FRACTURES

A fracture is a break or disruption in the continuity of bone

FIGURE: Common fractures in children. (A) Plastic deformation (bend). (B) Buckle (torus). (C) Greenstick. (D) Complete.

Epiphyseal Injuries

• Fifteen percent to 30% of all childhood fractures involve the physis (growth plate).
• The most frequent site of physeal injuries (excluding phalangeal fractures) is the distal radius and ulna.
• The 11- to 15-year-old age-group tends to sustain the majority of physeal injuries to the distal radius and ulna.
• The mechanism of injury is usually a fall on an outstretched arm.

Clavicle Fractures

• Frequent site of fracture in children.

• The shaft of the clavicle is the most common site of injury.
• A fall on the shoulder or excessive lateral compression of the shoulder is usually the mechanism of injury.
• Treatment involves support in the form of immobilization with a sling.
• Reduction of clavicle fractures occurs only in instances of extreme displacement.

Forearm and Wrist Fractures

• Most common site of fracture in children, with most occurring in children older than age 5.
• Account for 30% to 50% of all fractures in children.
• Seventy-five percent of forearm fractures occur in the distal third of the radius and ulna and most do not
involve the physis.
• Major categories of classification include fracture dislocations, midshaft fractures, and distal fractures.
• Most common cause is from a fall on an outstretched arm.

Humerus Fractures

• The mechanism of injury for the majority of humeral fractures is a fall onto an outstretched arm or hand.
• Less than 1% of fractures occur at the proximal humerus.
• Ten percent of all humeral fractures occur at the shaft of the humerus; they account for less than 2% of all
pediatric fractures.
o Humeral shaft fractures are usually a result of twisting injuries in infants and toddlers (child abuse is a
common cause of these fractures in this age group).
o Direct trauma to the humeral shaft is the most common mechanism of injury in older children.
• Supracondylar fractures account for 60% of all elbow fractures in children. There is a high incidence of
neurovascular injury with supracondylar fractures, 8% of which sustain a neurologic injury.
• Twenty percent of distal humeral injuries occur in the lateral condyle; this ranks as the second most common
elbow fracture in children.
• Medial epicondyle fractures are the third most common elbow fracture in children, accounting for 5% to 10% of
all pediatric elbow fractures.

Spinal Fractures
 • Rare in children they account for 1% to 2% of all pediatric fractures.
• Mechanism of injury is due to significant trauma, such as an motor vehicle accident, fall from a significant
height, athletic activities, beatings, or pedestrian-versus-motor-vehicle accident.
• Most spinal fractures involve the cervical spine.

Pelvic Fractures

• Pelvic fractures are uncommon in children and adolescents with an incidence of 1 per 100,000 children per
year.
• Pelvic fractures are commonly the result of high-energy trauma or a crush-type injury.
• Associated injuries are present in approximately 75% of children with pelvic fractures and include damage to
the abdominal wall and pelvic organs.

Hip Fractures

• Hip fractures account for less than 1% of all fractures in children.

• Seventy-five percent of hip fractures in children result from high-energy trauma, such as motor vehicle
accidents, bicycle accidents, and falls from significant heights.
• Half of children who sustain a hip fracture have been involved in a motor vehicle accident or pedestrian-
versus-motor-vehicle accident; these children usually have other injuries.
• Child abuse is the most common cause of hip fracture in children under age 3.
• Hip fractures can result in avascular necrosis of the femoral head, damage to the physis resulting in growth
arrest, malunion, and nonunion.

Femur Fractures

• Common in children. Peak incidence occurs in two age groups—children ages 2 to 3 and adolescents.
• The midshaft of the femur is the most common location for femoral fractures in children and accounts for 1%
to 2% of all childhood fractures.
• Usually the result of high-energy trauma, such as a motor vehicle accident or fall from a significant height.
• Seventy percent of femur fractures in children younger than age 1 are associated with child abuse.

Tibial Fractures

• The most common lower extremity fracture in children occurs in the tibial and fibular shaft constitutes 10% to
15% of all pediatric fractures.
• A rotational mechanism of injury to the lower leg is the most common cause of tibial fractures in children
under age 3 (toddler's fracture).
• Greater force is required to injure the tibia in older children; motor vehicle accidents and sports injuries are the
most common causes of tibial fractures in children and adolescents.

Ankle Fractures

• Common in children and adolescents approximately 5% of all pediatric fractures.

• Involve the growth plate in approximately every 1 of 6 injuries.
• Greatest incidence is in males ages 10 to 15.
• Usually the result of direct trauma.

Foot Fractures

• Metatarsal and phalangeal fractures make up approximately 7% to 9% of all pediatric fractures.

• Fractures of the tarsal bones are uncommon in children.
• Most metatarsal and phalangeal fractures are nondisplaced.
• Mechanism of injury is usually a direct or indirect trauma such as falls, jumping from heights, and twisting
injuries.

Classification of Fractures

• Open fractures: underlying fracture in bone communicates with an external wound.

o Usually the result of high-energy trauma or penetrance wounds.
o The tibia is the most common site of open fractures in children.
• Closed fractures: underlying fracture with no open wound.
• Plastic deformation: a bending of the bone in such a manner as to cause a microscopic fracture line that does
not cross the bone. When the force is removed, the bone remains bent. Unique to children, and most common
in the ulna.

