FRACTURE

INTRODUCTION:
A fracture is the separation of bone. The degree of the separation depends on the strength of the bone and
energy of events that caused the fracture. Accidental fractures are common in children. About 15% of all
injuries in children are fractures. Up to 66% boys and around 40% girls will sustain a fracture by their 15 th
birthday. Fractures heal faster in children than in adults because children have a thick vascular periosteum,
resulting in increased blood flow to the fracture site.

DEFINITION:
A break in the continuity of bone caused by trauma, twisting as a result of muscle spasm or indirect loss of
leverage or bone decalcification, is called as Fracture.

CHARACTERISTICS OF FRACTURE IN CHILDREN:

i. Increased mobility
ii. Insatiable curiosity
iii. Immature level of motor co-ordination
iv. Lack of mature judgement about dangerous situations
According to Rang and Willis (1977), there are specific differences between bones of children and adults
and their reaction to injury.

1. Growth plates: They have a rubber like consistency which protects joint surfaces from fractures. It is
weaker than ligaments. Epiphyseal separation occurs before ligament is disrupted or sprained.
Epiphyseal separation or buckle fractures are equivalent in childhood to an adult's sprain.
2. Thick periosteum: The periosteum of adults is thin; whereas that of the child is thick and strong.
3. Plastic bone: The child's bones are more porous and flexible than those of adults, so in response to
force they bend, buckle or sustain a greenstick fracture, unlike adults.
4. Rapid healing: The younger the child is, more rapidly the fracture heals.
5. Stiffness not usual: An injured joint will become stiff and should not be mobilized for longer than 3
weeks.
6. Response to injury: Children do not complain unless something is wrong.

TYPES OF FRACTURE:
Fracture is divided into different categories on the basis of following:
I. Communication with environment
II. Pattern
III. Miscellaneous
 I. Classification on the basis of communication with environment:

a. Simple or closed fracture: In this type, skin over the fracture area remains intact.
b. Compound or open fracture: The bone is exposed, through a break in the skin.
c. Complete fracture or incomplete fracture: In this type, bone is broken across entirely, destroying
the continuity of the bone, resulting in proximal and distal bone fragments.
d. Incomplete fracture: A fracture that does not entirely destroy the continuity of bone is an
incomplete fracture. This type of fracture is stable and undisplaced.

II. Classification on the basis of Pattern

a. Transverse fracture: Bone is fractured straight across, i.e. fracture at right angle to bone
b. Oblique fracture: Break extends in an oblique direction.
c. Spiral fracture: Fracture in which bone has been twisted apart. It is also called Torsion Fracture.
d. Linear fracture: The bone is fractured longitudinally.

III. Miscellaneous Types

a. Greenstick fracture: One side of the bone is broken and other side is bent. It is most commonly seen
in children.
b. Comminuted fracture: Bone is splintered or crushed with three or more fragments.
c. Impacted fracture: A part of fractured bone is driven into another bone.
d. Bend fracture: When bone bends to a breaking point and is not straightened completely without
intervention, it is termed as bend fracture. Bends occur most frequently in radius and ulna.
e. Buckle fracture: Results from compression of bone. It occurs near metaphysic of bones.
f. Periosteal hinge: Periosteum forms hinge at breakage side.

COMMON SITES OF FRACTURE IN CHILDREN

1. Clavicle: It occurs due to birth injury, at the time of rotation or manipulation.
2. Humerus: Supracondylar fracture of the humerous occurs when child falls forward with elbow
straight.
3. Radius and ulna: Occurs when child falls on hands with elbow flexed.
4. Femur: Fracture mostly occurs in middle third of femur. It occurs mainly due to child abuse.
5. Epiphyseal plate fracture: When it is weaker than associated ligament or joint capsule, injury will
cause joint dislocation or fracture.
PATHOPHYSIOLOGY:
CLINICAL FEATURES AND DIAGNOSTIC FINDINGS:
A. Assessment
The nurse assesses fracture as well as other injuries which the child may have sustained. Assessment is
organised under 5 “P”.
1. Pain: Nurse asks the child to describe the sensation present at the injured area, where there is pain, so
as to locate the fracture site.
2. Pallor: Color and temperature of injured limb are compared with uninjured extremity. Pallor and
coolness of injured limb could be an indication of reduced blood supply.
3. Pulse: Pulse is checked distal to injury and compared with the pulse in uninjured extremity. The
radial and ulnar pulses are checked if an arm is injured and posterior tibial and dorsalis pedis pulses
are checked, if leg is injured.
4. Paraesthesia: If the describes feeling of numbness, lack of sensation or “pins and needle
prick”sensation, nerve injuries should be suspected.
5. Paralysis: There may be pseudo paralysis from pain in young children.

