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Jordan University of Science and Technology Faculty of Nursing Advanced pediatric Nursing clinical 1 (Case presentation) Presented by: Nedaa Al msidein . 143513 Submitted to: DR. manal kassab.

Fracture

What is a fracture in a child? • A fracture is a break in the bone that occurs when more force is applied to the bone than the bone can withstand. Fractures are also known as broken bones. Arm bones are fractured more often than other bones. • Common childhoodfractures 1. Broken collarbone or shoulder 2. Broken arm 3. Broken elbow 4. Broken forearm, wrist or hand 5. Broken hip 6. Broken leg ,foot or ankle



Etiology Occurrence • Damage/disruption to bone or • All age groups can be affected. joint, respectively, from trauma, • Fractures are most common presentation of exertion, overuse. •Most common causes: Child abuse child abuse; 70% of fractures in children and neglect, sports, falls, motor younger than age 6 months are inflicted. vehicle or pedestrian/bicycle • Fractures suggestive of nonaccidental trauma events. in children: Metaphyseal, rib (seen in 5–20% of abused children), scapular/distal clavicle/night stick (midshaft ulna), vertebral fracture or subluxation, fingers in nonambulating child, humerus (except supracondylar) in those younger than 3 years of age, bilateral/multiple fractures in different stages of healing, as well as complex skull fractures.

Signs and symptom Older children will usually be able to tell you where they are sore and can explain what happened to cause the injury. This can make it easier to identify if a fracture has occurred. It can be more difficult to identify a fracture in infants or toddlers. They may cry and not use the affected area, but there may be no obvious injury. • They may have the following symptoms: 1. pain or tenderness at the injury site 2. swelling or redness around the injury 3. deformity (unusual shape) of the injured area 4. not wanting to move or use the injured area. 5. On rare occasions the force of an injury can cause the skin over a fracture to split – this is called a compound fracture. There may only be a small break in the skin (the bone may not be sticking out of the wound). If this has occurred, it is important to see your GP or go to your local hospital emergency department.

Type of fracture 1. Non-displaced fractures With non-displaced fractures, the bone typically stays aligned in an acceptable position for healing. Such fractures are usually treated with a splint, brace, or cast. This immobilizes the injured bone, promotes healing, and reduces pain and swelling. • The followingkindsof fracturescan be treated witha splint,brace, or cast: 1. Singlenon-displaced fractures: The bone cracks or breaks but stays in place. 2. stress fractures (hairline fracture): Tiny cracks form in the bone, usually as a result of overuse or repetitive stress-bearing motions. Stress fractures are common in children who run track or participate in gymnastics or dance. 3. Torus or buckle fractures: One side of the bone bends (buckles) upon itself. The bone is dented but not broken. This is a common childhood injury that typically results from a simple fall.

2.Displaced fractures 4. Greenstick fractures: One side of the bone is broken, causing the other side to bend. A greenstick fracture When a fracture is displaced, the ends of the bone have come resembles a broken tree branch. The branch cracks on one out of alignment. In such cases, the broken bone needs to be set side but remains partially intact on the other. back into alignment so it will heal properly. This is called a reduction. After the reduction, the injured limb is immobilized with a brace, splint, or cast while the bone heals. If the reduction is unsuccessful, other treatment may be necessary. • Types of displaced fractures include: 1. Angulated fractures: The two ends of the broken bone are at an angle to each other 2. Translated fractures: The ends of the bone have shifted out of alignment. 3. Rotated fractures: The bone spun (rotated) when it broke.

3. Other severe fractures Some fractures require reduction or surgery, or the bone will not heal properly. • Examples include: 1. Comminuted fracture: The bone has broken into more than two pieces that no longer line up properly. 2. Compression fracture: The bone collapses under pressure. This is most serious when it involves a joint surface.

4.Open and closedfractures Bone fractures are classified as either open or closed. A closed fracture occurs when the bone is broken, but the skin remains intact. An open fracture, also known as a compound fracture, occurs when the broken bone breaks through the skin. Open fractures are rare. They can become infected if not treated appropriately and require immediate surgical attention.

5. Growth plate fractures • Growth plate fractures are typically caused by great force during sports or playground accidents. Depending on the seriousness of the fracture, they may be treated with a splint, cast, or walking boot. Some serious growth plate fractures require surgery. • In rare cases, growth plate fractures can slow the growth of the affected leg or arm. Damage to a growth plate can also cause the limb to grow at a wrong angle. When surgeons operate on broken limbs in children, they must protect the growth plates as much as possible.



