Chapter 26 Fractures
PATHOPHYSIOLOGY
Fractures can have a variety of causes, including (1) a direct force applied to the bone; (2) an underlying pathologic condition, such as rickets, that leads to spontaneous fracturing; (3) abrupt, intense muscle contractions; and (4) an indirect force applied from a distance (e.g., being hit by a flying object). Other causes of fractures include child abuse, metastatic neuroblastoma, Ewing’s sarcoma, osteogenic sarcoma, osteogenesis imperfecta, copper deficiency, osteomyelitis, overuse injuries, and immobilization resulting in osteoporosis.
There are a variety of fractures, which can be categorized using the Salter-Harris classification system (Box 26-1). The most common type seen in children younger than 3 years of age is the greenstick fracture. This type is characterized by an incomplete break of the cortex, which occurs because the bone is softer and more pliable than the bones of older children. Other fractures (and their related sites) include upper epiphyseal and supracondylar fractures, lateral condylar humeral fractures, and medial epicondylar fractures (humerus); proximal radial physis and radial neck fractures, and nursemaid’s elbow (elbow); fractures of the shaft of the radius and ulna (forearm); and fractures of the femoral shaft and tibia (lower limb). Abuse should be considered in all children younger than 15 months of age with humeral fractures, including supracondylar and spiral fractures. In one study of 215 children, 60% of femur fractures in children younger than 1 year of age were due to abuse. Child abuse can also be suspected with rib and skull fractures.
INCIDENCE
1. Most fractures occur to pedestrians.
2. Upper-extremity fractures account for 75% of all fractures sustained by children and frequently occur during a fall onto an outstretched hand.
3. Skull fracture ranks first in terms of morbidity and mortality.
4. Pelvic fractures constitute a small portion of skeletal fractures in children; they rank second in terms of morbidity and mortality.
5. Injuries to the growth plate occur in one third of skeletal traumas.
COMPLICATIONS
1. Orthopedic: deformity of limb, limb length discrepancy, potential for growth arrest, joint incongruity, limitation of movement, and refracture
2. Neurologic: nerve injury resulting in numbness and/or nerve palsy
3. Cardiovascular: circulatory compromise, Volkmann’s contracture, gangrene, and compartment syndrome
LABORATORY AND DIAGNOSTIC TESTS
Refer to Appendix D for normal values and ranges of laboratory and diagnostic tests.
1. Radiographic study—to examine extent of the injury site
2. Bone scan—performed if radiographic studies are normal
3. Magnetic resonance imaging—to assess for pathologic interosseous features and growth plate injuries
4. Complete blood count—to determine presence of blood dyscrasias and/or anemia
5. Erythrocyte sedimentation rate—to determine level of inflammation
6. Ultrasonography—to assess intraarticular, extraarticular, and soft tissue abnormalities
MEDICAL MANAGEMENT
Management varies according to the type of fracture. Management modalities include open reduction, traction, casting, percutaneous pinning, and remodeling. Analgesics are used for pain relief. The dosage and type depend on the intensity of the child’s pain.
NURSING ASSESSMENT
1. Assess site of injury for pain, swelling, change in skin color, and neurovascular impairment.
2. Assess for cause of injury.
3. Assess child’s need for pain relief.
4. Assess for signs and symptoms of infection.
5. Assess for wound healing (if open reduction was performed).
6. Assess for skin irritation (if casted).
7. Assess for cast or traction integrity.
8. Assess for hydration status.
9. Assess for signs and symptoms of complications such as fat emboli and compartment syndrome.
10. Assess child’s and family’s ability to adhere to treatment regimen.
11. Assess child’s ability to participate in self-care activities.
NURSING DIAGNOSES
NURSING INTERVENTIONS
Admission
1. Monitor and document condition and cause of injury.
2. Apply splint or Jones dressing to affected limb to alleviate pain and prevent further injury (traction may be used).
3. Maintain nothing-by-mouth status until after treatment; child may have to be anesthetized.
4. Prepare child and family for selected treatment modality.
Later Treatment
1. Observe and report status of limb distal to fracture site.
2. Alleviate edema and swelling of trauma site and area distal to it.
4. Observe and report signs of infection.
5. Observe for and record bleeding; note and outline amount.
6. Provide cast care (as indicated).
7. Maintain traction (as indicated).
8. Provide age-appropriate diversional activities to alleviate or minimize effects of sensory deprivation and immobilization (see Appendix F).
9. Promote adequate fluid and nutritional intake.
10. Prevent complications of unaffected limb; provide daily exercises.
11. Refer case to child protective services if child abuse is suspected (see Chapter 12).
Discharge Planning and Home Care
1. Monitor child’s and family’s ability to keep follow-up appointments.
2. Instruct parents and child about care of cast, use of crutches, movement, weight bearing, and return to school or home teaching.
3. Instruct parents and child to monitor and report signs of complications (as described in Nursing Interventions section in this chapter).
4. Review home safety precautions to help prevent further injuries.
5. Review vehicular safety precautions such as proper use of seat belts and car seats.
6. Review recreational safety precautions such as using knee pads and helmets while skateboarding or bicycling.
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