Fractures in Children

Fractures in Children

• A fracture is a disruption of the bone's integrity, caused by stress exceeding bone resistance.
• Children's bone healing and remodeling differ from adults due to a thicker periosteum and better blood supply.
• Epiphyseal plate injuries can affect bone growth.
• Radiographic evidence of healed fractures in children can suggest past trauma or conditions like osteogenesis imperfecta.

Risk Factors for Fractures in Children

• Obesity
• Poor nutrition
• Developmental characteristics
• Common play activities
• Activities like climbing, running, or playing sports that increase risk of injury.

Expected Findings

• Physical Assessment:
  • Pain
  • Pallor
  • Edema
  • Ecchymosis
  • Warmth or redness
  • Decreased use of the affected area

Common Fracture Types in Children

• Plastic Deformation (Bend): Bone bends up to 45 degrees without breaking.
• Buckle (Torus): Compression causes a bulge at the fracture site.
• Greenstick: Incomplete fracture with one side broken, the other bent.
• Transverse: Fracture straight across the bone.
• Oblique: Fracture diagonal across the bone.
• Spiral: Fracture spirals around the bone.
• Physeal (Growth Plate): Injury at the end of a long bone, affecting the growth plate.
• Stress: Tiny fractures caused by repetitive muscle contractions.

Diagnostic Procedures

• Radiograph: Used to confirm diagnosis and assess bone positioning.

Nursing Actions for Radiographs

• Instruct and assist the client to remain still during the procedure.

Client Education for Radiographs

• Explain what to expect during the procedure.
• Provide emotional support.

Nursing Care for Fractures

• Provide emergency care at the time of injury.
• Obtain a history of the injury's cause.
• Monitor vital signs, pain, and neurological status.
• Assess circulation, sensation, and movement in extremities.
• Position the client in a sitting position for lower extremity injuries.
• Avoid any positions that may cause constriction.
• Stabilize the injured area.
• Assess above and below the injured area.
• Monitor for blood flow if a fracture is suspected.
• Elevate the injured limb and apply ice packs (20 minutes maximum).
• Administer pain medication as prescribed.
• Keep the client warm.

General Nursing Interventions

• Assess pain level using an age-appropriate scale.
• Provide pain management guidance.
• Monitor vital signs regularly.
• Report any changes in status.
• Maintain range of motion for unaffected extremities and fingers/toes.
• Instruct client and family on activity restrictions.
• Ensure caregiver and child safety.
• Increase calcium intake if not contraindicated.

Neurovascular Assessment

• Sensation: Check for numbness or tingling in extremities; loss indicates possible nerve damage.
• Skin Temperature: Assess temperature; should be warm, not cool.
• Skin Color: Check the color of the affected extremity, distal to the injury, for pigmentation changes.
• Capillary Refill: Apply pressure to nail beds until blanching occurs. Blood return should be within 3 seconds.
• Pulses: Pulses should be palpable, strong, and equal to those of the unaffected extremity.
• Movement: The client should be able to move joints distal to the injury (fingers or toes).

Medications

• Analgesics: Administer for pain.
• Opioid Analgesics: Monitor for respiratory depression.

Nursing Actions for Medications

• Monitor for adverse effects related to pain management.

Client Education for Medications

• Emphasize the importance of adequate pain relief.

Immunizations

• Administer tetanus for open fractures.

Antibiotics

• Administer for open fractures

Casting

• Cast Types: Long-leg, short-leg, bilateral long-leg, long-arm, short-arm, shoulder spica, 1½ spica, full leg.

Nursing Actions for Casting

• Instruct on cast application.
• Demonstrate the procedure using a doll or toy.
• Monitor and assess neurovascular status.
• Ensure limb elevation for the first 24 hours to reduce swelling.
• Turn and reposition the cast for 3-5 days.
• Avoid using heat sources or warm air for drying.
• Instruct on elevation and pillow use.
• Assess for increased warmth or hot spots on the cast.
• Monitor for drainage on the cast's exterior.
• Maintain skin integrity through routine skin care.
• For plaster casts, use palms of hands to avoid dents and expose to air for drying.

