Chapter 27​​​​​​​: Fractures

Chapter 27​​​​​​​: Fractures

When the force on a bone exceeds its strength, causing a break in its structure.

Healing in Children:

• Faster healing than adults.

  • Due to a thicker periosteum and better blood supply.

Growth Plate (Epiphyseal Plate) Injuries:

• Can affect bone growth.

• Require careful monitoring to avoid long-term complications.

Red Flag for Abuse or Disorders:

• Multiple fractures in different healing stages (especially in infants) may indicate:

  • Non-accidental trauma (abuse)

  • Osteogenesis imperfecta (brittle bone disease)

Fractures in Children S/S

Pain

Crepitus (grating sound or sensation)

Visible deformity

Edema (swelling)

Ecchymosis (bruising)

Decreased use of injured area

Fractures in Children Medications

Analgesics (e.g., opioids)

Immunizations (tetanus for open)

Antibiotics (for open)

Fractures in Children

Types

• Plastic deformation (bend): Bone bends ≤ 45° without breaking.

• Buckle (torus): Bulge or raised area from compressed bone.

• Greenstick: Incomplete break.

• Transverse: Break straight across the bone.

• Oblique: Diagonal break.

• Spiral: Twisting break around the bone.

• Physeal (growth plate): Break at the end of a long bone.

• Stress: Tiny cracks from repetitive stress (e.g., sports or weight-bearing activities).

• Complete: Bone fragments are separated.

• Incomplete: Bone fragments are still attached.

• Closed or simple: The fracture occurs without a break in the skin.

• Open or compound: The fracture occurs with an open wound and bone protruding.

• Complicated fracture: The fracture results in injury to other organs and tissues.

• Comminuted: The fracture includes small fragments of bone that lie in surrounding tissue.

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Risk Factors

• Obesity

• Poor nutrition

• Normal play activities or sports that involve running, climbing, jumping (e.g., skateboarding, skiing, soccer, basketball)

Fractures in Children Management

General Interventions

• Assess pain often; use age-appropriate pain scale

• Monitor neurovascular status regularly

• Maintain bone alignment

• Encourage movement of unaffected fingers/toes

• Teach activity restrictions

• Provide comfort and reassurance

Emergency Care at Time of Injury

• Get a history of the injury

• Maintain ABCs (Airway, Breathing, Circulation)

• Monitor vitals, pain, neuro status

• Check neurovascular status of the injured limb

• Positioning:

  • Supine: for leg, pelvis, or lower arm injuries

  • Sitting: for shoulder or upper arm injuries

• Remove jewelry near injury site

• Stabilize injury to prevent movement

• Splint above and below injury

• Monitor for shock (esp. with pelvic fractures)

• Elevate injury and apply ice (max 20 minutes)

• Administer pain meds

• Keep child warm

Neurovascular Assessment (6 P’s)

1. Sensation: Check for numbness or tingling

2. Skin Temperature: Should be warm, not cool

3. Skin Color: Look for changes (pale, blue, etc.)

4. Capillary Refill: Press nail beds—should return pink in ≤ 3 seconds

5. Pulses: Compare with unaffected limb; should be strong and equal

6. Movement: Fingers/toes distal to the injury should move normally

Fractures in Children Dx

Radiograph (X-ray):

• Confirms fracture and bone alignment

• Nursing Action: Help the child remain still during the procedure

Fractures in Children Therapy: Casting

Purpose:

• Immobilize injury

• Maintain bone alignment

• Promote healing of fractures

Types:

• Long-leg, short-leg, bilateral long-leg

• Long-arm, short-arm

• Shoulder spica, 1½ spica, full spica, single spica

Materials:

• Plaster of Paris: Heavy, not water-resistant, dries in 10–72 hrs

• Fiberglass: Light, water-resistant, dries in 5–20 mins

Before:

• Inspect and clean the skin

• Apply stockinette or waterproof liner

• Pad bony areas to prevent breakdown

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Nursing Actions

• Use age-appropriate teaching (toys, dolls)

