Gradual return to normal activities after radiographic healing
   • Avoid contact sports for 6-8 weeks after fracture

Direct Discharge Protocols

Recent evidence supports direct discharge protocols for children with greenstick or torus fractures of the wrist:

• Patients receive a brace and information (often via smartphone app)
• No routine follow-up appointments
• Access to helpline for questions during recovery
• This approach has shown non-inferior treatment satisfaction compared to traditional management
• Results in comparable functional outcomes with significantly reduced healthcare utilization 4

Potential Complications

• Refracture: More common in:

  • Older children (statistically significant risk factor)
  • Fractures with manual completion but only partial consolidation 3
  • Prevention requires adequate immobilization until complete healing

• Secondary deformities:

  • More likely with conservative management of significantly angulated fractures
  • May require corrective osteotomy if deformity exceeds remodeling capacity 3

• Stiffness and reduced range of motion:

  • Can be minimized with appropriate rehabilitation
  • More common with prolonged immobilization

By following this structured approach to greenstick fracture management, optimal functional outcomes can be achieved while minimizing complications and unnecessary healthcare utilization.