Bone Fractures



A child’s bone is generally much more flexible than an adult’s. It is covered with a fairly thick layer of fibrous tissue called periosteum, which contributes to healing if the bone should fracture. At each end of long bones (such as the shinbone) there is an area known as the growth plate, where growth in length and width of the bone takes place. The fastest growing growth plates are the lower end of the femur (thighbone) and the upper end of the tibia (shinbone). Growth plates disappear completely during adolescence.

Fractures

As a child grows, gains weight, and becomes more mobile, falls and other accidents can exert enough stress on a bone to cause a fracture, or break. There are several types of fractures.



Nondisplaced fracture. Sometimes a bone breaks completely but the pieces are not separated. Depending upon the location of the fracture, it will be straightened (if necessary) and then immobilized in a splint or cast for a period of time recommended by the treating physician.

Greenstick fracture. If you have ever taken a fresh branch off a tree and tried to break it, you may have noticed that one side of the branch may break while the other side bends. The same phenomenon can occur in a child’s bone; this is called a greenstick fracture. The treatment is the same as for a nondisplaced fracture.



Displaced fracture. This occurs when the bone breaks completely, and the broken ends move away from one another. This will be treated in one of three ways:

  • In a closed reduction, the child is usually sedated or given a general anesthetic, and the doctor then attempts to move the broken pieces into proper alignment. If the procedure is successful, a cast is applied for stabilization until the fracture heals.
  • Sometimes the broken ends of the bone can be brought together, but they are so unstable that they will not remain in proper alignment, even with a cast. In such cases metal pins are inserted into the bone to hold the pieces together. This is done under anesthetic, and usually a splint or cast is applied afterward. Depending upon the location of the fracture, the pins will be left in place for a few weeks and then removed.
  • If the ends of the fractured bone cannot be brought together by a closed reduction, an open reduction will be performed to accomplish this goal. In this case, the surgeon has to make an incision in the region of the fracture to be able to see the bone ends directly. The alignment is corrected and is often held in place with pins or a plate and screws.

Open fracture. This injury, in which one end of a fractured bone protrudes through the skin, is an urgent situation. The wound should be covered and the child taken immediately to the nearest emergency room. Often, open fractures are contaminated with dirt, grass, clothing, etc. The surgeon will attempt to re-move all of the debris to reduce the chance of infection. Antibiotics should be given. Usually the wound is not sutured together right away, but it may be dosed later if there is no sign of infection.



Sometimes weeks after a child has suffered a fracture, the bone will appear crooked, even though the healing process is going well. Because bone is a living tissue, it not only heals but also undergoes remodeling, a process by which the growth plate and periosteum gradually correct the deformity. If you see an X-ray of the same bone years later, you may find it hard to tell that it was ever broken.

Remodeling cannot correct all deformities, however, and the ability of bones own remodel decreases as a child gets older. If a fracture involves the growth plate, a crooked and/or short limb occasionally results, and surgery may be required to correct this problem.



Sprains

To move properly in relation to each other, the joint between adjacent bones is by strong but flexible fibrous bands called ligaments that help keep the bones proper alignment. A sudden, forceful twisting motion can cause stretching or tears of a ligament, better known as a sprain. This will typically produce pain when a doctor attempts to move or put weight on the affected area, as well as swelling and often a bluish discoloration. Since sprains are more common in adults than in children and since it may be difficult to determine if a fracture is present merely by looking at it as an injured arm or leg, a child with these symptoms should be evaluated by a physician.

The simple acronym RICE can help you remember the steps to take following a sprain:



  • Rest the injured area.
  • Ice or cold packs can decrease swelling and pain, but their contact with skin should he limited to 20 minutes three to four times a day.
  • Compression, such as an elastic wrap around the affected area, can also reduce swelling and pain. (This should not be tight enough to cause discomfort, numbness, or tingling.)
  • Elevate the injured area as much as possible for 24 hours to help reduce uncomfortable swelling.

Dislocations

When this happens, the relationship of the two bones that make up a joint is disrupted. In a dislocation of the hip, the ball comes out of the socket. The areas most commonly affected are the shoulder, elbow, kneecap, and fingers. Frequently, there is an associated fracture. Dislocations are best treated by a physician (not by untrained bystanders) and will likely require sedating medication or a general anesthetic to relax surrounding muscles before the bones are put back in their proper relationship. The injured area is usually protected for a few weeks and followed by a gradual return to normal activities. Shoulder and kneecap dislocations often occur repeatedly after the initial episode; sometimes surgery is needed to prevent further episodes. A common dislocation in younger children is the so-called nursemaid’s elbow, which occurs when a toddler or preschooler is tugged forcefully by one arm. Often the injury takes place when an adult is holding the hand of a child who trips while walking. The adult may actually pull upward in an effort to stop the fall. This causes the upper end of the radius (one of two bones in the forearm) to slip through a ring of fibrous tissue that normally holds it in place. Afterwards, the child’s arm may hang limp at his side, and the child will protest loudly if anyone attempts to move it. Often a doctor can resolve this type of dislocation with simple maneuver. Normally this quickly resolves the pain, and soon afterward the child will begin using the arm again.

Tendonitis

Tendons are fibrous tissues that attach muscle to bone. Some tendons, such as those extending to the fingers, are quite long. Repetitive use of certain muscles may cause local inflammation known as tendonitis at or near the attachment site. If your child’s doctor diagnoses this problem, avoidance of activities that provoke pain and possibly the use of anti-inflammatory medications such as ibuprofen may be recommended until the pain resolves.

Bone Fracture First Aid

Some fractures are obvious, and others are suspected when significant pain, swelling, or discoloration follow injury. If you know or suspect that your child has fractured a bone, do the following:

Make sure he avoids putting pressure or weight on it. Gently splint the affected area to reduce pain and the risk of further damage. For an arm injury, a simple sling or a magazine held against the arm with an elastic wrap will usually be adequate. A leg maybe splinted by carefully binding it to the other leg with a towel placed between them.



Don’t try to manipulate fractures or dislocations unless you are trained to do so and you are certain of the nature of the injury. Significant additional injury can occur through inappropriate movement of an injured limb.

  • If possible, cover any open wounds to prevent further contamination.
  • Don’t give the child anything to eat or drink until the injuries have been evaluated and it is clear that surgery will not be needed.
  • Take the child to the nearest emergency department for treatment.
  • If the neck appears to be injured it is very important that the child only be moved by people trained to deal with this type of injury. This is an emergency, and assistance should be sought immediately by calling 911. While waiting, keep the child from moving as much as possible. The transport team will carefully apply a neck brace and place the child on spine board.