Greenstick Research Articles

Are frequent radiographs necessary in the management of closed forearm fractures in children?

A prospective pooled case series was used to assess the value of frequent radiographic examinations during treatment of closed forearm fractures in children from major university pediatric medical centers in Israel and China. The sample consisted of 202 consecutive children (mean age 7 years; range 3-12 years) with closed forearm fractures treated nonoperatively. Children with open, growth-plate fractures or fractures associated with dislocation of the nearby joint (i.e., monteggia fractures) were excluded. In 28 children who had torus fractures, radiographic examination was performed at the time of cast removal, 3 weeks after the start of treatment. In 63 children who had stable fractures that did not require reduction (undisplaced or minimally displaced, complete or greenstick), radiographic examination was performed 1 week after the start of treatment and again at cast removal 4-6 weeks later. In the remaining 111 children with complete, displaced, or greenstick fractures (all with angulation of more than 15 degrees ) who underwent closed reduction, an additional X-ray was taken 2 weeks after cast placement. All children (except those with torus fractures) were followed clinically, without further radiographic examination, for 3 months after cast removal. Radiographs at cast removal showed good union in all stable fractures, indicating that additional X-rays on cast removal would have had no added value. In the children with unstable fractures, only 9 showed redisplacement with angulation of more than 15 degrees on repeated X-rays during the first 2 weeks after cast placement. All 9 underwent successful re-reduction. On clinical evaluation 3 months after cast removal, all patients in the sample had full range of elbow and forearm motion. Repeated fracture did not occur in any of the patients. On the basis of these results, radiographs are recommended 2 weeks after cast placement for greenstick or complete fractures. At the time of cast removal, if clinical examination does not show signs of nonunion or malalignment, no radiographic examination is necessary.

Greenstick fracture of the mandible: A case report

This case report is an insight in to pediatric traumatology whereby bilateral greenstick fracture of condyle is used as a means to discuss the incidence and anatomic considerations for the management of the same, highlighting the fact that dental surgeons require a unique understanding of the anatomy, growth considerations, healing pattern and operative management involving minimal manipulation while managing pediatric facial fractures.

Die Distale Radiusfraktur - eine Torwartverletzung bei Kindern und Jugendlichen

Fractures of the distal radius are the most frequent fractures of longbones during childhood and adolescence. A rare mechanism of injury is the attempt of a soccer goalkeeper to save the ball, shot with high velocity. Reports of all children and adolescents up to the age of 14, suffering from a distal radius fracture from a three year period were evaluated retrospectively and this particular mechanism of injury was identified. All patients were reinvestigated after at least 10 months clinically. Amongst 516 distal radius- and distal forearm fractures, there were 213 (41.3 %) sports injuries. 61(28.6 %) of them resulted from playing soccer, with 48 (78.7 %) after a fall. 13 distal radius fractures were identified as a goalkeepers injury by a sharply shot ball. We found 6 buckle fractures, 4 complete fractures, 2 physeal separations Salter II and 1 metaphyseal greenstick fracture. At the time of the last follow up investigation all injured had regained their level of sports. Injuries to the lower extremities are most frequent in soccer. The ball itself may lead to fractures and dislocations of the hand and finger skeleton, even not unfrequently to distal radius fractures. Wrist protectors and an adequate behaviour in game and training may contribute to their avoidance.

Post-traumatic cortical cysts in paediatric fractures: is it a concern for emergency doctors?

Post-traumatic cortical bone cyst is a rare occurrence in children. It is typically located in the distal radius, as a result of greenstick fracture. We report three cases referred to our fracture clinic as a tumour in bones. In one of our cases, the cystic lesion was noted following a displaced fracture in the femur, which is not previously published in the literature. The cyst-like lesion appeared as an oval radiolucency proximal to the previous fracture site on radiograph films. These lesions can cause concern for the on-call teams as they can mimic an infection or a tumour of the bone. We highlight the pathogenesis of the lesion with a review of the literature.

Greenstick fracture of the scapular blade; an unusual case of winging of the scapula

Greenstick fracture of the scapular blade; an unusual case of winging of the scapula

