What is the recommended treatment for a patient with a green stick fracture?

Treatment of Greenstick Fractures

Greenstick fractures should be treated with closed reduction and immobilization using either a cast or brace, with direct discharge from the emergency department being a safe and effective option that eliminates the need for routine follow-up in most pediatric cases. 1

Initial Management

Immediate Treatment Steps

• Provide appropriate pain management immediately before diagnostic investigations using regular analgesics tailored to patient comorbidities 2, 3
• Obtain radiographs to confirm the diagnosis and assess angulation 4
• Assess whether the angulation exceeds the child's remodeling capacity (generally >10-15 degrees depending on age and location) 4

Reduction Technique Decision

• For fractures with angulation exceeding remodeling capacity, perform closed reduction to minimize residual deformity 4
• Manual completion of the fracture (breaking the intact cortex) reduces secondary deformities when primary angulation is excessive, but does NOT prevent refracture 4
• Completion of the fracture should be considered when angulation is significant, as it results in significantly smaller residual deformities compared to reduction without completion or plaster fixation alone 4

Immobilization Options

Cast vs. Brace Selection

• For impacted greenstick fractures with minimal displacement, soft bandage therapy is safe and effective, allowing faster return to normal activities with comparable final outcomes to rigid casting 5
• Rigid cast immobilization remains appropriate for fractures requiring more stability 1, 5
• Removable braces are non-inferior to traditional casting for isolated greenstick fractures of the distal radius or ulna in children 1

Expected Pain Patterns

• Patients treated with soft bandage experience greater pain during the first week compared to cast therapy, but have significantly less overall discomfort and better wrist function at 4 weeks 5
• Cast therapy provides better pain control in the first week but results in more discomfort overall 5

Follow-Up Strategy

Direct Discharge Protocol

• Direct discharge from the emergency department without routine follow-up is non-inferior to traditional treatment for isolated greenstick fractures of the distal radius or ulna 1
• Provide patients with a brace, written information, and access to a helpline for questions during recovery 1
• This approach significantly reduces secondary healthcare utilization by eliminating an average of 1.17 follow-up appointments without compromising outcomes 1

When Follow-Up IS Required

• Routine radiographic follow-up at 4-6 weeks after injury is essential to detect partial consolidation and prevent refracture 4
• Continue immobilization if radiographs show only partial consolidation at 4-6 weeks 4
• Close monitoring with follow-up imaging is necessary to ensure proper healing and detect any loss of reduction 3

Refracture Prevention

High-Risk Factors

• Older children (approaching adolescence) have significantly higher refracture risk compared to younger children 4
• Refractures occur at a rate of 6.7%, typically within 49 days (range 29-76 days) after cast removal 4
• Patients with radiographic signs of only partial consolidation at the time of physical activity resumption have significantly higher refracture rates 4

Prevention Strategy

• Do not allow return to full physical activities until radiographic evidence of solid consolidation is present 4
• Manual completion of the fracture does not prevent refracture despite reducing deformity 4

Rehabilitation Protocol

Early Mobilization

• Begin aggressive finger and hand motion immediately after immobilization is discontinued to prevent edema and stiffness 6, 3
• Early physical training and muscle strengthening should be introduced in the postfracture period 3
• Inadequate pain management during rehabilitation can lead to poor outcomes, so pain control must be prioritized throughout healing 3

Special Considerations for Post-Surgical Cases

• In adults or cases requiring internal fixation, be aware that cortex near drill holes is weakened and greenstick fractures can occur during physical therapy 7
• Physicians and therapists should exercise caution during rehabilitation after implant removal 7

Key Clinical Pitfalls

• Failing to obtain follow-up radiographs at 4-6 weeks risks missing partial consolidation, leading to refracture when activities resume 4
• Assuming all greenstick fractures need routine orthopedic follow-up wastes healthcare resources when direct discharge protocols are safe and effective 1
• Delaying mobilization after immobilization ends results in stiffness and suboptimal functional recovery 3
• Allowing return to sports or physical activities based on clinical healing alone without radiographic confirmation of consolidation increases refracture risk 4