Injuries throughout childhood are inevitable. Trauma often occurs as a result of motor vehicle injury. The bulk of trauma resulting from physical activity or sports in children is due to running, skateboarding, and climbing trees. Only about one third of sports injuries in children occur dur- ing organized sports; the rest occur in physical education
the child, the more quickly the bone heals. However, plastic deformity and Salter-Harris type IV fractures may result in an angular deformity. Though healing of frac- tures is usually quick and without incident in children, delayed union, nonunion, or malunion can occur. Addi- tional complications include infection, avascular necro- sis, bone shortening from epiphyseal arrest, vascular or nerve injuries, fat embolism, relex sympathetic dystro- phy, and compartment syndrome, which is an ortho- pedic emergency. Later in life, osteoarthritis may occur as a long-term complication from childhood fracture (Dugdale & Zieve, 2010).
Take Note!
Any type of fracture can be the result of child abuse but spiral femur fractures, rib fractures, and humerus fractures, particularly in the child younger than 2 years of age, should always be thoroughly investigated to rule out the possibility of abuse (Wells, Sehgal, & Dormans, 2011).
Therapeutic Management
The vast majority of childhood fractures would heal well with splinting only, but casting of these fractures is per- formed to provide further comfort to the child and to allow for increased activity while the fracture is healing.
Displaced fractures require manual traction to align the bones, followed by casting. More severe fractures may require traction for a period of time, usually followed by casting. Severe or complicated fractures may alternatively require open reduction and internal ixation for healing to occur. Complex fractures are often treated with exter- nal ixation (Fig. 45.24).
Take Note!
Signiicant swelling may occur initially after immobili- zation with a splint. Delaying casting for a few days provides time for some of the swelling to subside, allowing for successful casting a few days after the injury.
Nursing Assessment
For a full description of the assessment phase of the nursing process, refer to page 1630. Assessment indings pertinent to fractures are discussed below.
Health History
Elicit a description of the present illness and chief com- plaint. Common signs and symptoms reported during the health history might include recent injury, trauma, or fall; complaint of pain; dificulty bearing weight; limp; or refusal to use an extremity. Young children often dem- onstrate sudden onset of irritability and refusal to bear class or nonorganized sports (Busch, 2006). Younger chil-
dren tend to suffer contusions, sprains, and simple upper extremity fractures; adolescents more frequently experi- ence lower extremity trauma. As the number of children participating in youth sports increases and the intensity of training and the level of competition also increase, the incidence of injury is also likely to increase.
Many types of musculoskeletal injuries exist. This discussion will focus on fractures, sprains, overuse syn- dromes, and dislocated radial head.
Fracture
Fractures occur frequently in children and adolescents;
42% of boys and 27% of girls will suffer a fracture during childhood (Grewal & Ahier, 2010). The most common frac- tures in children occur in the forearm and wrist (Grewal
& Ahier, 2010). Greenstick and buckle fractures account for about half of pediatric fractures, and only about 20%
of childhood fractures require reduction (Price, Phillips, &
Devito, 2006). Midclavicular, humerus, or femur fractures can occur as a result of birth trauma. They typically heal well but may require limiting mobility or splinting.
Fractures in children result most frequently from accidental trauma (Grewal & Ahier, 2010). Nonacciden- tal trauma (child abuse) and other disease processes are the other causes of fractures. In children younger than 2 years, most fractures that occur are the result of another person causing the injury (Grewal & Ahier, 2010).
Take Note!
Fracture in the newborn (with the exception of birth trauma) or infant should raise a high index of suspi- cion for abuse, as fractures are very unusual in children who cannot yet walk (Grewal & Ahier, 2010).
Pathophysiology
The growth plate is the most vulnerable portion of the child’s bone and is frequently the site of injury. The Salter- Harris classiication system is used to describe fractures involving the growth plate (Table 45.4). The thicker, more elastic periosteum in children yields to the force encoun- tered with trauma, resulting more frequently in nondis- placed fractures in children. The increased vascularity and decreased mineral content make the child’s bones more lexible. Plastic or bowing deformities and buckle and greenstick fractures are the result. Complete fractures do occur in children, but they tend to be more stable than in the adult, resulting in improved healing and function. Spi- ral, pelvic, and hip fractures are rare in children. Table 45.5 explains common types of fractures in children.
Fractures in children heal more rapidly and result in less disability and deformity than adults. The younger
(continued)
Type Description Illustration
I Fracture is through the physis, widening it.