S223: Alveolar Distraction for Implant Placement

Although alveolar distraction is a promising method for ridge augmentation in the atrophic maxilla and mandible for implant placement, horizontal alveolar distraction methods for expanding a narrow alveolar ridge have not been well established. We developed a prototype of horizontal alveolar distraction device using a titanium mesh plate. Alveo-Wider (Okada Medical Instrument Supply Co Ltd, Tokyo, Japan) is a novel horizontal alveolar distraction device consisting of a 0.3-mm-wide titanium plate and a 2 mm x 12 mm titanium distraction screw. For horizontal alveolar distraction, the transport segments were created by two vertical osteotomies that were connected with a horizontal osteotomy of the buccal plate, then the split osteotomy was made to separate the buccal from the lingual/palatal plates. The transport segment was then displaced labially creating a horizontal green stick fracture apically. The horizontal distraction device was fixated using titanium micro-screws. After 7-10 days of latency to allow for periosteal healing and early revascularization, the distraction device was activated by turning the distraction screw 0.25 mm twice a day. After a consolidation period for approximately 3 months, when the device was removed, it was confirmed that the distracted areas were completely filled with newly formed bone, and implant placement was safely performed. In this hands-on seminar, the concept and indication of this horizontal alveolar distraction is presented. Specifically, advantages of this method will be shown. Then, using an atrophic jaw model, hands-on training will be performed. This method using horizontal alveolar distraction seems to be a successful technique for widening a narrow alveolar ridge.

Death comes for the salivary gland

As it morphs from a squirming maggot into a buzzing adult, a fruit fly jettisons its juvenile salivary glands. On page 85, Yin et al. show how the insects get rid of a protective protein, allowing the glands to break down at the right time. The research helps clarify how certain tissues prepare themselves to die. Figure 1 The juvenile salivary glands (green) stick around in this pupa with a mutation in the CBP gene. During metamorphosis, a larva's obsolete internal organs degenerate, and replacements sprout. Surging quantities of the steroid hormone ecdysone spur the salivary glands and other juvenile structures to melt away. Researchers have mapped out some of the molecular details of this deterioration. Ecdysone cranks up several genes, including one called reaper, that trigger salivary gland cells to perish. But getting rid of the glands requires one more change: elimination of a protein called diap1, which shields salivary cells. How a fly-to-be cuts the levels of diap1 on schedule was unknown. To find out, the researchers screened the insects for mutations that allowed the youthful salivary glands to persist. They found three such glitches in the transcriptional coactivator CBP. The scientists assumed that faulty CBP spared the salivary glands by preventing the activation of reaper and other killer genes. Instead, Yin et al. determined, CBP slashed the amount of diap1 shortly before pupation. Although the decline in diap1 primed the salivary glands to die, enough of the protein remained to spare cells from reaper. A second surge of ecdysone triggered salivary cells to purge the vestiges of diap1 without using CBP, and the glands deteriorated. This two-step process ensures that the salivary glands don't disappear prematurely, the researchers speculate. They now want to pin down how CBP influences diap1. CBP normally helps switch genes on rather than off, so it probably works by activating another gene that curtails diap1 production.

Depressed skull fracture in Ping Pong: elevation with Medeva extractor

The bones of the skull of the newborn and nursing infants, in general, possess great malleability. For this reason, the depressed fractures occurring at this age are called "Ping Pong" or "Green Stick" fractures. The treatment of these fractures is surgical according to different authors, although some of these fractures that happen in childbirth can elevate themselves spontaneously. A breast milk extractor trade mark "MEDEVA" was used for the procedure in newborns with a depression larger than 2 cm in diameter. Minimal aspiration was performed while observing the elevation through the transparent breast milk extractor MEDEVA until the depression elevated without leaving any trace. The aspiration procedure was satisfactory and curative in the five children treated. The fracture was successfully elevated and the skull returned to its normal position and configuration without complications for the patients. Finally, it has been demonstrated that this procedure is simple, inexpensive, and avoids surgical intervention.

Impact of Phlebotomine Sand Flies on U.S. Military Operations at Tallil Air Base, Iraq: 3. Evaluation of Surveillance Devices for the Collection of Adult Sand Flies

We evaluated the effectiveness of commercially available light traps and sticky traps baited with chemical light sticks for the collection of phlebotomine sand flies. Evaluations were conducted at Tallil Air Base, Iraq, in 2003. In an initial study, a Centers for Disease Control and Prevention (CDC)-style trap with UV bulb collected significantly more sand flies than did an up-draft CDC trap, a standard down-draft CDC trap (STD-CDC), or a sticky strap with a green chemical light stick. In a subsequent study, we found that the addition of chemical light sticks to sticky traps resulted in a significant increase in the number of sand flies collected compared with sticky traps without the light sticks. These data indicate that 1) the CDC light trap with an UV bulb is an effective alternative to the standard CDC light trap for collecting phlebotomine sand flies in Iraq, and 2) that the addition of a chemical light stick to a sticky trap can result in a field-expedient tool for the collection of sand flies.

