FRACTURES IN CHILDREN

By Susan Nabakooza
 Learning Objectives
By the end of this session, class members
should be able to;
 Define the word ‘Fracture’
 Classify fractures in children
 Describe the general management principles
of fractures
 Identify Common nursing diagnoses of
fractures
 Manage fractures in accordance with nursing
diagnoses
 Definition
 A fracture is a complete or incomplete disruption in the
continuity of bone.
 A fracture is a break in the continuity of a bone tissue when
subjected to excessive abnormal force or when a force ia
applied to the bone than a bone can with stand
 Fractures are also known as broken bones
Common childhood
fractures
 Arm bones are fractured more often than other
bones
 Collar bone or shoulder bone
 Elbow fractures
 Fore arm, wrist, or hand fracture
 Leg, foot or ankle fractures
 Etiology
 Trauma is the most common cause of childhood
fractures. It is often due to falls especially in the home
environment (home, sports fields, school environment,
road traffic accident).
 Direct blows or force: fracture occurs at the point of contact\
 Torsion: a fracture occurs at the point opposite the location of the
force e.g Sudden twisting motions like; twisting of the foot may lead to
break of bones of the leg.
 Extreme muscle contractions or Violent contractions: forcibly
throwing an object produces powerful muscle contractions which can
fracture the humerus, in tetanus, there are usually strong contracions
 Disease process: osteoporosis, bone tumors, malnutrition
 Crushing forces; gets in contact with bones and crushes them. E.g
in a car accident
 Risk for fractures
 Sporting accidents
 Fails from heights
 Bike or car accidents
 Poor nutrition. Low calcium diet

Note: when a bone is broken, associated structures are

also affected, resulting in;
 Soft tissue edema
 Joint dislocation
 Ruptured tendons
 damanged blood vessels
 Haemorrage into the muscle and the joints
Classification of fractures
 Communication with the environment
 Open/compound fractures; fractured part is exposed to the external
envt
 Closed simple fracture; fracture with the overlying skin intact
 Complete fracture/incomplete; fracture lines run entirely through the
bone
 Anatomical site
 Avulsion: a fracture occurring from pulling effects of ligments and
tenstions
 Potts fracture; type of fracture that occurs at the ankle joint
 Colles fracture; fracture that occurs at the wrist joint
 Pattern
 Transverse; bone is broken perpendicular to the length
 Obligue
 Spiral; bone twisting
 Miscellenious
 Green stick fracture; commonest in children one side of the
bone is broken causing the other side to bend
 Depressed fracture; afracture having its edges driven below
the surrounding e.d fractured skull
 Comminuted fracture: bone fragments are crushed in small
peces
 Displaced/overriding fracture; bone fragments are separated
away from the structure line and bone ends overlap each other
 Impacted fracture: a bone fragment is moved into another
 Complicated fracture: associated with many structures
including the nerves, musles, joints, blood vessels etc
 Stress fractures: constant exposure to stress; jumping a rope,
running long distance
 Pathological fracture: fracture caused by disease
ILLUSTRATION OF VARIOUS
FRACTURES
 Fracture patterns
 The most common fracture pattern is a complete fracture
of both cortices e.g.; spiral, transverse, oblique,
multifragmentary.
 However, the following fractures are specific to children;
 Buckle/torus fractures; children <10yrs, usually caused
by a fall on an outstretched hand, ends are driven into
each other,
 Inherently stable.
 Treatment immobilize in plaster of Paris/backslab
 Fracture clinic follow-up within 2–3 days. Remove plaster in
3–4wks and mobilize.
 Fracture patterns
 Greenstick fractures; like bending a young twig, an
incomplete fracture in which the bone is bent at one side
with a slight tear at the other.
 The energy is insufficient to result in complete bicortical
fracture.
 It may require manipulation under anesthesia.
 Plastic deformation or bend fractures; traumatic
bending/bowing of bone, but insufficient energy to
produce a fracture.
 No fracture seen on X-ray (limb may appear ‘bent’).
 Commonly ulna (look out for radial head dislocation),
occasionally fibula.
 Treat as for torus fracture. If severe bowing or
dislocation require manipulation under anesthetic.
 Salter–Harris fractures/physeal injuries; 20% of
all children’s fractures involve the physis (most
commonly the distal radius).
 It is usually extra-articular, but fractures in the
proximal femur/humerus, radial neck, distal fibula may
be intra-articular.
 Spinal fracture or femoral shaft fracture in the non-
ambulant, rib fractures, two separate fractures at
different stages of healing, should be referred for full
investigation.
 Clinical manifestations
 Pain; continuous, increasing severity and intensity
 Loss of function
 Localized edema or Soft tissue swelling, ecchymosis
and tenderness
 Deformity
 Crumbling sensation “crepitus” felt on gentle palpation.
A granting sound felt when the broken ends rub on each
other
 Visible bone protrusion through the skin
 Involuntary muscle spasms
 Lengthening or shortening of the extremity depending
on where fracture is.
 Shock as a result of blood loss
 Investigations&
Diagnosis
 History taking
 Physical exam
 X-ray
 Bone scans
 MRI
 Arteriograms
 CBC
 Coagulation profile
Process of fracture healing
 Varies according to the type of bone and the amount of
movement at the fracture site
There are 5 stages of healing
1. Tissue destruction and haematoma formation
 Destructed The blood cells, fibrin and debris and inflammatory
exudates come together and form a blood clot
2. Inflamatory and cellular proliferations
 This takes about 5 days, fibroblasts migrate to the site,
granulation tissue and new capillaries develop
3. Stage of callus formation (soft callus)
 New deposits of born and cartilage are called callus. Theres need
to minimize movements at this point
4. stage of consolidation (hard callus)
 Callus matures and cartilage is gradually replaced by new bone
4. Stage of remodeling
 Reshaping of callus by a continuous process of resorption and
laydown
 Internal callus is hallowed out into the marrow cavity while external
callus is slowly removed.
 Reshaping of the bone continues, callus tissue is completely
replaced replaced with mature compact bone
Factors influencing bone healing
Systemic factors Local factors
 Type of bone (cancellous
 Age (children heal faster
heals faster than cortical
than adults)
bones)
 Actiity level  Type of fracture (spiral
(immobilization)
better than transverse)
 Nutrition status
 Blood supply
 Hormonal factors ( growth
 Reduction; restoring
hormone, coerticosteroids)
fracture fragments to
 Diseases e.g DM, Anaemia, anatomic ligaments and
Neuropathies positioning
 Vitamin deficiencies e.g  Infection
ACDK
 Soft tissue interposition
 Drugs e.g. anti coagulants,
anti inflammatory  Mobilization
Mnagement

