Fracture

A. Description 1. A fracture is a break in the continuity of the bone. 2. Common fracture sites:  Clavicle  Humerus In subpracondylar fractures, which occur when child falls backward on hands with elbows straight, there is a high incidence of neurovascular complications due to the anatomic relationship of the brachial artery and nerves to the fracture site.  Radius and ulna  Femur (often associated with child abuse)  Epiphyseal plates (potential for growth deformity) 3. Types of Fracture  Closed or simple fracture The bone is broken, but the skin is not lacerated.  Open or compound fracture- The skin may be pierced by the bone or by a blow that breaks the skin at the time of the fracture. The bone may or may not be visible in the wound.  Transverse fracture The fracture is at right angles to the long axis of the bone.  Greenstick fracture Fracture on one side of the bone, causing a bend on the other side of the bone.  Comminuted fracture - A fracture that results in three or more bone fragments.
 Oblique Fracture The fracture is diagonal to a bones long axis.

 Spiral Fracture At least one part of the bone has been twisted.

4. Complications of fractures include:  problems associated with immobility (muscle atrophy, joint contracture,pressure sores)  growth problems ( in children)  infection  shock  venous stasis and thromboembolism  pulmonary emboli and fat emboli  and bone union problems B. Etiology 1. Fractures in children usually are the result of trauma from motor vehicle accidents, falls or child abuse. 2. Because of the resilience of the soft tissue of children, fractures occur more often than soft tissue injuries. C. Pathopysiology 1. Fractures occur when the resistance of bone against the stress being exerted yields to the stress force. 2. Fractures most commonly seen in children:  Bend Fracture is characterized by the bone bending to the breaking point and not straightening without intervention.  Buckle fracture results from compression failure of the bone, with the bone telescoping on itself.  Greenstick fracture is an incomplete fracture. D. Assessment Findings 1. Clinical Manifestations  The five Ps pain, pulse, pallor, paresthesia, and paralysis are seen with all types of fractures.  Other characteristic findings include deformity, swelling, bruising, muscle spasms, tenderness, pain, impaired sensation, loss of function, abnormality, crepitus, shock or refusal to walk (in small children). 2. Laboratory and diagnostic findings  Radiographic examination reveals initial injury and subsequent healing progress. A comparison film of an opposite, unaffected extremity is often used to look for subtle changes in the affected extremity.

 Blood studies reveal bleeding (decreased hemoglobin and hematocrit) and

muscle damage (elevated aspartate transaminase (AST) and lactic dehygrogenase (LHD). E. Nursing Management 1. Provide emergency management when situation warrants, for a new fracture.  Assess the five Ps.  Determine the mechanism of injury.  Immobilize the part. Move injured parts as little as possible.  Cover any open wounds with a sterile, or clean dressing.  Reassess the five Ps.  Apply traction if circulatory compromise is present.  Elevate the injured limb, if possible.  Apply cold to the injured area.  Call emergency medical services. 2. Assess for circulatory impairment (cyanosis, coldness, mottling, decreased peripheral pulses, positive blanch sign, edema not relieved by elevation, pain or cramping). 3. Assess for neurologic impairment (lack of sensation or movement, pain, or tenderness, or numbness and tingling). 4. Administer analgesic medications. 5. Explain fracture management to the child and family. Depending on the type of break and its location, repair (by realignment or reduction) may be made by closed or open reduction followed by immobilization with a splint, traction or a cast. 6. Maintain skin integrity and prevent breakdown. Institute appropriate measures for cast and appliance care. 7. Prevent Complications  Prevent circulatory impairment by assessing pulses, color and temperature, and by reporting changes immediately.  Prevent nerve compression syndromes by testing sensation and motor function, including subjective symptoms of pain, muscular weakness, burning sensation, limited ROM, and altered sensation. Correct alignment to alleviate pressure if appropriate, and notify the health care provider.

