Fractures

What is a fracture?

A fracture is a break in a bone that occurs when more stress is placed on the bone than the bone can withstand•Types of Fractures: ◦Open: broken bone protrudes through the skin leaving a path to the fracture site, high risk of infection ‣Closed: broken bone does not protrude through the skin ‣Complete (Transverse): break across entire section of a bone at right angle to the bone shaft resulting ‣in two or more fragments Incomplete: break occurs in only one side of the cortex ‣Oblique: fracture slants across the long axis of bone ‣Spiral: is a fracture in which the line of the fx extends in a spiral direction along shaft/encircles bone ‣Greenstick: incomplete fracture with one side splintered and other side bent; caused by compression ‣force; often seen in young children Comminuted: associated with high impact forces; bone breaks into three or more segments ‣Note: Most Common Type of Fracture: Greenstick fracture- which is caused by compression More common in pediatric patients because bones of children are:•Porous and Less Dense than adults

Goals of Care

Adequate Nutrition •Absences of fractures •Normal bone density

Nursing Interventions for Traction

Assess child in traction by first checking equipment: check if in proper position, proper alignment, ‣observe attached weights Assess skin under the straps and pin insertion sites for: redness, edema, skin breakdown ‣Assess extremity by checking neurovascular status frequently (check warmth, color, distal pulses, ‣capillary refill time, movement, sensation)When ordered, provide pin care using sterile technique ‣When external skin traction is used, perform skin care every 4 hr when traction device is removed ‣Manage pain ‣Ensure weights hang freely

Nursing Interventions

Assessment •Be alert to s/s of fractures before moving the child ◦Identify cause◦In doubt about an injury? Apply a splint to immobilize joints above and below injury ◦Neurovascular Status ◦used to detect early signs of compartment syndrome ‣May occur with a crush injury or when a fracture is reduced, or with a cast ‣Condition in which pressure increases in a confined anatomical space, leading to decreased blood ‣flow, ischemia, dysfunction of tissues Pain (unrelieved by medication, characterized by crying child)•Paresthesia (tingling and numbness) •Pressure (skin tense, cast appears tight) •Pallor (pale, gray or white skin tone) •Paralysis (weakness or inability to move extremity) •Pulselessness (diminished/absent pulse) •Poikilothermia (skin temperature assumes the temperature of environment) •Interventions for compartment syndrome ‣Notifying HCP immediately •Monitor child's sensation to touch, temperature, movement, strength of pulses, and capillary •refill time open reduction closed Medical Interventions aim mobilization closed reduction aligns the bone by manual manipulation or traction followed by immobilization open reduction requires surgical alignment of the bone often using fixation devices such as pins plates wires screws fracture reduction complications infection malfunction delayed healing cerebrovascular nonunion vascular injury leg length discrepancy Monitor VS q15 min after the cast is applied for at least 2 hrs and then every 1-2 hrs•Keep leg at heart level

During first 24 hrs

Check casted extremity q15-30 min for 2 hrs, then q1-2 hrs thereafter •Skin should be warm •Should blanch when slight pressure is applied and then return to its normal color within 3 secs

Etiology/Risk Factors

Direct trauma to a bone (falls, sports injuries, abuse, motor vehicle crashes) •Bone diseases (osteogenesis imperfecta, osteoporosis) •Related to nutritional imbalance [Vitamin D and Calcium Insufficiency] ◦Related to chronic conditions [Spinabifida or Cerebral Palsy] = decreased movement = decreased pressure◦on bones = decreased development of bone mass Acute injury or Chronic/repetitive activities •Child abuse

After Cast is applied:

Elevate extremity on pillow or above heart = reduce edema & increase venous blood flow •Assess distal pulses, check fingers and toes for color, warmth, capillary refill, edema, sensation, •movement

Facture reduction complications

Infection delayed healing

Development impacts risk: School Age

Injury to Epiphyseal plate can impact future growth •Epiphyseal weakest point, common site of trauma ◦Salter Harris Classification System: [Based on the angle of the ◦fracture in relation to the epiphysis] Type 1 (Common)- injury to the growth plate undisturbed; ‣Growth Disturbances Rare [low risk] Type 2 (Most Common)- growth disturbances rare‣ Type 3 (Less Common)- serious threat to growth and joint‣ Type 4- Serious threat to growth‣ Type 5 (Rare)- crush injury causes cell death in growth ‣plate resulting in arrested growth and limited bone length;if growth plate is destroyed, angular deformities mayoccur

