Green Stick Frx of Forearm     

- See:
      - Greenstick Frx of Distal Radius & Ulna 
      - Green Stick Frxs of Mid 1/3 of Radius & Ulna

- Discussion:
     - frx may be incomplete (greenstick) in radius and/or ulna, or the frx may be complete in one bone and incomplete (green stick) in the other;
           - eg. complete radius and green stick ulna;
     - anatomy:
           - incomplete long bone frx, w/ failure of cortex on tension side (convex side of angulation) w/ plastic deformation of cortex on concave side;
     - angulation:
           - note that the normal ulna should have a completely straight posterior border on the lateral radiograph;
           - may be dorsal, volar,  or toward or away from interosseous membrane
           - dorsal fracture sustained with forearm in pronation
           - volar fracture sustained with forearm in supination

- Workup:
    - when only 1 bone of forearm is broken, integrity of the proximal & & distal radioulnar joints needs to be evaluated;
    - w/ "isolated" ulnar shaft green stick frx, always check for radial head tenderness, which would indicate a Monteggia frx eqivalent, in which there has been spontaneous reduction of the radial head;

- Managment:
    - green stick frxs of mid 1/3 of radius & ulna:  
    - overcorrection of fracture may be required (completing the fracture)
    - these do not require reduction if dorsal angulation is insignificant;
    - acceptable reduction:
          - infants:
                 - up to 30 deg may be accepted;
                 - consider reduction w/ completion of frx by reversal of deformity if angulation > 25-30 deg;
          - children:
                 - up to 15 deg may be accepted depending on age of patient;
                 - there is no need to attempt correction for angulation measuring < 10 deg in children less than 10 yrs of age;
    - reduction:
          - a volarly angulated greenstick frx is manipulated w/ forearm in pronation while a dorsally angulated frx is manipulated w/ forearm in supination;
          - during manipulation, deformity is reversed, so that the distal frag is angulated toward volar aspect until intact dorsal cortex is fractured;
          - following reduction, need 3 Point Molding to keep tension on intact periosteal hinge.
          - long arm cast is applied after forearm gently rotated into supination;
          - long arm cast is applied for a period of 4 to 6 weeks;
          - even minimally angulated greenstick frx can angulate more in a cast so consider reduction if anguation exceeds 10 deg or more;
                - in these green stick frxs, if the cortex is not completely broken thru, increasing deformity may occur;

- Complications:
    - recurrent deformity w/in cast is number one problem w/ green stick frx
    - recurrent angulation is more likely w/ volar rather than dorsal;
    - charnley noted that recurrent angulation is esp common in radial green stick frx with an intact ulna;
    - median nerve entrapment

Dorsally angulated solitary metaphyseal greenstick fractures in the distal radius: results after immobilization in pronated, neutral, and supinated position.

Angular remodeling of midshaft forearm fractures in children.

Forearm fractures in children. Cast treatment with the elbow extended.

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Wednesday, December 12, 2012 4:12 pm