II Fracture is partially through the physis, extending into the metaphysis.
III Fracture is partially through the epiphysis, extending into the epiphysis.
TABLE 45.4 THE SALTER-HARRIS CLASSIFICATION SYSTEM
TABLE 45.4 THE SALTER-HARRIS CLASSIFICATION SYSTEM (continued)
Type Description Illustration
IV Fracture is through the metaphysis, physis, and epiphysis.
V Crushing injury to the physis
TABLE 45.5 TYPES OF FRACTURES IN CHILDREN
Fracture Type Description Illustration
Plastic or bowing deformity
Signiicant bending without breaking of the bone
Buckle fracture Compression injury; the bone buckles rather than breaks.
Greenstick fracture Incomplete fracture of the bone
Complete fracture Bone breaks into two pieces.
A
B
C
D
weight. Ask about the mechanism of injury and obtain a description of the traumatic event. Be alert to incon- sistencies between the history and the clinical picture or mechanism of injury; inconsistency may be an indicator of child abuse. Explore the child’s current and past medi- cal history for risk factors such as:
• Rickets
• Renal osteodystrophy
• Osteogenesis imperfecta
• Participation in sports, particularly contact sports
• Failure to use protective equipment as recommended for various physical activities and sports (e.g., wrist guards while rollerblading)
Physical Examination
Perform the physical examination of the child with a potential fracture carefully, so as not to cause further pain or trauma. The physical examination particular to fractures includes inspection, observation, and palpation.
Take Note!
Do not atempt to straighten or manipulate an injured limb.
INSPECTION AND OBSERVATION
Inspect the skin for bruising, erythema, or swelling.
Observe the extremities for deformity. Note neglect of an
extremity or an inability to bear weight. If ambulating, note any limp.
PALPATION
Carefully palpate the joint or injured part. Distract the young child with a toy or activity while palpating. Note point tenderness, which is a reliable indicator of frac- ture in children. Assess neurovascular status, noting distal extremity temperature, spontaneous movement, sensation, numbness, capillary reill time, and quality of pulses. The neurovascular assessment is critical to pro- viding a baseline so that any changes associated with compartment syndrome can be identiied quickly.
Laboratory and Diagnostic Tests
Usually plain x-ray ilms are all that is required to iden- tify a simple fracture. Complicated fractures that require surgical intervention may require further evaluation with CT or MRI.
Nursing Management
Immediately after the injury, immobilize the limb above and below the site of injury in the most comfortable position with a splint. Use cold therapy to reduce swell- ing in the irst 48 hours after injury. Elevate the injured extremity above the level of the heart. Perform frequent neurovascular checks.
Take Note!
Assess the injured, splinted, or casted extremity frequently for the “5 P’s,” which may indicate com- partment syndrome: pain (increased out of proportion), pulse- lessness, pallor, paresthesia, and paralysis. Report these ind- ings immediately.
Assess pain level and administer pain medications as needed. Utilize nonpharmacologic methods of pain relief as needed. Administer tetanus vaccine in the child with an open fracture if he or she has not received a tetanus booster within the past 5 years. Additional nurs- ing interventions include providing family education and teaching on fracture prevention.
Providing Family Education
Unless bed rest is prescribed, children with upper extrem- ity casts and “walking” leg casts can resume increased levels of activity as the pain subsides. Children who require crutches while in a cast may return to school, but those in spica casts will be at home for several weeks.
Providing distraction and inding ways to keep up with school work are important. Teach families to care for the cast (see Teaching Guidelines 45.1).
B A
FIGURE 45.24 (A) External ixation is required for compli- cated fractures. (B) The Ilizarov ixator is a circular apparatus usually used for complicated lower extremity fractures. The pins are smaller in diameter, more like wires, than those used in other ixators.
Preventing Fractures
Discourage risky behavior such as climbing trees and per- forming tricks on bicycles. Provide appropriate supervi- sion, particularly with outdoor activity. Encourage appro- priate use of protective equipment, such as wrist guards with rollerblading and shin guards with soccer. Ensure that playground equipment is in good working order and intact;
there should not be protruding screws or unbalanced por- tions of equipment, which may increase the risk for falling.