Clinical Manifestations
 • Inability to stand, walk, or use injured part
• Limb deformity (visible or palpable)
• Ecchymosis
• Pain
• History of injury or trauma (may not be the case with pathologic fractures)
• Spontaneous onset of pain (usually seen with pathologic fractures).
• Local swelling and marked tenderness
• Movement between bone fragments
• Crepitus or grating
• Muscle spasm

Diagnostic Evaluation

• X-rays of suspected limb fractures should include the joint above and below the injury.
o Should always include a minimum of two views at 90-degree angles to each other (anteroposterior and
lateral).
o Comparison views of the opposite extremity are frequently needed. They help to distinguish the
fracture line from the growth plate.
o In some situations, oblique X-rays are warranted in order to help identify a fracture that is difficult to
detect.
• Further radiologic studies may be indicated in certain instances to evaluate a fracture: tomography, computed
tomography (CT) scan, magnetic resonance imaging (MRI), bone scan, fluoroscopy.
• Vascular assessment may include the use of:
o Doppler studies.
o Compartment pressure monitoring.
o Angiography.

Management
Treatment is dependent upon the type of fracture, its location, and the age of the child.

• Treatment may consist of:

o Immobilization by cast, splint, or brace.
o Closed reduction followed by a period of immobilization in a cast or splint.
o Open reduction with or without internal fixation and usually followed by a period of immobilization in a
cast or splint.
o Closed reduction and percutaneous pinning followed by a period of immobilization.
o Closed or open reduction and application of an external fixator.
o Traction (skin, skeletal) followed by a period of immobilization.
• Most children's fractures heal in 12 weeks or less. Simple fractures that are closed and nondisplaced can heal
enough to be free from immobilization within 3 weeks.

Nursing Diagnoses

• Acute Pain related to tissue trauma and reflex muscle spasms secondary to fracture
• Ineffective Tissue Perfusion: Peripheral related to swelling and immobilization
• Impaired Skin Integrity related to mechanical trauma (eg, fixation device, traction, casts, other orthopedic
devices)
• Ineffective Coping related to separation from family and home
• Impaired Physical Mobility related to fracture and external immobilization device (eg, cast, splint, external
fixator)
• Bathing/Hygiene/Feeding/Toileting Self-Care Deficit related to external devices (eg, cast, splint)
• Risk for Infection related to trauma (fracture) and surgery
• Risk for Peripheral Neurovascular Dysfunction related to restrictive envelope secondary to cast or splint

Promoting Comfort

• Monitor and assess pain level using an age-appropriate pain scale (eg, Oucher or FACES scale).
• Properly position, align, and support affected body part.
• Administer analgesics as indicated and monitor effectiveness of analgesia.
• Use nontraditional methods of pain relief—music therapy, diversionary activities, relaxation techniques,
therapeutic touch, play therapy.

Maintaining Tissue Perfusion

• Frequently assess perfusion of limb by checking temperature, color, sensation, and pulses.
• Elevate extremity above heart level to prevent edema.
• Encourage movement of digits on affected limb.
• Remove compressive bandages (eg, elastic bandages, splints) that restrict flow of circulation.

Maintaining Skin Integrity

 • Assess for and relieve pressure caused by tight bandages, casts, and splints.
• Provide periodic cleaning, thorough drying, and lubrication to pressure points if in traction.
• Encourage frequent position changes as allowed.
• Assess skin condition on a regular basis.
• Massage healthy skin around affected area to stimulate circulation.
• Protect skin at risk with special dressings or products (eg, barrier cream, moisture-permeable dressing).
• Discourage the use of sticks, knitting needles, or small toys to scratch itchy skin.
• Promote a diet high in protein, carbohydrates, and calcium.

Promoting Effective Coping

• Assess the child's and parents' response to events.

• Explain condition, treatment, and rehabilitation goals as indicated.
• Provide reassurance and emotional support when needed.
• Refer to community-based support agencies (eg, social services, United Way) if indicated.
• Structure the child's day with routine, activities, and therapy to keep him or her busy.
• Encourage the child and parents to verbalize feelings.
• Encourage child to express feelings and emotions through writing (eg, journal), drawing, or play therapy.

Promoting Mobility

• Encourage exercise of uninvolved limbs regularly throughout day.

• Teach appropriate ambulation techniques using aids, such as crutches, walkers, or wheelchairs, as indicated.
• Teach safety precautions when using an ambulatory aid.

Attaining Independence

• Assess family situation for ability to care for child at home.

• Allow child to care for self when able.
• Encourage parents and siblings to assist only as needed.
• Encourage child to participate in care as much as possible.
• Evaluate child's ability to participate in self-care activities.

Preventing Infection

• Assess wounds frequently for warmth, erythema, swelling, tenderness, or purulent drainage.
• Report signs of infection.
• Provide appropriate wound care for open injuries and surgical wounds.
• Administer antibiotics as ordered.
• Encourage child to eat and maintain good caloric and protein intake to promote healing.
• Teach good hand-washing technique to child and parents.

Preventing Peripheral Neurovascular Dysfunction

• Assess the neurovascular status of affected limb every hour for the first 24 hours (or as indicated by hospital
protocol)—compare with unaffected limb.
• Assess for nerve injury (eg, abduct all fingers, touch thumb to small finger, plantar flexion, dorsiflexi)