MRT zur Beurteilung von Begleitverletzungen distaler Unterarmbrüche im Wachstumsalter

The study was made to evaluate the role of MR imaging in pediatric distal forearm fractures by comparison with the findings of plain radiographs and MRI. 38 patients (27 boys and 11 girls, mean age of 12 years, range 7 to 15 years) with radiographically open distal radius and ulna growth plates requiring first aid for a fracture of the distal third of the forearm, were included in this study. The fractures were diagnosed on plain radiographs and conservative treatment was performed. In 35 patients MR imaging was performed within 3 weeks after the accident and in 3 patients MRI was performed after 6 to 9 weeks because of persistent wrist pain. Fifteen Salter/Harris II injuries of the radius and 1 of the ulna, 1 torus fracture of the radius and 2 of the ulna, 12 greenstick fractures of the radius and 3 of the ulna, 10 complete displaced radius fractures and 15 ulnar styloid fractures were found on plain radiographs. Twelve patients had evidence of associated triangular fibrocartilage complex (TFCC) lesions in MRI, there was no statistical correlation between TFCC lesions and fracture types, fracture dislocations or patients age (p > 0.5). One patient had an avulsion of the radioscaphocapitate ligament from the radius accompanying a greenstick fracture of the distal radius. 19 bone bruises and two radiographically occult fractures were identified. In 2 patients, a bone marrow oedema was seen in the radial epiphysis immediately adjacent to the germinal zone of the growth plate. In these patients premature physeal arrest occurred. MRI plays an important role in the evaluation of acute pediatric wrist injuries. It allows a better evaluation of osseous lesions than plain radiographs. In our study, a tear of the triangular fibrocartilage complex accompanied distal radius fractures in 32 % of patients. Simultaneous rupture of the TFCC insertion in the fovea ulnaris and ulnar styloid fracture lead to destabilisation of the distal radioulnar joint (DRUJ).

Greenstick Fracture of the Scapula: A Cause of Scapular Winging

A case of an angulated, greenstick fracture of the scapula mimicking scapular winging in a skeletally immature 12-year-old boy is described. The bony deformity was visualized with plain radiography. CT was helpful in exclusion of a thoracic injury or an underlying neoplasm. Closed reduction yielded satisfactory results. Based on this 1 case only, we recommend consideration of closed reduction in children with significantly angulated greenstick fractures of the scapula without underlying thoracic pathology.

A Green Stick or A Fresh Stick? Locating Customary Penalties in The Post-Colonial Era

Former colonies and dependencies in the South Pacific do not have the luxury of entirely ‘homegrown’ laws. Their legal systems are burdened with a ‘legacy’ of transplanted laws, developed for use in a foreign country, imposed on pre-existing systems of custom and culture. As a result, many small island countries are struggling to balance the demands of law from different sources, designed to operate in fundamentally different circumstances. In addition to the conflict that occurs in areas of substantive law, where customary and introduced law may prescribe a different rule for the same situation, the two systems differ in their approach to procedure, penalties and relief. This paper considers the divide between the theory and practice of introduced law and customary law and examines the way in which conflicts have been dealt with by the courts. In particular, it uses the example of banishment to illustrate the type of problems that arise in a plural system. The paper looks at the balancing exercise which has been necessary when custom, in the form of banishment, comes into conflict with introduced law, in the form of constitutional rights.

THE CLASSIC: The Principle of Early Active Movement in Treating Fractures of the Upper Extremity

THE CLASSIC: The Principle of Early Active Movement in Treating Fractures of the Upper Extremity

Internal Fixation in Trapdoor-Type Orbital Blowout Fracture

The most common orbital blowout fracture is a trapdoor type. In many cases of trapdoor fracture, the bony segment has a stable hinge consisting of a greenstick fracture and the sinus mucoperiosteum that is attached to the intact orbital wall. If the displaced bony segment opposite the hinge is reduced into the original position and fixed on the unaffected bone, the orbital fracture may be reconstructed by internal fixation of the bony segment itself rather than requiring substitution with alloplastic implants or a bone graft. In 20 cases of orbital blowout fracture of a trapdoor type, internal fixation was performed using a cantilever fixation technique (with a piece of titanium micromesh or a titanium microplate plus a microscrew) or a ledge fixation technique (with a piece of micromesh). In all cases, the orbital wall was accurately reconstructed in its normal anatomical position. The associated ocular problems disappeared except for mild diplopia in one patient and there were no surgical complications associated with the internal fixation. The advantages of internal fixation include anatomical reconstruction of the orbital wall; preservation of the original orbital bone and the mucoperiosteum of the sinus as an osteomucoperiosteal flap resulting in rapid wound healing and normal mucus drainage function of the sinus; the simplicity of the procedure; and consequently, the absence of surgery-related complications. This technique is presented as one of the preferred treatments for trapdoor-type orbital blowout fractures.