Sprains
Sprains result from a twisting or turning motion of the affected body part. The tendons and ligaments stretch excessively and may tear slightly. They are uncommon in young children as their growth plates are weaker than their muscles and tendons, making them more prone to fracture. They may occur at any joint, but the most common are ankle and knee sprains. Therapeutic man- agement of sprains includes rest, ice, compression, and elevation (RICE). Other treatment options may include activity restrictions, splints or casts, crutches or wheel- chair, and physical therapy. On initial evaluation, sprains need to be differentiated from torn ligaments and menis- cal tears, as those conditions are more serious and may require surgical intervention.
Nursing Assessment
Elicit a health history, determining the mechanism of injury (whether it occurred during sports or simply a
misstep or fall). Determine what treatment the family has used so far. Inspect the affected body part for edema, which is frequently present, and bruising, which some- times occurs. Note limp or inability to bear weight. Do not attempt to perform passive range of motion on the affected body part. Assess neurovascular status distal to the injury (usually normal).
Nursing Management
Instruct the child and family in appropriate treatment of sprains, which includes:
• Rest: limit activity.
• Ice: apply cold packs for 20 to 30 minutes, remove for 1 hour, and repeat (for the irst 24 to 48 hours).
• Compression: apply an Ace wrap or other elastic bandage or brace; check skin for alterations when rewrapping.
• Elevation: elevate the injured extremity above the level of the heart to decrease swelling (Fig. 45.25).
The child may require instruction in crutch walk- ing as well. Teach families that to prevent sprains during sports, it is important for the child to perform appropri- ate stretching and warm-up activities.
Take Note!
If the child’s ingers or toes become increas- ingly swollen or discolored, remove the Ace wrap immediately.
Rest Ice
Compression Elevation
R I C E
FIGURE 45.25 RICE (rest, ice, compression, elevation) is the appropriate treatment for sprains.
Overuse Syndromes
The term “overuse syndrome” refers to a group of disor- ders that result from repeated force applied to normal tis- sue. The connective tissues fail in response to repetitive stress, leading to a small amount of tissue breakdown.
They develop over the course of weeks to months. There is usually no identiiable injury associated with overuse syndromes. Pain is usually associated with the activity and worsens with continued participation in the activ- ity. The incidence of overuse injuries in the young ath- lete has increased as participation of youths in organized sports has grown along with children today participating in sports year-round and sometimes in multiple sports simultaneously (Brenner & the Council on Sports Medi- cine and Fitness, 2011). The young athlete is at risk for more serious overuse injuries due to the following:
• The growing bones of the young athlete cannot han- dle as much stress as mature bones in adults.
• The child is just learning the proper mechanisms for skills, such as throwing a baseball.
• The child is unable to recognize vague signs of injury such as fatigue and poor performance (Brenner & the Council on Sports Medicine and Fitness, 2011).
Table 45.6 gives details on several common over- use syndromes. Therapeutic management is aimed at reassurance, pain management, and limiting rather than eliminating activity.
Nursing Assessment
Elicit a health history to determine the extent of involve- ment in sports. Note onset of pain, duration, intensity, aggravating factors, and treatments used at home. Exam- ine the painful part, noting indings similar to those noted for each syndrome in Table 45.6.
Nursing Management
Initially, apply ice when pain is severe. Anti-inlammatory medications such as ibuprofen may be helpful. Encour- age the child to limit exercise and participate in a differ- ent activity. After a few weeks, most overuse syndromes resolve; at that point, the athlete may resume the prior activity. Osgood-Schlatter disease is the exception and may require 12 to 24 months to resolve (Gunta, 2009).
Using pads or braces that are appropriate to the pain- ful body part is also helpful. Supporting the arm with a
TABLE 45.6 OVERUSE DISORDERS
Disorder
Anatomic Area Affected
Most Commonly
Occurs in Symptoms
Osgood- Schlatter disease
Partial avulsion of the ossiication center of the tibial tubercle
Active adolescents, most often boys. Most frequently during periods of rapid growth
• Mild to moderate pain, activity related
• Tibial tubercle is tender when palpated
• Painful swelling or prominence of the anterior portion of the tibial tubercle Epiphysiolysis
of proximal humerus
Proximal humerus (widening of growth plate)
Occurs with rigorous upper extremity activity, such as baseball pitching
• Tenderness in the shoulder or proximal humerus
• Pain with active internal rotation
• Full shoulder range of motion continues
Epiphysiolysis of distal radius
Distal radius (widening of growth plate)
Occurs with overuse of the distal radius, such as in gymnasts
• Wrist pain that worsens with activity
Sever disease (calcaneal apophysitis)
Calcaneus (heel) Usually in 9- to 14-year-
olds • Pain over the posterior aspect of the calcaneus
• Limited active and passive dorsilexion of foot Shin splints Refer to a variety of
overuse syndromes associated with the shin (stress fracture, tibial stress, muscular issues)
Occur with activities that place repeated exertion on the lower leg, as in runners, ballerinas, elite soccer players
• Exercise-induced pain of the anterior aspect of the middle part of the lower leg
• May be sharp pain
• Worsens with exercise
• With stress fracture, may have a limp that worsens with activity
The child will hold the arm slightly lexed at the side or across the abdomen and refuse to move it. When the arm is still, the child apparently has no discomfort. Neu- rovascular status is normally intact with no bruising or swelling present.