Management and treatment • Patient management This requires an assessment of the whole patient, then focus on the injured limb, followed by definitive fracture management. • Initial assessment and management The Advanced Trauma Life Support (ATLS) protocol of airway, breathing and circulation must be applied to all trauma patients. The history may determine the direction and magnitude of the force applied to the broken bone.

• Assessment of the broken bone Clinical examination must be systematic and repeated, to identify established and evolving limb-threatening conditions. This must include assessment of the soft tissues and the distal neurovascular status of the limb. Radiological assessment should include the whole of the fractured bone, typically for long bone fractures this includes the joint above and below. The condition of the soft tissue surrounding the fracture dictates management, even in closed fractures. Operating through bruised and highly swollen tissues should be avoided, as the wound may be impossible to close or subsequently break down .

Management of open fractures • Hemorrhage is controlled by direct pressure or, as a last resort, by a tourniquet. Broad-spectrum antibiotics should be administered as soon as possible after the injury, and certainly within 3 hours. Tetanus vaccination status should be checked and booster injection should be considered. Any gross contamination should be removed, the wound photographed, adequately splinted and covered with sterile dressings until formal debridement can be performed in an operating theatre. No provisional cleaning of the wound should be performed before surgery. Complex open fractures require a combined orthopedic and plastic surgical opinion, and may need immediate referral to a regional specialist centre. The primary surgical procedure should ideally be performed at the same centre that all further surgery is to occur, to ensure appropriate planning and continuity. • The only reasons for immediate surgical exploration are: 1. removal of gross contaminants 4. multiply injured patient going to theatre. 2. compartment syndrome 3. devascularized limb

Definitive fracture management • The principles of definitive fracture management are reduction, stable fixation (external or internal), preservation of blood supply, and early mobilization (rehabilitation). There are different methods for treating the same fracture, but regardless of the means used, basic principles need to be followed in order to avoid poor outcomes. Reduction can be achieved by closed (traction and manipulation) or open methods (surgery). Stabilization is achieved by relative or absolute stability, using nonoperative, internal or external fixation techniques. • Relative stability: 1. Plaster casts: prevent angulation and malrotation. Indirect fracture healing takes place with callus visible on radiographs. However, only transverse fractures have axial stability in a cast, and oblique fractures may displace and shorten . 2. Traction: is an effective and safe way of maintaining reduction in some clinical situations; however, improvements in fracture fixation methods in conjunction with holistic care of injured patients has seen this method of fracture treatment decrease. Early mobilization of patients following surgery decreases the complications associated with the prolonged period of bed rest required. Healing is by abundant callus formation.

3. External fixation: is particularly useful if there is a surrounding soft tissue injury. All external fixators allow movement at the fracture site, so promote healing with callus formation. Circular frames are particularly useful if the fracture is very close to a joint and associated soft tissue injuries preclude internal fixation. They provide stability in three planes and allow axial micromovement to encourage callus formation. 4. Internal fixation: generally can be used to permit some controlled motion at the fracture site and encourages callus formation. Indications for internal fixation include displaced and intra-articular fractures, fracture instability (axial, rotational, angular) and associated neurovascular injury.





Follow up 1. Should be per orthopedist. Note that fracture healing is 6. In 2–6 weeks: Callus develops, bone ends become “sticky,” rapid in these patients; cannot wait for an appointment a pain is reduced. week out. 7. Consolidation begins at 3 weeks in infants, may take 3–6 2. Many will not allow use of extremity for a period of time months in older children, adults. while healing. 8. Weight bearing, casting, splinting, bracing, or full use are 3. Muscles will spasm around fracture to try to pull bone all related to fracture configuration, healing, patient ends together for healing. specifics. 4. Fractures without fixation move for 10–14 days after injury 9. Increased circulation to fractured bone causes some while granulation occurs (even in casts). This is painful. overgrowth (basis for 1-cm overlap of fractured femurs in 5. Frequent X-rays may be needed to ensure alignment of young children). fractures.

1. Compartment syndrome. 2. Loss of alignment. 3. Shortening, angulation, delayed or nonunion of fracture. 4. Skin breakdown. 5. Neurovascular problems. 6. Infection. 7. Missed abuse.

Statistics

Reference https://www.childrenshospital.org/conditions-and- treatments/conditions/f/fractures https://my.clevelandclinic.org/health/diseases/15241-bone-fractures https://www.rch.org.au/kidsinfo/fact_sheets/Fractures_broken_bone https://www.slideshare.net/harjotsgurudatta/orthopaedic-fractures-in- children Nyary, T., & Scammell, B. E. (2018). Principles of bone and joint injuries and their healing. Surgery (oxford), 36(1), 7-14. Ömeroğlu, H. (2018). Basic principles of fracture treatment in children. Joint Diseases and Related Pediatric primary care book