Green-stick fracture management in children
Green-stick forearm fractures in children are managed with immobilization in a well-molded cast or splint, with reduction performed when alignment is unacceptable. [1][2] Urgent reassessment is required for neurovascular compromise, open fracture, or inability to maintain reduction. [2][3]
Initial assessment and injury recognition
Forearm fracture assessment should include evaluation of elbow, wrist, and forearm alignment and function. [2] Neurovascular status in the hand should be documented, including sensation and perfusion/capillary refill. [2] Radiographs should include the involved forearm, and additional views of elbow and wrist can be obtained because those regions may also be injured in the same fall. [2]
Fracture alignment goals
Acceptable residual deformity criteria for pediatric diaphyseal forearm fractures (age ≤10 years) include the following radiographic parameters: angulation <15°, rotation <45°, shortening <1 cm, and 100% translation. [2] These criteria are used to determine whether reduction is required and whether loss of reduction has occurred during follow-up. [2]
Medication and procedural analgesia
Analgesia should be provided during the initial evaluation and during any closed manipulation. [2] Adequate analgesia or anesthesia should be provided when closed reduction is required. [2]
Immobilization method
Closed reduction followed by immobilization is the standard non-operative approach for most pediatric radial and ulnar shaft fractures. [2] Immobilization should be delivered with careful cast or splint application because cast technique strongly influences stability and risk of displacement. [2] Green-stick fractures should be treated with attention to rotational deformity during reduction maneuvers. [2]
Reduction principles for green-stick deformity
Reduction maneuvers for green-stick fractures should account for a rotational component. [2] A commonly used reduction principle is to rotate the palm toward the apex of the deformity. [2]
Monotherapy versus combination therapy
Non-operative care (closed reduction plus casting) is appropriate for most pediatric diaphyseal forearm fractures when stable alignment can be restored and maintained. [2] Operative fixation is indicated for absolute indications such as open fracture or instability patterns that include radio-capitellar or distal radio-ulnar joint instability. [2] Operative fixation is also considered when reduction cannot be maintained, when refracture occurs, or when residual deformity is unacceptable. [2]
Initiation timing and follow-up imaging
After casting, follow-up radiographic assessment is used to confirm maintained alignment and healing progression. [2][4] Casting duration for long-bone green-stick fractures is commonly about 6 weeks. [1]
Common pitfalls to avoid
Inadequate cast molding is a major risk factor for loss of reduction in pediatric diaphyseal forearm fractures. [2] Excessive or insufficient cast padding can compromise comfort and molding quality. [2] Failure to protect bony prominences and failure to obtain an effective interosseous mold and straight ulnar border increase displacement risk. [2]
Target outcomes and healing goals
Treatment goals include restoration of acceptable length, alignment, and rotation, followed by stable immobilization until clinical and radiographic healing. [2] Acceptable radiographic residual deformity targets (age ≤10 years) include angulation <15°, rotation <45°, shortening <1 cm, and 100% translation. [2] Return-to-activity restrictions after cast removal depend on fracture severity, and stiffness after cast removal is expected to improve without routine physical therapy for many pediatric patients. [5]