• Check neurovascular status regularly

• Elevate casted area for 24–48 hrs

• Apply ice for the first 24 hrs to reduce swelling

• Reposition every 2 hrs to dry the cast evenly

• Avoid heat lamps or hair dryers

• Use sling or pillow for support

• Mark and monitor any drainage on cast

• Check skin around the edges of the cast

• Keep skin clean and dry

• Petal rough cast edges with moleskin

• Cover cast when near urine/feces

• Teach proper crutch use

Client Education

• Cast may feel warm when applied but won’t burn

• Report severe pain or pain not relieved 1 hr after meds

• Teach how to do neurovascular checks

• Review proper crutch use

• Instruct on perineal care for spica cast

• Do NOT insert objects into the cast

• Use proper restraints during transport

• Teach about cast removal and cutter

• Report soft spots, increased pain, or changes in sensation

• Clean soiled skin with damp cloth

• Soak extremity in warm water after cast removal

Fractures in Children Therapy: Traction

Purpose:

• To immobilize a fracture, reduce dislocation, maintain bone alignment, and relieve muscle spasms using pulling force.

Types:

• Skin:

  • Uses weights with tape/straps on skin (e.g., Buck, Russell, Bryant traction).

• Skeletal:

  • Pins/rods inserted into bone; stronger force than skin traction.

  • Pulley system applies continuous traction.

  • Weights must not be removed by the nurse.

• Halo (cervical):

  • Metal halo around head attached to vest or bed for neck/spinal injuries.

• Manual:

  • Hand-applied during casting or reduction by the provider.

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Nursing Actions

• Maintain proper body alignment.

• Give pain/spasm medications (pharmacologic + nonpharmacologic).

• Report unrelieved severe spasms.

• Monitor neurovascular status (pulses, cap refill, sensation, movement).

• Check skin and pin sites (redness, swelling, drainage).

• Monitor elimination patterns (urine/stool).

• Ensure bed and hardware are secure and knots don’t touch pulley.

• Do not adjust weights or equipment unless ordered.

• Use overbed trapeze to help child reposition.

• Encourage range of motion on non-immobilized limbs.

• Promote deep breathing with incentive spirometry.

• Reposition frequently to avoid skin breakdown.

• Use pressure-relieving mattresses if needed.

Fractures in Children Therapy: Surgery

When needed

• Common for supracondylar, humerus, and femur fractures.

Types of reductions:

• Closed reduction: No incision.

• Open reduction: Requires incision, possibly with pins.

Distraction: External fixator used to:

• Immobilize fracture

• Correct deformities

• Lengthen bone

Nursing Actions

• Monitor incision site for infection.

• Encourage early mobilization (as ordered).

• Administer pain medications.

• Teach crutch use for lower limb fractures.

• Educate on limited weight-bearing for affected limb.

Pre-Op & Immediate Post-Op:

• Explain procedure expectations, including NPO instructions.

• Emphasize infection monitoring.

• Discuss pain control.

After Discharge:

• Teach cast and pin care (if applicable).

• Perform neurovascular checks and know when to call the provider.

• Use anti-itch medications if prescribed.

• Follow all physical restrictions.

• Teach proper pain management.

• Report signs of infection (redness, swelling, fever).

• Encourage follow-up appointments.

Fracture Complications

Compartment Syndrome

• Cause: Tight casts, traction, trauma, burns, surgery, hemorrhage, IV infiltration.

Patho: Increased pressure in a muscle compartment leads to:

• Nerve/blood vessel compression

• Ischemia

• Common in tibial or forearm fractures

If untreated: Can lead to deformity, paralysis, or infection.

• Volkmann Contracture: Permanent hand/forearm deformity from compartment syndrome.