Unstable diaphyseal fractures of both bones of the forearm in children: Plate fixation versus intramedullary nailing

This retrospective study evaluated the results of plating versus intramedullary fixation in the management of unstable, diaphyseal fractures of both bones of the forearm in children. Of the 64 children included, 45 were treated with intramedullary fixation, 19 with plating. Only A3 forearm fractures of the middle third or the transition zones were included; Galeazzi, Monteggia, and Greenstick fractures were excluded. Full radiological follow-up to union was obtained in all cases and 60 patients returned for clinical evaluation 32.3 months (plating) and 20.6 months (intramedullary fixation) after injury. The functional outcome did not differ significantly. In the intramedullary fixation group, we found two major complications (refracture and non-union) and nine minor complications (two delayed unions, three thumb neuropathies, two rod migrations, two skin infections). In the plate group, there were two major complications (refractures) and one minor complication (thumb neuropathy). Plating resulted in significantly worse results for surgical approach, operating times, frequency and duration of hospitalisation, and cosmetic outcome. In conclusion, intramedullary fixation of an unstable forearm fracture in skeletally immature patients is a safe, child-friendly, minimally invasive technique that allows early functional treatment with an excellent functional and cosmetic outcome.

Cellular and Molecular Foundation for Fracture Healing in Children

Dealing with pediatric fracture patients requires a funded knowledge of complications and remodeling capability of the youth skeleton to find the accurate therapy decision and to avoid unnecessary invasive procedures. Due to the different mechanical environment, fractures in children occur at specific fracture-vulnerable areas. One of those is the growth plate, which on one hand gives rise to the unique ability of correcting angular deformities by specifically increasing the growth rate in definite regions, and on the other hand leads to complications like growth arrest or angular deformity. The pediatric diaphysis presents the exclusive greenstick fracture, only seen in the growing skeleton, which occurs because of the different composition of the pediatric bone. To understand these very specific features of the youth skeleton, the molecular and cellular basis should be taken into consideration. Therefore, this review will present the common characteristics of skeletal development and fracture healing. An insight into the mechanotransduction as part of the remodeling and self-correcting ability of pediatric bone is given to span the bridge between clinical treatment options and scientific background.

The Classic: Forearm Fractures in Children

The Classic: Forearm Fractures in Children

Die Unterarmschaftfraktur im Kindesalter

Fractures of the forearm in children are quite frequent injuries, treated in emergency rooms. Most of them occur during leisure or sport activities. Most cases are monotraumatic. The diagnosis can be made by a conventional x-ray examination of the forearm in two planes. It is possible to differentiate between stable fractures (greenstick fractures) and unstable (dislocated) fractures. The first-line therapy for stable fractures or fractures which can be reduced anatomically correctly, is the conservative procedure using a long arm cast. Axial dislocation up to 20 degrees (age <5 years) or up to 10 degrees (age >5 years) can be accepted. Special cases, such as Monteggia or Galeazzi fractures, must be considered. Unstable fractures have to be reduced during surgical stand-by. The state of the art in surgical therapy is intramedullary nailing with titanium elastic nails. Open fractures and fractures with severe soft tissue injuries can be treated with external fixation. Osteosynthesis with plates should only be used for special indications. By following therapeutic principles, a successful outcome can be achieved and later complications are rare.

Pediatric Skeletal Trauma

Pediatric fractures are commonly classified into five types: plastic deformation, buckle fracture, greenstick fracture, complete fracture, and physeal injuries. The most important anatomic characteristic in the pediatric skeleton is the presence of growth plates and the thick periosteum. It is important to emphasize that just as adult intra-articular fractures require anatomic reduction, so do pediatric articular injuries. The periosteum in children contributes immensely to rapid fracture healing and helps in the reduction and in the maintenance of reduction. In this study, I review some basic principles for the treatment of fractures in children, the main complications of pediatric fractures, and the outcomes assessment in children. The main complications of fractures in children are malalignment, physeal arrest, and refracture cause by fast fracture healing. Nearly all fractures in children can be treated in a cast without worry about stiff joints or need for physical therapy to mobilize injured joints.

The choice of treatment according to the type and location of the fracture and the age of the child

Children injure themselves more today then they have in the past.Injuries that were sustained by older children are now occurring in younger children as a result of the new variety of sports ad equipment. In addition, children are traveling and running at higher speeds and the fractures sustained are becoming more complex. This requires a new "code of practice" to ensure children are correctly treated in every hospital. These new types of fractures are not always treated correctly; people tend to think of children as only small adults and that children's fractures always heal well. However, specific injuries to the growth plate and the joints as well as special fractures like the green stick and bowing (plastic deformation) fractures maybe assessed incorrectly in their healing behavior. In the following article, the basis of adequate fracture treatment will be explained. Factors that particularly influence the treatment include: age; weight; type of fracture, bone segment; available equipment; own experience; postoperative management; and cost effectiveness.