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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.