Various combinations of following clinical manifestation may be present:

1. Deformity: Strong muscle spasms may cause bone fragments to override, therefore alignment and
contour changes occur.
2. Swelling: Edema may appear rapidly from localization of serous fluid at fracture site.
3. Bruishing (ecchymosis): It occurs due to the subcutaneous bleeding.
4. Muscle spasm near fracture site.
 5. Loss of normal functions
6. Abnormal mobility
7. Crepitus due to rubbing of broken bone ends.
8. Hypovolemic shock- Blood loss or other injures may cause shock.

B. Diagnosis:

Diagnosis is done on the following basis:

1. Complete history: including circumstances of injury.

2. Clinical manifestations
3. X-ray or CT scan
4. Lab diagnosis:

- Hemorrhage due to severe injury leads to decreased Hb and Hematocrit level and increase in bilirubin
level
- Elevation in WBC count can be caused by inflammatory process following injury or result of
infection.

MANAGEMENT OF FRACTURE:

The major objectives of care of children who have fracture are:

 To restore fracture fragments to their normal anatomic position (reduction).

 To maintain bone fragments in place until healing occurs (immobilization).
 To help the children regain normal functions and strength of the affected part (rehabilitation).
Reduction and immobilization are achieved by traction or closed manipulation and casting until
sufficient callus has formed at fracture site.

1. Fracture Reduction:

Fractures are reduced, before edema occurs and tissues are infiltrated by hemorrhage. Method used for
fracture reduction depends on

- Child's age
- Status of bone (displaced / overriding)
- Condition of skin and soft tissue
- Status of neurovascular functioning

Any of the following methods may be used for reduction-

a. Closed Reduction: It is accomplished by bringing bone fragments into apposition (ends in contact by
manipulation and manual traction).
b. Traction: Traction is a pulling force applied in a longitudinal direction to reduce a fracture. It can also
be used to immobilise a fracture.
c. Open reduction:

 Some fractures require surgery or open reduction so that the bone fragments can be repositioned
under direct visualisation.
 Internal fixation devices like metallic screws, plates or rods may be used to hold fragments of
bone in position until solid bone healing occurs.
  After wound closure, external immobilization of fracture is achieved by applying external fixation
device such as a splint or cast.

2. Fracture Immobilization:

Immobilization can be achieved with external fixation devices like bandages, casts, splints, continuous
traction, pin and plaster technique or internal fixation devices like plates, screws and rods.

a. Casts:

When a cast is applied for immobilizing a fracture bone, the joint above and below the fracture is
immobilized to eliminate the possibility of movement that might cause displacement at the fracture site.
Any of the following types of casts may be used for immobilization

 Upper extremity cast Short arm cast

Long arm cast

 Lower extremity cast Short arm cast

Long arm cast

 Hip spica cast

  Body cast

Most casts are made from gauze strips and bandage impregnated with plaster of paris. Other lighter weight
and water resistant materials (e.g. fiberglass and polyurethane resin) are also being used with increasing
frequency for selected types of fractures.

b. Traction

Traction is excretion of a pulling force along the long axis of a body part, used to-

- Align bone fragments and immobilize them if they can’t be aligned by simple traction and casting.
- Decrease muscle spasm, especially associated with fracture.
- Align dislocated bones.
- Prevent or treat contractures.

Principles of traction:

- When equal and opposite forces act on same point simultaneously, the object remains in equilibrium.
The use of traction in management of fracture involves direct application of these forces to produce
equilibrium at fracture site. A forward force (traction) is produced by attaching weight to distal
bone fragment, which is balanced by backward force of the muscle pull (counter traction) and
frictional force between patient and the bed.

Thus, the three components of traction management are:

 Traction
 Counter traction
 Friction
Methods of attaching traction devices
1. Manual Traction: Traction is applied to body part by hand, holding the extremity distally to the
fracture site.

2. Skin traction: Pull is applied directly to the skin surface and indirectly to skeletal structures. The
pulling mechanism is attached to skin with adhesive material or an elastic bandage.
3. Skeletal traction: Pull is applied directly to skeletal structure by a pin wire or tongs inserted into or
through the diameter of bone distal to the fracture.