Key Findings: "5 P's"

1. Pain (not relieved by meds or elevation)

2. Paresthesia (tingling/numbness)

3. Pulselessness (late sign)

4. Paralysis (nerve damage)

5. Pallor (cold, pale skin, cyanosis)

Nursing Actions

• Assess hourly for first 24 hours

• Ensure space for 1 finger between skin and cast

• Report signs immediately

• Avoid elevation

• Loosen dressings

• Prepare for fasciotomy if needed

Client Education

• Report pain not relieved by meds or worsening pain

• Watch for color change or numbness

Renal Calculi (Kidney Stones)

• Cause: From immobility or poor hydration during non-weight-bearing

Nursing Action: Encourage fluids, monitor urine output

Fat Embolism

• Fat from bone marrow enters bloodstream after long bone fracture

Pulmonary Embolism

• Clot from injury site travels to lungs

Nursing Actions

• Monitor for chest pain and difficulty breathing

• Notify provider if suspected

• Give anticoagulants and oxygen

• Promote movement (active/passive ROM)

• Elevate HOB

• Apply SCDs (compression devices)

Osteomyelitis

• Bone infection caused by bacteria from

  • External source (e.g., open fracture)

  • Bloodstream (hematogenous spread)

Key Manifestations

• Irritability

• Fever

• Fast heart rate (tachycardia)

• Edema (swelling)

• Constant pain, worse with movement

• Avoids using the affected limb

• Infection site: tender, swollen, warm to touch

Nursing Actions

• Assist with diagnostic testing (blood, skin, bone cultures)

• Assist with joint/bone biopsy

• Give IV and oral antibiotics

• Monitor liver, kidney, and blood labs

• Monitor vital signs, I&O, and infection drainage

• Watch for superinfections (e.g., candida, C. diff)

• Position limb for comfort and limit movement

• Administer pain meds

• Coordinate with parents and physical therapy

Client & Family Education

• Treatment may require long-term antibiotics

• Monitor for hearing loss from some antibiotics

• Avoid putting weight on affected limb

• Support normal development with safe activities

• Encourage nutritious diet for healing

Compartment Syndrome

Cause: Tight casts, traction, trauma, burns, surgery, hemorrhage, IV infiltration.

Patho: Increased pressure in a muscle compartment leads to:

• Nerve/blood vessel compression

• Ischemia

• Common in tibial or forearm fractures

If untreated: Can lead to deformity, paralysis, or infection.

• Volkmann Contracture: Permanent hand/forearm deformity from compartment syndrome.

Key Findings: "5 P's"

1. Pain (not relieved by meds or elevation)

2. Paresthesia (tingling/numbness)

3. Pulselessness (late sign)

4. Paralysis (nerve damage)

5. Pallor (cold, pale skin, cyanosis)

Nursing Actions

• Assess hourly for first 24 hours

• Ensure space for 1 finger between skin and cast

• Report signs immediately

• Avoid elevation

• Loosen dressings

• Prepare for fasciotomy if needed

Client Education

• Report pain not relieved by meds or worsening pain

• Watch for color change or numbness

Fat Embolism

Fat from bone marrow enters bloodstream after long bone fracture

Osteomyelitis

Bone infection caused by bacteria from

• External source (e.g., open fracture)

• Bloodstream (hematogenous spread)

Key Manifestations

• Irritability

• Fever

• Fast heart rate (tachycardia)

• Edema (swelling)

• Constant pain, worse with movement

• Avoids using the affected limb

• Infection site: tender, swollen, warm to touch

Nursing Actions

• Assist with diagnostic testing (blood, skin, bone cultures)

• Assist with joint/bone biopsy

• Give IV and oral antibiotics

• Monitor liver, kidney, and blood labs

• Monitor vital signs, I&O, and infection drainage

• Watch for superinfections (e.g., candida, C. diff)

• Position limb for comfort and limit movement

• Administer pain meds

• Coordinate with parents and physical therapy

Client & Family Education

• Treatment may require long-term antibiotics

• Monitor for hearing loss from some antibiotics

• Avoid putting weight on affected limb

• Support normal development with safe activities

• Encourage nutritious diet for healing