 Aims of Management
 To regain and maintain the normal alignment of
the injured part
 To regain normal function f the injured part
 To achieve the above objectives in the shortes
time possible
 Basic principles of
management
 Reduction
 Process of restoring bone ends into their normal positioning
 Open; surgical opening is made, bone is educed manually under
direct visualization, internal fixation of devices is used to maintain
the bone fragments
 closed reduction; traction, Xrays are taken to determine the position
 Immobilization
 Maintains fracture reduction until healing occurs
 External fiaxations; Casts , splints, continuous traction
 Internal fixations; pins, wires, screws, rods, nails and plates
 Rehabilitaion
 regainning od strength and normal function in the affected area
Emergency management
First aid management
 Airway should be clear
 Breathing should be maintained
 Check pulse and control bleeding
 Deformity should be immobilized before patient is
moved. Adequate splinting is required
 The neurovascular status distal to the injuery
should be assessed to determine adequacy of
peripheral tissue perfusion
 Open wound, cover with a clean or sterile dressing
 In emergency unit, patient is evaluated
completely
 Clothes are gently removed or cut
Medical management
 Care depends on the class and type of fracture
 Immobilization/ reduction done
 Pain relief
 Antibiotic
 Supportive treatment e.g Multivitamin, feso4, FA
 Bone Xray
 Fluid resuscition
 Infection prevention
 Nutrition; calcium more emphasized
 Exercises; physiotherapy
 Nursing
 Nursing interventions
 Teach on how to control swelling and pain on
discharge
 Care for affected area
 Diet; high protein and less fat
 Provide mobility aids
 Complications
 Early;
o Neurovascular problems: e.g. median nerve paresthesia
with distal radius fractures.
o Compartment syndrome: especially associated with
closed mid-shaft tibia fractures. Perfusion pressure falls
below tissue pressure in a closed anatomic compartment.
o Fat embolism syndrome, especially for long bone
fractures.
o Hypovolemic shock, especially in open fractures.
 Complications
 Intermediate;
o Joint stiffness; especially fractures around the
elbow.
o Mal-union; usually well tolerated if mal-union is
within plane of motion; may be compensated in
younger children with remodeling.
 Complications
 Late
o Overgrowth; occurs in long bones. Femoral
fractures in children may overgrow by 1–3cm.
o Deformity; if epiphysis is damaged, child may
develop progressive deformity several months
later. Require long-term follow-up.
o Non-union; rarely shaft of tibia/ulna