 Prevent compartment syndrome by assessing for muscle weakness and

pain out of proportion to injury. Early detection is critical to prevent tissue damage.  Causes of compartment syndrome include tight dressings or casts, hemorrhage. trauma, burns and surgery.  Treatment entails pressure relief, which sometimes require performing a fasciotomy. 8. Prevent infection, including osteomyelitits, bys using infection control measures. 9. Prevent renal calculi by encouraging fluids, monitoring I&O, and mobilizing the child as much as possible. 10. Prevent pulmonary emboli by carefully monitoring adolescents and children with multiple fractures. Emboli generally occur within the first 24 hours.

Osteomyelitis
Osteomyelitis is infection in the bone. Osteomyelitis can occur in infants, children, and adults. Different types of bacteria typically affect the different age groups. In children, osteomyelitis most commonly occurs at the ends of the long bones of the arms and legs, affecting the hips, knees, shoulders, and wrists. In adults, it is more common in the bones of the spine (vertebrae) or in the pelvis. Causes
y y y y Bacteremia spread to the bone, causing an infection. (Such as pneumonia or a urinary tract infection, that spreads through the blood to the bone) Open fracture A recent surgery or injection around a bone can also expose the bone to bacteria and lead to osteomyelitis. Patients with conditions or taking medications that weaken their immune system are at a higher risk of developing osteomyelitis. These include patients with cancer, chronic steroid use, sickle cell disease, human immunodeficiency virus (HIV), diabetes, hemodialysis, intravenous drug users, and the elderly.

Symptoms and signs

y In children, osteomyelitis most often occurs more quickly. They develop pain or tenderness over the affected bone, and they may have difficulty or inability to use the affected limb or to bear weight or walk due to severe pain.

In adults, the symptoms often develop more gradually. Other symptoms include fever,chills, irritability, swelling or redness over the affected bone, stiffness, and nausea.

Diagnosis
y y Complete medical history and physical examination. Recent infections elsewhere in the body, past medical history, medication usage. Blood tests y Complete blood count (CBC) y Erythrocytesedimentation rate (ESR) y C-reactive protein (CRP) y Blood cultures. Imaging studies. (X-rays), bone scans, computed tomography (CT) scans,magnetic resonance imaging (MRIs), and ultrasounds. Biopsy

y y

Treatment
y y Antibiotics (Biopsy results can help guide the choice of the best antibiotic) Surgery

Nursing Interventions 1. Focus care on controlling infection, protecting the bone from injury, and providing support. 2. Encourage the patient to verbalize his concerns about his disorder. 3. Encourage the patient to perform as much self-care as his conditions allows. 4. Help the patient identify care techniques and activities that promote rest and relaxation and encourage him to perform them. 5. Use strict aseptic technique when changing dressings and irrigating wounds. 6. Provide a well-balanced diet to promote healing. 7. Support the affected limb with firm pillows. 8. Provide thorough skin care. 9. Provide complete cast care. 10. Administer prescribed analgesics for pain. 11. Assess vital signs, observe wound appearance, and note any new pain which may indicate secondary infection. 12. Watch for signs of pressure ulcer formation. 13. Look for sudden malpositioning of the affected limb, which may indicate fracture.

14. Explain all the test and treatment procedures.

Potts disease
 Is a spine infection associated with tuberculosis that is characterized by bone destruction, fracture, and collapse of the vertebrae, resulting in kyphotic deformity.  Is the presentation of the extra-pulmonary tuberculosis arthritis of the intervertebral joints  Also called tuberculosis spondylitis, tuberculous spondyloarthropathy, spinal TB, musculoskeletal tuberculosis  The causative agent is Mycobacterium Tubercule  Particularly the lower thoracic and the upper lumbar regions are affected.  Commonly localized in the thoracic 11 and thoracic 12.  The original name was formed after Percivall Potts a London surgeon.  Patient with BCG has 80% immunity.  Pathognomonic Sign: Gibbus Formation  Signs and Symptoms: Back Pain, Fever, Night Sweating, Anorexia, Weight Loss, Spinal mass, sometimes associated with numbness, tingling, or muscle weakness of the legs  Diagnostic Exam: Blood Test: elevated erythrocyte sedimentation rate, Tuberculin test, Bone Scan, Radiographs of the spine, CT of the spine, Bone biopsy, MRI  Predisposing Factors: Direct contaminant especially in children, Malnutrition, Poor Environmental Condition, Trauma

