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FIGURE: Common fractures in children. (A) Plastic deformation (bend). (B) Buckle (torus). (C) Greenstick. (D) Complete.
Epiphyseal Injuries
• Fifteen percent to 30% of all childhood fractures involve the physis (growth plate).
• The most frequent site of physeal injuries (excluding phalangeal fractures) is the distal radius and ulna.
• The 11- to 15-year-old age-group tends to sustain the majority of physeal injuries to the distal radius and ulna.
• The mechanism of injury is usually a fall on an outstretched arm.
Clavicle Fractures
• Most common site of fracture in children, with most occurring in children older than age 5.
• Account for 30% to 50% of all fractures in children.
• Seventy-five percent of forearm fractures occur in the distal third of the radius and ulna and most do not
involve the physis.
• Major categories of classification include fracture dislocations, midshaft fractures, and distal fractures.
• Most common cause is from a fall on an outstretched arm.
Humerus Fractures
• The mechanism of injury for the majority of humeral fractures is a fall onto an outstretched arm or hand.
• Less than 1% of fractures occur at the proximal humerus.
• Ten percent of all humeral fractures occur at the shaft of the humerus; they account for less than 2% of all
pediatric fractures.
o Humeral shaft fractures are usually a result of twisting injuries in infants and toddlers (child abuse is a
common cause of these fractures in this age group).
o Direct trauma to the humeral shaft is the most common mechanism of injury in older children.
• Supracondylar fractures account for 60% of all elbow fractures in children. There is a high incidence of
neurovascular injury with supracondylar fractures, 8% of which sustain a neurologic injury.
• Twenty percent of distal humeral injuries occur in the lateral condyle; this ranks as the second most common
elbow fracture in children.
• Medial epicondyle fractures are the third most common elbow fracture in children, accounting for 5% to 10% of
all pediatric elbow fractures.
Spinal Fractures
• Rare in children they account for 1% to 2% of all pediatric fractures.
• Mechanism of injury is due to significant trauma, such as an motor vehicle accident, fall from a significant
height, athletic activities, beatings, or pedestrian-versus-motor-vehicle accident.
• Most spinal fractures involve the cervical spine.
Pelvic Fractures
• Pelvic fractures are uncommon in children and adolescents with an incidence of 1 per 100,000 children per
year.
• Pelvic fractures are commonly the result of high-energy trauma or a crush-type injury.
• Associated injuries are present in approximately 75% of children with pelvic fractures and include damage to
the abdominal wall and pelvic organs.
Hip Fractures
Femur Fractures
• Common in children. Peak incidence occurs in two age groups—children ages 2 to 3 and adolescents.
• The midshaft of the femur is the most common location for femoral fractures in children and accounts for 1%
to 2% of all childhood fractures.
• Usually the result of high-energy trauma, such as a motor vehicle accident or fall from a significant height.
• Seventy percent of femur fractures in children younger than age 1 are associated with child abuse.
Tibial Fractures
• The most common lower extremity fracture in children occurs in the tibial and fibular shaft constitutes 10% to
15% of all pediatric fractures.
• A rotational mechanism of injury to the lower leg is the most common cause of tibial fractures in children
under age 3 (toddler's fracture).
• Greater force is required to injure the tibia in older children; motor vehicle accidents and sports injuries are the
most common causes of tibial fractures in children and adolescents.
Ankle Fractures
Foot Fractures
Classification of Fractures
Clinical Manifestations
• Inability to stand, walk, or use injured part
• Limb deformity (visible or palpable)
• Ecchymosis
• Pain
• History of injury or trauma (may not be the case with pathologic fractures)
• Spontaneous onset of pain (usually seen with pathologic fractures).
• Local swelling and marked tenderness
• Movement between bone fragments
• Crepitus or grating
• Muscle spasm
Diagnostic Evaluation
• X-rays of suspected limb fractures should include the joint above and below the injury.
o Should always include a minimum of two views at 90-degree angles to each other (anteroposterior and
lateral).
o Comparison views of the opposite extremity are frequently needed. They help to distinguish the
fracture line from the growth plate.
o In some situations, oblique X-rays are warranted in order to help identify a fracture that is difficult to
detect.
• Further radiologic studies may be indicated in certain instances to evaluate a fracture: tomography, computed
tomography (CT) scan, magnetic resonance imaging (MRI), bone scan, fluoroscopy.
• Vascular assessment may include the use of:
o Doppler studies.
o Compartment pressure monitoring.
o Angiography.
Management
Treatment is dependent upon the type of fracture, its location, and the age of the child.
Nursing Diagnoses
• Acute Pain related to tissue trauma and reflex muscle spasms secondary to fracture
• Ineffective Tissue Perfusion: Peripheral related to swelling and immobilization
• Impaired Skin Integrity related to mechanical trauma (eg, fixation device, traction, casts, other orthopedic
devices)
• Ineffective Coping related to separation from family and home
• Impaired Physical Mobility related to fracture and external immobilization device (eg, cast, splint, external
fixator)
• Bathing/Hygiene/Feeding/Toileting Self-Care Deficit related to external devices (eg, cast, splint)
• Risk for Infection related to trauma (fracture) and surgery
• Risk for Peripheral Neurovascular Dysfunction related to restrictive envelope secondary to cast or splint
Promoting Comfort
• Monitor and assess pain level using an age-appropriate pain scale (eg, Oucher or FACES scale).
• Properly position, align, and support affected body part.
• Administer analgesics as indicated and monitor effectiveness of analgesia.
• Use nontraditional methods of pain relief—music therapy, diversionary activities, relaxation techniques,
therapeutic touch, play therapy.
• Frequently assess perfusion of limb by checking temperature, color, sensation, and pulses.
• Elevate extremity above heart level to prevent edema.
• Encourage movement of digits on affected limb.
• Remove compressive bandages (eg, elastic bandages, splints) that restrict flow of circulation.
Promoting Mobility
Attaining Independence
Preventing Infection
• Assess wounds frequently for warmth, erythema, swelling, tenderness, or purulent drainage.
• Report signs of infection.
• Provide appropriate wound care for open injuries and surgical wounds.
• Administer antibiotics as ordered.
• Encourage child to eat and maintain good caloric and protein intake to promote healing.
• Teach good hand-washing technique to child and parents.
• Assess the neurovascular status of affected limb every hour for the first 24 hours (or as indicated by hospital
protocol)—compare with unaffected limb.
• Assess for nerve injury (eg, abduct all fingers, touch thumb to small finger, plantar flexion, dorsiflexi)