General cast info

Keep cast dry •Cover cast with plastic when child bathes •Never leave the child alone to bathe, and discard safely due to suffocation risk •Itchy skin? Do not use powders or lotions near the edges or under the cast as they can cause skin• irritation Can use blow dryers on cool setting •Do not insert any objects inside cast

Cast Care

Nursing Care ◦Plaster cast take about 24-48 hours to dry ‣Drying period: ‣Be gentle, use palms of hands instead of finger tips to avoid denting and creating pressure areas

Nursing Diagnosis

Pain r/t to injury •Skin integrity, Risk for impaired r/t treatment •Infection, risk for r/t open fracture or trauma •Mobility: Physical, Impaired, r/t treatment •Health Behavior, Risk Prone, r/t peer group influence and chosen activities

Teach

Remove clothing from injured part ‣Apply cold compress or ice pack wrapped in cloth ‣Keep injured limb in position you find it ‣Do not move child is broken bone comes through the skin (apply pressure with clean gauze pad or ‣thick cloth)Teach cast care ‣Activity restrictions

Family Education

Teach s/s ◦You or the child heard a snap or a grinding noise during injury ‣Swelling, bruising, tenderness, or pins/needles ‣Painful to bear weight

External Fixators

These devices can be used in treatment of simple fractures, both open and closed; complex •fractures with extensive soft tissue involvement; correction of bony or soft tissue deformities Attached to extremity by pins or wires to the bone •When used to lengthen an extremity the device can be turned as ordered by the surgeon for a •very small amount several times daily This separates bone and allows new growth, gradually lengthening the extremity

Indications Traction Care

To provide rest for an extremity ‣To help prevent or improve contracture deformity ‣To treat deformity ‣To treat dislocation ‣To allow position and alignment ‣To provide immobilization ‣To reduce muscle spasms (rare in children)

Healing [Early Recognition is Key as healing occurs quickly

Typically rapid healing in children ◦Neonatal period: 2-3 weeks ◦Early Childhood- 4 weeks ◦Later Childhood- 6-8 weeks ◦Adolescence- 8-12 weeks Fractures are rare in infancy and warrant further investigation to rule out the possibility of a child abuse and to•identify bone structure defects

Cervical Traction (Skeletal):

Used for cervical spine injuries to reduce fractures and dislocations •Crutch field or Barton Tongs are placed in the skull with burr holes •Weights are attached to the hyper extended head•As neck muscles fatigue, vertebral bodies gradually separate so the spinal cord is no longer •pinched between vertebrae NC: Has a wrench to unscrew different components for a medical emergency ‣Assess skin reddened areas and reposition q2hrs ‣Pin care ‣Teach to not hold the child with the brace

Russell Traction (Skin):

Used for fractures of the femur and lower leg. Traction is•placed on lower leg while the knee is suspended in padded sling. The slightly flexed hips and knees are im mobilized. One force is applied by a double pulley to the foot and another force is applied upward using a sling under the knee and an overhead pulley NC: Maintain ordered angle of hip flexion & assess for foot drop 90 degree-90 degree Traction (Skeletal): ‣Used for fractures of the femur or tibia. A skeletal •pin or wire is surgically placed through the distal part of the femur, while the lower part of the extremity is in a boost cast Traction ropes and pulleys are applied at the pin site •and on the boot cast to maintain the flexion of both the hip and knee at 90 degrees. This traction can also be used for treatment of an upper extremity fracture NC: check pin sites, risk for infection, pin care

Buck's Traction

Used for knee immobilization to correct contractures or •deformities or for short term immobilization.Keeps the leg in an extended position, without hip flexion •Traction is applied to the extremity in one direction •(straight line) with a single pulley

Signs/Symptoms

Vary depending on location, type, and nature of causative injury •Pain •Abnormal positioning •Edema •Immobility & Decreased ROM •Ecchymosis •Guarding •Crepitus

Traction Care

What is it? ◦extended pulling force may be used

Common Sites of Fractures

clavicle, tibia, ulna, femur, distal femur fractures the most common types •Stress Fracture Sites: tibia, fibula, metatarsals, and calcaneus

Medical Interventions

closed Reduction aligns the bone by manual manipulation or traction followed by immobilization Open reduction requires surgical alignment of the bone of tensing fixation device such as pins plates wires screws

Skin Traction

pull is applied to the skin surface, which puts traction directly on bones and muscles. Traction is •attached to the skin with adhesive materials or straps, or foam boots, belts, or halters

Skeletal Traction

pull is directly applied to the bone by pins, wires, tongs, or other apparatus that have been •surgically placed through the distal end of the bone