Scoliosis  A lateral curvature of the spine, may be found in thoracic, lumbar, or thoracolumbar spinal segment.  The curve may be convex to the right (more common in lumbar curves) or to the left (more common in lumbar curves).  Rotation of the vertebral column around its axis occurs and may cause rib cage deformity.  It is often associated with kyposis (humpback) and lordocis (swayback). Etiology And Pathophysiology 1. Idiopathic scoliosis exact etiology is unknown. Accounts for 65% of cases. Possible causes include genetic factors, vertebral growth abnormality. Classified into three groups based on age at time of diagnosis.

Infantile birth to age 3.  Juvenile presentation between age 11 and 17. 2. Congenital scoliosis exact etiology unknown; represented as malformation of one or more vertebral bodies that results in asymmetric growth.  Type I failure of vertebral body formation e.g. isolated hemivertebra, wedged vertebra, multiple wedged vertebrae, and multiple hemivertebrae.  Type II failure of segmentation e.g. unilateral unsegmented bar, bilateral block vertebra.  Commonly associated with other congenital anomalies. 3. Paralytic or musculoskeletal scoliosis develops several months after symmetrical paralysis of the trunk muscles from polio, cerebral palsy, or muscular dystrophy. 4. Neuromascular scoliosis child has a definite neuromascular condition that directly contributes to the deformity. 5. Additional but less common causes of scoliosis are osteopathic conditions, such as fractures, bone disease, arthritic conditions, and infections. 6. Miscellaneous factors that can cause scoliosis include spinal irradiation, endocrine disoders, postthoracotomy, and nerve root irritation. 7. As the deformity progresses, changes in the thoracic cage increase. Respiratory and cardiovascular compromise can occur in cases of severe progression. Assessment 1. Poor posture, uneven shoulder height. 2. One hip more prominent than the other. 3. Scapular prominence. 4. Uneven waist line or hemline 5. Spinal curve observable or palpable on both upright and bent forward. 6. Back pain may be present but is not a routine finding in idiopathic scoliosis. 7. Leg length discrepancy. Nursing Diagnosis  Disturbed body image related to negative feelings about spinal deformity and appearance in brace.  Risk for impaired skin integrity related to mechanical irritation to brace.  Risk for injury related to postoperative complications.


Diagnostic Evaluation

1. X-ray of the spine in the upright position, preferably on one long 36-inch cassette, show characteristic curvature. 2. MRI, myelograms, or CT scan with three dimensional reconstruction may be indicated for children with severe curvatures who have a known or suspected spinal column anomaly, before management decisions are made. 3. Pulmonary function tests for compromised respiratory status. 4. Evaluate for renal abnormalities in children with congenital scoliosis. Nursing Interventions 1. Prepare the child for casting or immobilization procedure by showing materials to be used and describing procedure in age-appropriate terms. 2. Promote comfort with proper fit of brace or cast. 3. Provide opportunity for the child to express fears and ask questions about deformity and brace wear. 4. Assess skin integrity under and around the brace or cast frequently. 5. Provide good skin care to prevent breakdown around any pressure areas. 6. Instruct the patient to examine brace daily for signs of loosening or breakage. 7. Instruct patient to wear cotton shirt under brace to avoid rubbing. 8. Instruct about which previous activities can be continued in the brace. 9. Provide a peer support person when possible so the child can associate positive outcomes and experiences from others.