Commonly used tractions:

The tractions commonly used are

a. Upper extremity traction (e.g. Dunlop traction)

b. Lower extremity traction - example

 Bryant traction
 Buck's traction
 Russell traction
 Ninty - Ninty skeletal traction
 Balanced suspension traction with Thomas leg splint and pearson attachment

c. Cervical traction
NURSING MANAGEMENT:

Nursing Management of Children with Cast:

A. The nursing management of children while application of casts is as follows:

i. Before cast is applied, extremities are checked for presence of rings or other items that might
cause constriction from swelling so these are removed.
ii. A tube of stockinette is stretched over the area to be casted and over it cast is applied.
iii. Care should be taken to form a smooth padded edge to protect skin from injury by hard cast
edges.
iv. Cast must be kept uncovered until it dries from inside out.
 v. A fan can be used to circulate air around the cast.
vi. A dryer or heated fan should not be used because the outside of cast would dry before inside,
resulting in burns due to heat conduction from cast to the skin.

B. Nursing responsibilities after the application of cast are:

1. Prevention of circulatory, neurologic or respiratory disturbances.

a. Wet cast is supported with palms of hands and not finger tips, to prevent denting the cast that may
cause pressure on underlying skin.

b. The casted lower extremity is elevated and supported on plastic covered pillow, avoiding pressure on
the heel, to decrease swelling that could impede blood circulation to the part.

c. The casted upper extremity is elevated and supported on plastic covered pillow or in sling suspension
from an infusion pole or around the child's neck.

d. Neurovascular status is assessed by looking for

- Swelling or unusual coldness, paleness, cyanosis or mottled appearance of toes or fingers of

casted extremity.
- Absence of nail bed blanching on application of pressure indicates decreased blood supply.
- Weak or absent peripheral pulses.
- Lack of ability to move toe or fingers of a casted extremity.
- Neurologic signs including tingling, numbness, pain or burning sensation of casted body part.

e. The tightness of cast is assessed by inserting fingers between skin and cast. The cast should be
neither too tight nor too loose.

f. The nurse assists in bivalving cast, if circulatory or neurosensory disturbance exists.

g. The child's respiratory rate and depth, colour and behavior are assessed to determine respiratory trouble,
if any.

2. Maintenance of body temperature:

The child's temperature is taken routinely. Chilling can occur because of evaporation of water from cast
and heating can occur because of reaction within the cast, when drying occurs.

3. Maintenance of skin integrity and prevention of infection.

 Rough edges of plaster cast are trimmed and padded

 Skin is assessed for signs of infection or irritation.
 The nurse inspects beneath the cast for food particles or small objects which children may insert
between cast and skin.
 Nurse observes for signs of infection like elevation of temperature, discomfort, irritability or
unpleasant odour from the cast.
 The child in a cast is turned every 2 hourly to prevent pressure on bony prominences.

4. Maintenance of cleanliness

 The spica or body cast around the perineum is protected with pliable plastic film to prevent soiling
with excreta.
 The head and upper body are elevated on pillows, higher than buttocks when toileting an older child
to prevent urine from flowing beneath the body/hip spica.
 Weight bearing is allowed only when leg cast is totally dry.
 Cast made of materials which are impervious to water can be wiped clean with a damp cloth and mild
cleanser.

5. Promotion of appropriate muscle activity.

 Active or passive ROM exercises should be done for unaffected parts.

 The child should be turned every 2 hourly.
 Ambulation is encouraged as soon as possible.
 Child with casted leg is taught to use crutches.

6. Provision of comfort measures.

 Uncasted areas of child's body are supported with pillows for comfort.
 Diversion therapy may be provided to reduce stress.
 The child should be told not to insert objects inside the cast for scratching.

7. Prevention of urinary stasis and constipation

 Prevention of urinary stasis and constipation in an inactivated child can be achieved via liberal
fluid intake and high fiber diet.
 If constipation occurs, provide stool softeners.
 Provide small frequent feeds, because child's appetite and digestion may be poor.

8. Education of parents and the child:

 The parents are taught about care of child in cast because many children are discharged as soon as
cast drys.
 Nurses teach the parents about sign and symptoms of neurosensory and circulatory impairment.