Education for Cast Care

• Provide written instructions to the client and parents.
• Educate on signs and symptoms to report.
• Explain proper crutch fitting and reinforce usage.
• Instruct parents and client on:
  • Weekly skin checks
  • Proper crutch care and use
• Discuss cast removal and care.

Traction Care

• Traction uses pulling force to reduce pain, maintain alignment, and provide muscle rest.
• The type of traction used depends on the specific indication.

Types of Traction

• Balanced Suspension Skeletal Traction: Continuous pulling force through ropes, weights, and a system applied to the extremity (e.g., Buck, Russell, Bryant traction).
• Halo Traction: Halo-type bar encircles the head, secured with screws inserted into the outer skull. Halo is attached to bed traction or rods secured to a vest worn by the client.

Nursing Actions for Traction

• Maintain body alignment.
• Provide pharmacological and nonpharmacological pain management interventions.
• Notify the provider if client experiences severe pain from muscle spasms not relieved by medications or repositioning.
• Assess and monitor neurovascular status.
• Monitor skin integrity routinely and document findings.
• Assess pin sites for redness, swelling, drainage, or odor.
• Provide pain care per facility protocol.

Additional Notes for Traction Care

• Assess for changes in elimination and maintain regular patterns.
• Verify all hardware is tight and the bed is level.
• Ensure comfort and safety during repositioning.
• Encourage mobility and exercise as tolerated.
• Promote regular deep breathing and coughing exercises.
• Reinstruct patient on changing restrictions as needed.

Complications

Compartment Syndrome

• Definition: Compression of nerves, blood vessels, and muscles.
• Causes:
  • Constricted compartment
  • External pressure
  • Forearm injuries
• Symptoms:
  • Pain
  • Hardening of the extremity
  • Numbness or tingling
  • Possible contracture
• Interventions:
  • Remove dressing or cast
  • Monitor for signs of compartment syndrome.

Parental Education for Compartment Syndrome

• Ensure adequate hydration and nutrition.
• Teach client and parents about symptoms of compartment syndrome.
• Report any symptoms immediately.

Surgical Interventions

• Surgery may be required depending on the type of fracture.
• Common fractures requiring surgery include supracondylar fractures and those affecting the humerus.

Nursing Actions for Surgical Interventions

• Monitor for signs of infection at the incision site.
• Encourage prescribed immobilization.
• Administer pain medication as needed.
• Provide crutch training for lower extremity fractures.

Interprofessional Care

• Orthopedic specialists are usually consulted for fracture care.
• Notify social services in cases of suspected abuse.

Client Education for Discharge

• Perform proper cast care and pin care (if applicable).
• Conduct neurovascular checks and know when to seek medical attention.
• Use prescribed antipyretics.
• Maintain prescribed physical restrictions.
• Report increasing pain, redness, inflammation, or fever.
• Follow up as instructed.

Osteomyelitis

• Definition: Infection within the bone caused by bacterial invasion from an outside source (open fracture) or bloodstream.

Assessments for Osteomyelitis

• General:
  • Signs of infection (local and systemic)
  • Tenderness, swelling, and warmth to touch
• Pain: May increase with movement
• Range of Motion: Assess ability to use the affected extremity.

Nursing Actions for Osteomyelitis

• Initiate diagnostic procedures (skin, blood, and bone cultures).
• Administer:
  • IV antibiotics or oral therapy
  • Pain management
  • Supportive care (hydration, hematologic, and renal function)
• Maintain immobilization and elevation of the extremity.
• Teach parents about the treatment course.
• Collaborate with parents and provider regarding home care.

Client Education for Osteomyelitis

• Instruct the client and parents on the length of treatment.
• Provide information on:
  • Need for long-term antibiotic therapy
  • Monitoring the affected limb and avoiding weight-bearing
  • Reporting activities inconsistent with therapy
  • Ensuring proper nutrition.