Nursing Management
After treatment, usually hyperpronation to reduce the dislocation, assess the child’s ability to use the arm with- out pain. Typically after reduction the child will dem- onstrate less pain almost immediately. Educate parents that once a radial head subluxation occurs it may recur.
Teach parents to avoid excessive pulling or pulling up on the child’s arm, particularly in an abrupt jerking fashion, to prevent recurrence. Encourage parents and caregivers to always lift the child under the arms.
sling may relieve stress on the proximal humerus when epiphysiolysis occurs. Heel cups used in athletic shoes help relieve stress on the heels associated with Sever disease. To prevent overuse syndromes, encourage ath- letes to perform appropriate stretching exercises during a 20- to 30-minute warm-up period before each practice or game. Also encourage several weeks of conditioning training before the season begins.
There is currently limited research pertaining to overuse injuries in the young athlete. The American Academy of Pediatrics has developed some guidelines to help prevent these injuries such as the following:
encourage 1 to 2 days off per week of competitive ath- letics, sports training, and competitive practice; encour- age 2 to 3 months away from a speciic sport during the year; and educate to increase weekly training time, number of repetitions, or total distance by no more than 10% a week (Brenner & the Council on Sports Medicine and Fitness, 2011).
Take Note!
“Energy healing” such as therapeutic touch and Reiki may provide a nonpharmacologic adjunct to pain management for musculoskeletal injuries.
Radial Head Subluxation
Subluxation of the radial head (“nursemaid’s elbow”) occurs when a pulling motion on the arm causes the annular ligament surrounding the radial head to stretch or tear, therefore displacing the radial head. The ligament becomes entrapped within the joint, preventing sponta- neous reduction. It usually occurs in children younger than 7 years of age and is a common injury in children aged 2 to 5 years (Rodts, 2009). In most cases a par- ent, sibling, or caregiver inadvertently injures the child while holding or pulling on a pronated upper extrem- ity. Radiologic examination may be done, especially if the mechanism of injury is not clear, to rule out fracture or dislocation. To reduce the injury, the elbow is lexed to 90 degrees and then the forearm is fully and irmly supinated, causing the ligament to snap back into place.
With appropriate reduction of the radial head, no com- plications result.
Nursing Assessment
Elicit a health history to help determine the mechanism of injury. Common precipitators of this injury include pulling on the child’s arm while leading him or her in one direction, helping the child up the stairs, a child drop- ping or falling to the ground while an adult is holding the hand, or swinging or lifting the child by the hands.
Assess neurovascular status and examine the extremity.
KEY CONCEPTS
At birth, muscles, tendons, ligaments, and cartilage are all present and functional.
Rapid muscle growth in the adolescent years places the teenager at increased risk for injury compared with other age groups.
The bones of the infant and young child are more lexible and have a thicker periosteum and more abundant blood supply than the adult’s; as a result, bending occurs more frequently than breaking of the bone, and the fractured bone heals more quickly.
The epiphysis of long bones is the growth center of the bones in children. Injury to this area may result in long-term extremity deformity.
Plain radiographs are usually suficient for diag- nosing injuries in children. If CT or MRI scans are required, the nurse may need to help the child stay calm and still during the procedure.
Apply a pressure dressing following joint aspiration to prevent hematoma formation or luid recollection.
Perform frequent assessments of pain status and the effect of pain medication in the child with a musculoskeletal disorder.
Diazepam (Valium) may be helpful in relieving muscle spasm associated with traction.
Maintain traction and the appropriate amount of weight as ordered.
The bulk of cast care occurs in the home. Teach the family of a child with a cast to perform neuro- vascular assessments, prevent the cast from getting wet, and care for the skin appropriately.