II. Nursing Management of children in traction

1. Educate the child and parents.

 Parents are explained the purpose of traction as well as care of child in traction
 Parents should support the child during the period of immobilization

2. Maintaining traction

 Traction may be maintained continuously or intermittently, depending on the type of traction and
its purpose. Skin traction is generally applied continuously, harness traction intermittently and
skeletal traction is always applied continuously.
 The nurse must make sure that the line of pull of traction is as ordered; to align the bone fragments
properly. The nurse is also responsible for checking various parts of traction apparatus like-

a. Bandages used in skin traction should be correctly applied.

b. Frames and splints must be checked for correct positioning.
c. Pulleys should be in original position.
d. Ropes should be placed in pulley correctly and they should be taut and secured tightly with knots.
e. Weights should be hanging freely.

3. Maintain correct body alignment.

 The nurse observes child's position in bed so as to keep the child in good alignment.
 The nurse maintains the line of pull of traction by making sure, that child's joints are positioned
correctly in degree of flexion or extension, as ordered.
 Restraints may be applied as needed.

4. Maintain skin integrity.

 Place sheep's skin under pressure areas or use air/water mattress.

 Change child's position two hourly and massage the skin over pressure areas.
 Check if pressure bandages or restraints are too tight and excoriating the skin.
 Keep the child's skin clean and dry. Bath and dry the child at least once a day
 Inspect the skin frequently for sign and symptoms of bed sore.

5. Promote appropriate muscle activity:

 Prevent foot drop by using padded

 Internal or external rotation may occur due to long term malpositioning of the extrimities. Correct
positioning of the child is necessary to prevent this.
 Providing comfort devices and pain relief:
 Comfort devices like pillows, soft pads, foam supports, rolls or padded sand bags can be used for
positioning or supporting a part.
 If traction is painful, analgesics may be administered as prescribed.
 Keep the child warm and comfortable.

6. Provide adequate fluids and nutrients:

  Prevent dehydration by encouraging fluid intake.
 Provide high calcium diet to enhance bone healing.
 Provide small frequent feeds, which the child can digest easily, as digestion is already impaired
due to prolonged immobility.
 Provide low calorie and fat diet as the child is immobile for long duration, which increases the risk
of obesity

7. Observing for complications:

Observe for possible complications of fracture and immobilization, like-

 Circulatory impairment.
 Volkmann ischemic contracture
 Neurological complications like wrist drop, foot drop, lack of sensation, numbness etc.

COMPLICATION OF FRACTURE:-
1) Infection: Pathogen may enter through the broken skin or may be blood born, healing will not occur
until the infection resolves.
2) Fat embolism: Emboli consisting of the fat from the marrow in the medullary canal may enter the
circulation through torn veins. They are most likely to lodge in lungs into pulmonary capillaries.
3) No- union: There are two types of no-unions atrophic and hypertrophic. Atrophic non-union occur
due to re-absorption and rounding of the bone ends due to inadequate blood supply and excess
mobility of the bones. Hypertrophic non-union occur due to formation of excess of callus formation.
4) Pseudoarthrosis: Type of non-union occurring at fracture site in which false joint is formed on shaft
of long bones. It is fracture site that failed to fuse. Each bone end covered with fibrous scar tissue.
5) Delayed union: Fracture healing occurring more slowly than expected healing eventually occur.
6) Malunion: Fracture heals in expected time but in unsatisfactory position, possibly resulting in
deformity, and dysfunction.
7) Angulation: Fracture heals in abnormal position in relation to midline of structure (type of malunion).
8) Refracture: New fracture occur at original fracture site.
9) Myositis ossification: Deposition of calcium in muscle tissue at the site of significant blunt muscle
trauma or repeated muscle injury.

REFERENCE:
1. Suddarth’s and Brunner “textbook of Medical Surgical Nursing” 12 th edition, volume 2 published by
Wolters Kluwer India Pvt. Ltd. Page no.- 2010-2011
2. Chintamani “Levi’sMedical Surgical Nursing” 2013 published by Elsevier India Private Limited 305,
Rohit House, 3 Tolstoy, Marg, New Delhi 110001. Page no 1600-1601
3. Sharma Rimple, Essentials of pediatric nursing, edition 1 st, published by Lotus publishers, page
referred 608-621.
4. Sethi Neeraj, Awasthi Shikha; “Essential of pediatric nursing” Edition 3 rd, published by lotus
publishers, page referred 439-442.